(Mindfulness in Behavioral Health) Amy Finlay-Jones, Karen Bluth, Kristin Neff - Handbook of Self-Compassion-Springer (2023)

Mindfulness in Behavioral Health
Series Editor: Nirbhay N. Singh
Amy Finlay-Jones
Karen Bluth
Kristin Neff Editors
Handbook of
Self-Compassion
Editor-in-Chief
Nirbhay N. Singh, Medical College of Georgia, August University,
Augusta, GA, USA
Mindfulness-based therapy is one of the fastest evolving treatment approaches
in psychology and related fields. It has been used to treat many forms of
psychological and psychiatric distress and medical conditions as well as to
foster health and wellness. Early empirical studies and meta-analyses of
current research suggest that mindfulness-based therapies are effective and
long lasting, but much more data from research and training studies are
needed to fully understand its nature and effective practice. The Mindfulness
in Behavioral Health series aims to foster this understanding by aggregating
this knowledge in a series of high-quality books that will encourage and
enhance dialogue among clinicians, researchers, theorists, philosophers and
practitioners in the fields of psychology, medicine, social work, counseling
and allied disciplines. The books in the series are appropriate for upper level
undergraduate and graduate courses. Each book targets a core audience, but
also appeals to others interested in behavior change and personal
transformation.
Amy Finlay-Jones • Karen Bluth
Kristin Neff
Editors
Handbook of
Self-Compassion
Editors
Amy Finlay-Jones Karen Bluth
Telethon Kids Institute University of North Carolina at Chapel Hill
Nedlands, WA, Australia Chapel Hill, NC, USA
Kristin Neff
University of Texas at Austin
Austin, TX, USA
ISSN 2195-9579 ISSN 2195-9587 (electronic)

ISBN 978-3-031-22347-1 ISBN 978-3-031-22348-8 (eBook)
https://doi.org/10.1007/978-3-031-22348-8
© Springer Nature Switzerland AG 2023

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To Judy Long, Celedra Gildea, Silvia Fernandez Campos,
Maria Paula Jimenez, Petrina Barson, and Janina Scarlet, my
dear friends, and wise teachers
Amy Finlay-Jones
To all teens and young adults everywhere – May self-
compassion research provide the foundation to alleviate
suffering and help navigate the often treacherous waters of this
life stage.
Karen Bluth
To Chris Germer and the Center for Mindful Self-Compassion,
who helped take self-compassion from an idea to a practice
that is now taught to tens of thousands of people around the
globe.
Kristin Neff
Preface
Since its emergence as an area of scientific enquiry almost 20 years ago, a

mounting body of work attests to the benefits of self-compassion for indi-
vidual and collective well-being. Alongside this, a global movement has
driven communities of practice to support self-compassion cultivation across
populations and contexts. Bringing together world-leading researchers, clini-
cians, and practitioners, the Handbook of Self-Compassion provides a deep
dive into self-compassion research over the past two decades, consolidating
research findings, integrating these with clinical insights, and providing rec-
ommendations for refining and extending work in this field. It explores criti-
cal questions of how to enhance rigor and precision in self-compassion
conceptualization and measurement, how we can understand the develop-
ment of self-compassion across the life course, how self-compassion is best
cultivated, and why it is associated with adaptive outcomes. As we continue
to pursue new frontiers in self-compassion science and practice, this hand-
book is an invaluable resource for researchers and practitioners alike.
Nedlands, WA, Australia Amy Finlay-Jones

Chapel Hill, NC, USA Karen Bluth
Austin, TX, USA Kristin Neff
vii
Contents
1 Self-Compassion: Theory and Measurement�� 1

Kristin Neff
2 Self-Compassion and Mindfulness �� 19
Shauna Shapiro and Anna Fitch
3 To Be Compassionate and Feel Worthy:
The Bidirectional Relationship Between
Self-Compassion and Self-Esteem�� 33
Madeleine I. Fraser, Joseph Ciarrochi, Baljinder K. Sahdra,
and Caroline Hunt
4 Self-Compassion: An Evolutionary, Biopsychosocial,
and Social Mentality Approach�� 53
Paul Gilbert
5 Attachment and Self-Compassion: Associations Across
the Lifespan�� 71
Trisha L. Raque, Kathryn Ziemer, and John Jackson
6 Self-Compassion in Adolescence�� 89
Karen Bluth and Melissa Clepper-Faith
7 Self-Compassion and Positive Aging�� 109
Lydia Brown
8 Self-Compassion Across Cultures�� 129
Kohki Arimitsu
9 Self-Compassion Among Sexual and Gender
Minorities: The Importance of Self-Kindness
in a Frequently Unkind World�� 143
Abra Vigna and Penelope Strauss
10
Self-Compassion as a Resource of Resilience�� 165
J. Austin, C. H. C. Drossaert, and E. T. Bohlmeijer
11
Self-Compassion and Body Image�� 183
Tracy L. Tylka and Katarina L. Huellemann
ix
x Contents
12 Self-Compassion,
Personal Improvement, and Motivation�� 201
Anaïs Ortiz, Aleah Goold, and Jia Wei Zhang
13 Self-Compassion
in Competitive Sport�� 213
Amber D. Mosewich, Leah J. Ferguson,
and Benjamin J. Sereda
14 Caring
for the Carer – Self-Compassion
in the Health Professions �� 231
Alina Pavlova and Nathan S. Consedine
15 S
elf-Compassion in Relationships
and Caregiving Contexts �� 251
Christine Lathren
16 Self-Compassion in Parenting�� 263
Helena Moreira
17 The
Psychophysiology of Self-Compassion�� 291
Elizabeth T. Slivjak, Alex Kirk, and Joanna J. Arch
18 A
Triadic Pathway Model of Self-Compassion
and Health�� 309
Fuschia M. Sirois
19 Self-Compassion
and Chronic Medical Conditions�� 329
Amy Finlay-Jones, Anna Boggiss, and Anna Serlachius
20 Self-Compassion in Trauma Treatment �� 347
Christine Brähler
21 Self-Compassion
and Non-suicidal Self-Injury �� 369
Penelope Hasking
22 Self-Compassion
in Psychotherapy: Clinical
Integration, Evidence Base, and Mechanisms of Change�� 379
Christopher Germer
23 Compassion
Focused Therapy – What It Is,
What It Targets, and the Evidence �� 417
James N. Kirby and Nicola Petrocchi
24 A
House with Many Doors – Toward a More Nuanced
Self-Compassion Intervention Science �� 433
Amy Finlay-Jones
Index�� 455
About the Editors
Editors
Amy Finlay-Jones, Ph.D., is a senior research fellow and head of the Early
Neurodevelopment and Mental Health Team at Telethon Kids Institute. After
completing training in clinical psychology, Dr. Finlay-Jones undertook fur-
ther postgraduate training in health economics. Her research reflects the con-
tinuum of clinical to through implementation science, with a focus on
translating evidence into policy and practice to improve mental health out-
comes for children and families. Dr. Finlay-Jones’ personal connection to
self-compassion practice came at a young age when she was diagnosed with
a chronic illness. Since that time, she has undertaken academic study of self-
compassion, including developing the world’s first online self-compassion
training program during her doctoral studies. Dr. Finlay-Jones is interested in
the development of self-compassion in children and adolescents, its applica-
tion within clinical contexts, and its intersection with self-regulation. She is a
trained teacher of the Compassion Cultivation Training program, the Mindful
Self-Compassion program, the Mindfulness-Based Compassionate Living
program, and the Making Friends with Yourself program, and she has a strong
interest in co-designing accessible approaches to self-compassion training
with underrepresented groups.
Karen Bluth, Ph.D., is research faculty in the Department of Psychiatry at

the University of North Carolina, and a fellow at the University of North
Carolina Frank Porter Graham Child Development Institute, where she con-
ducts research on self-compassion and its influences on the emotional well-
being of teens. Dr. Bluth is a certified instructor of Mindful Self-Compassion,
co-creator of curriculum Mindful Self-Compassion for Teens (formerly known
as Making Friends with Yourself), Embracing Your Life, the adaptation of
Mindful Self-Compassion for young adults, and one of the creators of Self-
Compassion for Educators, a self- compassion program offered through
Mindful Schools. Dr. Bluth is author of the books The Self-Compassion
Workbook for Teens: Mindfulness and Compassion Skills to Overcome Self-
Criticism and Embrace Who You Are, The Self-Compassionate Teen:
Mindfulness and Compassion Skills to Conquer Your Critical Inner Voice,
co-author of Mindfulness and Self-Compassion for Teen ADHD: Build
Executive Functioning Skills, Increase Motivation, and Improve Self-
xi
xii About the Editors
Confidence (New Harbinger Publishers), and the Audible Original Self-

Compassion for Girls: A Guide for Parents, Teachers, and Coaches.
Additionally, Dr. Bluth is a mindfulness practitioner for over 40 years and an
educator with 18 years of classroom teaching experience. In addition to
teaching and mentoring self-compassion classes for teens and young adults,
she trains teachers in Mindful Self-Compassion for Teens internationally.
Kristin Neff, Ph.D., is Associate Professor of Educational Psychology at the

University of Texas at Austin. During Kristin’s last year of graduate school,
she became interested in Buddhism and has been practicing meditation in the
Insight Meditation tradition ever since. While doing her postdoctoral work,
she decided to conduct research on self-compassion – a central construct in
Buddhist psychology and one that had not yet been examined empirically.
Kristin developed a theory and created a scale to measure the construct over
20 years ago. She has written numerous academic articles on self-compassion
and has been recognized as one of the most highly cited and influential schol-
ars in the field of psychology. Kristin is also the author of the bestselling
books Self-Compassion: The Proven Power of Being Kind to Yourself and
Fierce Self-Compassion: How Women Can Harness Kindness to Speak Up,
Claim Their Power, and Thrive. Along with her colleague Chris Germer, she
developed the Mindful Self-Compassion program and co-founded the Center
for Mindful Self-Compassion. They co-wrote The Mindful Self-Compassion
Workbook and Teaching the Mindful Self-Compassion Program. She con-
ducts workshops and lectures on self-compassion internationally. For more
information go to www.self-compassion.org.
Contributors
Joanna J. Arch, Ph.D., is Associate Professor of Psychology and

Neuroscience at the University of Colorado Boulder, Member in Cancer
Prevention and Control at the University of Colorado Cancer Center, and a
licensed clinical psychologist. Her research focuses on developing and evalu-
ating interventions designed to address anxiety disorders and to improve
well-being among adults with cancer, with a focus on mindfulness, compas-
sion, and acceptance-based interventions. She has received funding from the
National Institutes of Health, American Cancer Society, and the Templeton
Foundation.
Kohki Arimitsu, Ph.D., is Professor of Clinical Psychology in the

Department of Psychological Science at Kwansei Gakuin University, Japan.
He is currently president of Japan Society for Research on Emotions (JSRE).
He has published and edited 14 books, the most recent being Handbook of
Emotion Regulation which 54 Japanese researchers contributed, and several
scientific articles regarding self-compassion. His research focuses on emo-
tion regulation, compassion-based intervention for anxiety related disorders,
and cultural differences of self-compassion and well-being.
J. Austin holds a master’s degree in medical psychology and is currently in

the final stage of pursuing her Ph.D. in the Department of Psychology, Health
& Technology at the University of Twente. She is trained in (self-)compassion
practices, interventions, theory, and research. Her research interests include:
1) the application, conceptualization, and measurement of (self-compassion
and self-criticism; 2) resilience processes (including growth facilitators such
as gratitude) in the adaptation to adversities such as cancer and chronic ill-
ness; and 3) the role of technology in contributing to a compassionate society
and in offering interventions that are rooted in both theory and practice. In her
mixed methods doctoral research, Austin develops and evaluates a mobile
self-compassion intervention for people with newly diagnosed cancer.
Anna Boggiss is a Ph.D., candidate and pre-intern health psychologist in the

Department of Psychological Medicine at the University of Auckland, New
Zealand, and a Mindful Self-Compassion for Teens Teacher Trainee. Anna’s
Ph.D. has focused on developing a clinically usable self-compassion inter-
vention for adolescents with type 1 diabetes. More broadly, she is passionate
about partaking in research aimed at improving the wellbeing of young peo-
xiii
xiv Contributors
ple, especially those with chronic health conditions, and continuing to develop
clinically usable coping skill interventions.
E. T. Bohlmeijer, Ph.D., graduated in 2007 on the effects of life-review on

depression in older adults. Since 2007 he worked as an associate professor
and since 2011 as full professor in the Department of Psychology, Health &
Technology at the University of Twente. His research focuses on public men-
tal health: the development and evaluation of interventions aiming to promote
well-being and reduce distress in the general population and people with
chronic diseases. These, partly eHealth and mHealth, interventions are pri-
marily based on Compassion, Acceptance and Commitment Therapy and
Positive Psychology. He developed the model of sustainable mental health to
integrate meaning- and strengths-based interventions in mental health care.
Since 2010, Professor Bohlmeijer (co-) published over 150 peer-reviewed
papers and three scientific books. He is editor of the Dutch Handbook of
Positive Psychology.
Christine Brähler, DClinPsy, Ph.D., is a clinical psychologist, psychother-

apist, author, and honorary lecturer at the University of Glasgow. She has
been teaching self-compassion around the world since 2008. She is a key
contributor to the first clinical adaptations and to the non-clinical training
program, Mindful Self-Compassion, and its teacher training. Her mission is
to guide people to overcome obstacles to gentle and fierce self-compassion to
connect with others from a place of empowerment and genuine compassion.
Lydia Brown, Ph.D., is a clinical psychologist and researcher in the fields of

healthy aging and women’s mental health. She holds a Ph.D. in Clinical
Psychology and completed her postdoctoral training at Harvard Medical
School and The University of Melbourne. Her research focuses on how psy-
chological resilience factors can help people cope with aging and physical
health issues, especially the menopause. After studying meditation in a Sri
Lankan Buddhist monastery during her 20s, she developed a lifetime interest
in self-compassion and meditation. She remains an active meditation practi-
tioner exploring the Buddhist understanding of suffering and compassion.
Alongside her research, she is a clinical psychologist in private practice. She
also teaches into the University of Melbourne’s Master of Clinical Psychology
program, helping train the next generation of psychologists.
Joseph Ciarrochi, Ph.D., is a Research Professor at the Institute of Positive

Psychology and Education, Australian Catholic University. His research
seeks to help individuals and organizations apply the latest findings from
behavioral science to achieve health, well-being and peak performance.
Professor Ciarrochi has published over 90 scientific journal articles and many
books, including the bestselling, Get out of your mind and into your life teens
and The Thriving Adolescent. He has been honored with over 4.5 million dol-
lars in research funding. His work has been discussed on T.V., and in maga-
zines, newspaper articles, and radio. Joseph is ranked in the top 2% of
scientists in the world across all disciplines.
Contributors xv
Melissa Clepper-Faith, MD, MPH, is a pediatrician with public health

training and experience working with diverse populations. After 24 years in
clinical practice, including the establishment and management of a private
pediatric practice in Hillsborough, NC, she completed a master's in public
health at Gillings School of Global Public Health, UNC-Chapel Hill. Her cur-
rent position as a translational research program and policy coordinator in the
FRONTIER program at the Frank Porter Graham Child Development
Institute, UNC-Chapel Hill, focuses on neuro-prevention, the translation of
neuroscience knowledge into programs and policies that support healthy
child development and ameliorate the adverse effects of toxic stress and child
maltreatment.
Nathan S. Consedine, Ph.D., is health psychologist in the School of

Medicine at the University of Auckland. His training is in the experimental
study of emotion and emotion regulation, specifically looking at how such
factors may be linked to physical health in diverse groups. Current research
foci include compassion in healthcare, disgust in medical contexts, self-com-
passion, and mindfulness. After graduating from Canterbury in 2000 and
spending 10 years working on grants in New York, Nathan returned to tradi-
tional academia in New Zealand in 2009. In addition to teaching in health
psychology and medical programs, he has supervised 50+ master’s and Ph.D.
students, including studies evaluating psychosocial interventions in patient
populations and testing how patient, physician, clinical and environmental
factors impact medical compassion. Nathan has published more than 170
articles and chapters and reviews for numerous international journals and
funding agencies. He enjoys fishing, playing tennis with his son, and listening
to the sort of music that his colleagues dislike.
C. H. C. Drossaert, Ph.D., is Associate Professor of Health Psychology in

the Department of Psychology, Health & Technology at the University of
Twente. She teaches health psychology to bachelor’s and master’s students.
In 2002 she graduated on “Psychosocial aspects of participation in Breast
Cancer Screening.” Her current research interests are in the field of patient
participation and patient empowerment. Central in her work is the question:
“How can we equip patients and their caregivers with adequate information,
skills or tools, to facilitate their active involvement in the management of
their disease, or to help them live a happy and meaningful life despite or with
the condition?” Dr. Drossaert is especially interested in the role of (internet-)
technology herein.
Leah J. Ferguson, Ph.D. (she/her/hers), is an associate professor in the

College of Kinesiology at the University of Saskatchewan. A Métis woman,
Leah’s nationally funded sport psychology research explores how women
athletes flourish and reach their potential, and she is particularly interested in
understanding the role and impact of self-compassion in the lives of women
athletes. Leah translates her sport psychology research into practice through
her applied work as a Mental Performance Consultant with the Sport Medicine
& Science Council of Saskatchewan, and she is a Professional Member of the
xvi Contributors
Canadian Sport Psychology Association. She works with athletes, coaches,

and parents to facilitate well-being and performance for positive sport experi-
ences. She has worked with athletes and teams at all competitive levels –
community, provincial, varsity, national, and international, including athletes
competing at the Paralympic Games.
Madeleine I. Fraser, Ph.D., is a qualified clinical psychologist and provides

assessment and treatment in a private practice based in Sydney CBD. She is
also a full-time clinical psychology lecturer At Australian Catholic University
(ACU, Strathfield campus). She supervisors honors and master’s research
projects in topics related to clinical psychology and with a particular focus on
self-compassion. Madeleine lectures in the undergraduate and postgraduate
psychology programs and is also an AHPRA board approved supervisor. Dr.
Ferrari completed a Master of Philosophy and a Doctor of Clinical Psychology
at Macquarie University, and a Ph.D. at the University of Sydney titled "Self-
Compassion in Adolescence: A Protective Psychological Framework for
Relating to Oneself." She is a member of the Healthy Brain and Mind
Research Centre at ACU and maintains an active research profile.
Anna Fitch is a recent graduate of Santa Clara University and has her
Master of Arts in Counseling Psychology. During her time in university, she
worked closely with renowned mindfulness researcher Dr. Shauna Shapiro,
serving as both research and teaching assistant to Dr. Shapiro. Throughout
her studies, Anna amassed an extensive knowledge of both theory and imple-
mentation of evidence-based mindfulness practices. With a specialty in
Positive Psychology, she holds a deep passion for the relationship between
mindfulness and wellbeing. Post graduation, Anna began working toward her
clinical licensure as a Marriage and Family Therapist along with her certifica-
tion in Mindfulness-Based Stress Reduction. Currently, she serves as a coun-
selor for diverse populations in the San Francisco Bay Area. Anna implements
her backbone in mindfulness and health psychology to offer accessible and
approachable practices based on clinical needs. Additionally, Anna utilizes
her expertise to consult with start-ups and local organizations interested in
incorporating mindfulness and meditation into the workplace.
Christopher Germer, Ph.D., is a clinical psychologist and lecturer on psy-

chiatry (part-time) at Harvard Medical School. He co-developed the Mindful
Self-Compassion (MSC) program with Kristin Neff in 2010 and they wrote
two books, The Mindful Self-Compassion Workbook and Teaching the Mindful
Self-Compassion Program. MSC has been taught to over 200,000 people
worldwide. Dr. Germer is also the author of The Mindful Path to Self-
Compassion; he co-edited two influential volumes on therapy, Mindfulness
and Psychotherapy, and Wisdom and Compassion in Psychotherapy. Dr.
Germer is a founding faculty member of the Center for Mindfulness and
Compassion, Harvard Medical School, and the Institute for Meditation and
Psychotherapy, Cambridge MA, USA. He maintains a small psychotherapy
practice in Massachusetts, USA.
Contributors xvii
Paul Gilbert, Ph.D., is Professor of Clinical Psychology at the University of

Derby and visiting professor at the University of Queensland. He has
researched evolutionary approaches to mental health alongside clinical work
as a Consultant Clinical Psychologist for over 40 years in the NHS. He
founded and developed Compassion Focused Therapy (CFT) and established
the Compassionate Mind Foundation in 2006, which promotes wellbeing
through facilitating the scientific understanding and application of compas-
sion. Professor Gilbert has written over 300 publications including 22 books.
He was awarded an OBE in 2011 by the Queen for services to mental health
Aleah Goold is a graduate student in the Master of General Psychology

Program, with a focus in Experimental Psychology, at the University of
Memphis. She graduated from The University of Tennessee at Martin in 2019
with a B.A. in Psychology and a minor in Sociology. For her thesis, she is
currently studying the impact of a self-compassion intervention on intrinsic
motivation in college students. She has also been a Teaching Assistant for the
General Psychology class at the University of Memphis since Fall 2020,
which includes her teaching small sections of the course once a week. Aleah’s
main drive is to let her research inform her teaching, and her teaching inform
her research, with the ultimate goal to help students become more open-
minded and eager about their learning. She hopes to continue with her educa-
tion and earn a Ph.D., and eventually teach Psychology at a university level.
Penelope Hasking, Ph.D., Professor Hasking’s work focuses on mental

health in adolescents and young adults. Her primary interests are in the social
and cognitive factors that initiate and maintain non- suicidal self-injury
(NSSI) among youth. She is also interested in the needs of school staff who
address NSSI in the school setting, and the views of parents of young people
who self-injure. More recently she has focused her work on the “experience”
of self-injury, delving into topics such as NSSI stigma, experience of disclo-
sure, meanings of scarring, and approaching NSSI recovery from a person-
centered, multifaceted framework.
Katarina L. Huellemann (she/her), M.Sc., is a Ph.D. student in psychology

studying body image, gender, adaptive physical activity, and compassion-
focused interventions. Her research considers sociocultural and individual
forces that may foster stigma towards the self and others, and how this stigma
may contribute to worsened mental and physical well-being in various popu-
lations (e.g., women, adolescents). Her research has been published in Body
Image, Mindfulness, and the Canadian Journal of Public Health. She is
supervised by Dr. Rachel Calogero and Dr. Eva Pila at Western University in
Canada, and is a member of both the Stigma, Objectification, Bodies, and
Resistance Lab (Calogero) and the Body Image and Health Lab (Pila). She is
also an assistant editor for Sex Roles: A Journal of Research.
Caroline Hunt, Ph.D., is a clinical psychologist, and currently president of

the Australian Clinical Psychology Association (ACPA). She is a professor in
the School of Psychology at the University of Sydney where she is also the
xviii Contributors
academic lead of the Clinical Psychology Unit. Her teaching key role is to
oversee the training of clinical psychology students. Caroline has worked in
the field of anxiety disorders for over 20 years. Her expertise and interests are
in anxiety disorders, the assessment and prevention of peer victimization in
schools, and emotional problems in youth. Caroline has developed and imple-
mented several school-based intervention programs targeting emotional
problems, and more recently bullying and victimization.
John Jackson, Ph.D., is a psychologist working primarily in the role of

training director for postdoctoral, doctoral, and master’s level interns at a
university counseling center. John’s training interests involve methods of
attending to and addressing trainee self-awareness and self-regulation, par-
ticularly with attention to attachment style and enactment of self-compassion.
In his clinical work with university students, John’s interests lie in addressing
complex trauma and related health difficulties. John integrates psychody-
namic and Emotionally Focused Therapy (EFT) approaches in individual
therapy and finds great challenge and reward in an interpersonal process
approach to group therapy.
James N. Kirby, Ph.D., is a senior lecturer, clinical psychologist, and co-

director of the Compassionate Mind Research Group at the School of
Psychology at the University of Queensland. He has two major areas of focus
to his research, 1) understanding the decision-making process to how we
choose to act compassionately or not, and 2) evaluating the effectiveness of
Compassion Focused Therapy. James also maintains an active practice where
he delivers Compassion Focused Therapy for those experiencing self-criti-
cism and shame. James also holds a Visiting Fellowship at the Center for
Compassion and Altruism Research and Education at Stanford University.
Alex Kirk completed his PhD in clinical psychology and neuroscience at

the University of Colorado Boulder. He is a naval medical officer with
research and clinical interests spanning anxiety disorders, medical/physical
health correlates of mental health concerns, and behavioral mechanisms of
change.
Christine Lathren, Ph.D. is a research assistant professor at the University

of North Carolina at Chapel Hill within the Program on Integrative Medicine.
Her research interests include examining the impact of self-compassion inter-
vention in various caregiving and family contexts using both quantitative and
qualitative methods. Recent interests explore if and how learning self-com-
passion might improve parent-child relationships, parenting behavior, and
child socioemotional outcomes in families experiencing high stress. Other
work examines the impact of self-compassion training for professional care-
givers, including certified nursing assistants in long-term care contexts.
Helena Moreira, Ph.D., is a clinical psychologist and an assistant professor

at the Faculty of Psychology and Educational Sciences of the University of
Coimbra, Portugal. After obtaining a Ph.D. in Psychology from the University
Contributors xix
of Coimbra, she did 6 years of postdoctoral studies at the same university,

studying the interrelationship between parenting and the parent-child rela-
tionship. During her postdoctoral years, she became very interested in under-
standing the role of self-compassion and mindfulness in parenting. Since
then, she has been conducting extensive research on mindful and compas-
sionate parenting at different stages of the life cycle, with a particular empha-
sis on the post-partum period. Recently, Helena Moreira has also become
interested in a transdiagnostic approach to the treatment of children’s emo-
tional disorders. She has published over 80 academic articles on topics related
to parenting, mindful parenting, self-compassion, attachment, and emotion
regulation. She serves as associate editor of the Journal of Child and Family
Studies and of the Mindfulness journal.
Amber D. Mosewich, Ph.D., (she/her/hers) is an associate professor in the

Faculty of Kinesiology, Sport, and Recreation at the University of Alberta.
Amber’s research interests focus on stress, coping, and emotion within the
sport domain. A key directive of her research is to understand the psychologi-
cal skills and resources necessary to promote adaptive responses to stress and
emotion and support athletes in attaining their performance potential while
maintaining high levels of well-being. One major focus in this line of research
is understanding the role of self-compassion in athlete support and develop-
ment, and the application of self-compassion in sport more broadly. Amber
has been and continues to be involved in several research and applied initia-
tives directed at providing psychological support for athletes involved in
grassroots, developmental, national, and international sport programming.
Anaïs Ortiz is a doctoral student at the University of Florida. She studies

ways in which healthy relationships with ourselves can help us be kinder and
more compassionate with others. Anais is particularly interested in integrat-
ing psychological concepts with Eastern roots, such as mindfulness and self-
compassion, with Western research on well- being and transformative
experiences. She is additionally extending this research to examine the social
effects of these concepts on prosocial behavior, self-expansion, and meaning
in life. In addition to this work, she enjoys putting research into practice
through teaching yoga and meditation.
Alina Pavlova, M.A., M.Sc., is a Ph.D. candidate in the Department of

Psychological Medicine at the University of Auckland studying the nature of
self- and other-focused compassion in healthcare. By investigating the rela-
tionships between physician-, organizational-, and patient-related factors,
Alina's biggest commitment is to design multilevel interventions to enhance
care at patient, physician, and organizational levels. Adjacent to her Ph.D.,
Alina is currently clinically training to become a Health Psychologist and is
involved in self-harm and suicide prevention research collaborating with
international experts and lived-experience researchers worldwide. Before her
Ph.D., Alina completed two master's degrees (in Sociology and Economics)
from the Erasmus University Rotterdam, where she studied stigma in the con-
xx Contributors
text of mental health. Alina is a Yoga Alliance Certified yoga instructor and
teaches yoga and mindfulness in the community.
Nicola Petrocchi, Ph.D., is Adjunct Professor of Psychology at John Cabot

University in Rome and a compassion-focused therapist in Rome. Dr.
Petrocchi founded Compassionate Mind Italia, the Italian association, linked
to the Compassionate Mind Foundation (UK), with the aim to deepen research
and promote training and good practice of CFT in Italy. Dr. Petrocchi sees
patients privately (both in English and Italian) in his studio in the center of
Rome. He manly sees patients in individual sessions, and he runs a 12-week
Compassionate Mind Trainings for clients struggling with issues of shame
and self-criticism.
Trisha L. Raque, Ph.D., is a licensed psychologist and an associate profes-

sor in the Department of Counseling Psychology at the University of Denver.
She is the Chair of the American Psychological Association Division 17
(Counseling Psychology) Health Section. She serves on the editorial board of
the Journal of Counseling Psychology and the Journal of Career Assessment.
Dr. Raque’s area of research includes cancer survivorship, self-compassion,
the intersection of work and health, and health equities. She applies social
justice principles, intersectionality, and the Multicultural Orientation to can-
cer survivorship scholarship and advocacy.
Baljinder K. Sahdra, Ph.D., is a Senior Lecturer and full-time researcher at

the Institute for Positive Psychology and Education, Australian Catholic
University. She has previously held positions at the University of California,
Davis, and University of Western Sydney, Australia. Dr. Sahdra’s research
publications reflect her diverse substantive interests in psychological assess-
ment, educational psychology, personality, developmental psychology, and
mindfulness related constructs and interventions. They also showcase diverse
computational methods, including structural equation modelling, multilevel
modelling, network analysis, mixture modelling, longitudinal analysis, text
mining, and machine learning advances in psychometrics. She has been
awarded with several prestigious awards and competitive grants ($7+ mil-
lion). Her research is published in top-tier journals, is highly cited, and has
been featured in The Sydney Morning Herald, The Sun, Radio Canada
International, Boston Globe, New York Daily Post, Huffington Post, New
Scientist, The Guardian, ABC Radio, and other major media outlets.
Benjamin J. Sereda, M.Sc. (he/him/his), is a doctoral student in the Faculty

of Kinesiology, Sport, and Recreation at the University of Alberta. In addition
to his involvement in sport psychology and performance research, he actively
coaches and consults with athletes at a variety of ages, competitive levels, and
sport contexts. He is passionate about using research to inform efforts to prac-
tically support athletes in achieving their sport-related goals while supporting
their well-being both inside and outside of sport. Ben’s research has focused
on how athletes and performers perceive and attempt to manage demands that
they experience surrounding training and competition. Further, guided by his
Contributors xxi
applied work and coaching experience, Ben is particularly interested in how

athletes attend to, perceive, and respond to setbacks and challenges in sport.
Anna Serlachius, Ph.D., is a health psychologist and senior lecturer in the

Department of Psychological Medicine at the University of Auckland. She
completed her M.Sc. in Health Psychology at University College London and
went on to do a Ph.D. at the University of Melbourne/Murdoch Children's
Research Institute. After her Ph.D., she worked on the Cardiovascular Risk in
Young Finns Study, based at Helsinki University and later at Columbia
University. Dr. Serlachius has published more than 40 journal articles and her
research program aims to develop cost-effective and scalable interventions to
improve psychological and physical health outcomes, with a focus on youth
with chronic health conditions. Her work is increasingly focused on develop-
ing and testing digital wellbeing interventions. She is section editor for JMIR
Pediatrics and Parenting (Journal of Medical Internet Research).
Shauna Shapiro, Ph.D., is a best-selling author, clinical psychologist, and

internationally recognized expert in mindfulness and self-compassion. She is
a professor at Santa Clara University and has published over 150 papers and
three critically acclaimed books, translated into 16 languages. Shauna has
presented her research to the King of Thailand, the Danish Government,
Bhutan’s Gross National Happiness Summit, and the World Council for
Psychotherapy, as well as to Fortune 100 Companies including Google, Cisco
Systems, and LinkedIn. Her work has been featured in the Wall Street Journal,
Mashable, Wired, USA Today, Dr. Oz, the Huffington Post, and the American
Psychologist. Shauna is a summa cum laude graduate of Duke University and
a Fellow of the Mind and Life Institute, co-founded by the Dalai Lama. Her
TEDx Talk, The Power of Mindfulness, has been viewed over 2.5 million
times
Fuschia M. Sirois, Ph.D., is a professor in the Department of Psychology at

the University of Durham in England, and a former Canada Research Chair
in Health and Well-being. She has authored over a 120 peer-reviewed journal
papers, over 200 conference papers, 19 book chapters, and authored/edited 10
books. Her research has been funded by several national funding agencies
including the Social Sciences and Humanities Research Council, Canada,
The Economic and Social Research Council (UK), the Engineering and
Physical Sciences Research Council (UK), and the Welsh Government.
Professor Sirois’ research investigates the temporal, affective, cognitive, and
behavioral dynamics of personality traits and states that that help or hinder
people in their efforts to regulate their emotions, thoughts, and behaviors
when dealing with life’s challenges. Her research aims to understand ways to
enhance resilience and support physical and mental health across a range of
populations, including vulnerable populations and individuals living with
chronic illness. This research has a particular focus on how positive psychol-
ogy qualities and interventions, including self-compassion, can support self-
regulation and enhance physical health and well-being.
xxii Contributors
Elizabeth T. Slivjak is a doctoral student in clinical psychology at the

University of Colorado Boulder. Her research focuses on the development
of self-compassion-based interventions among anxious adults.
Penelope Strauss, Ph.D., (she/her) is a Research Fellow in Youth Suicide

Prevention at the Telethon Kids Institute and an adjunct research fellow at the
University of Western Australia. Her current research aims to decrease rates
of suicidality among LGBTQA+ young people. Penelope received her Master
of Public Health and Ph.D. from the University of Western Australia. She led
the Trans Pathways project, the seminal study conducted on the mental health
of trans and gender diverse young people in Australia and barriers experi-
enced when accessing medical and mental health services.
Tracy L. Tylka (she/her), Ph.D., is Professor of Psychology at The Ohio

State University. She is also editor-in-chief of Body Image: An International
Journal of Research and serves on the editorial board of Eating Disorders: A
Journal of Treatment and Prevention. Her research interests include positive
body image, negative body image, intuitive eating, disordered eating, and
sociocultural influences on these variables. She edited the Handbook of
Positive Body Image and Embodiment with Niva Piran and wrote the Positive
Body Image Workbook: A Clinical and Self-Improvement Guide with Nichole
Wood-Barcalow and Casey Judge. Along with colleagues, she has developed
several scales to measure these constructs, such as the Body Appreciation
Scale-2, Functionality Appreciation Scale, Broad Conceptualization of
Beauty Scale, Intuitive Eating Scale-2, Interpersonal Sexual Objectification
Scale, Personal Safety Anxiety and Vigilance Scale, and Transgender
Congruence Scale. To date, she has written over 100 peer-reviewed articles
and book chapters.
Abra Vigna, Ph.D., is an action researcher and evaluator at the University of

Wisconsin-Madison Population Health Institute in the School of Medicine
and Public Health. Dr. Vigna received her Ph.D. in Human Development and
Family Studies from the School of Human Ecology at the University of
Wisconsin-Madison. Her research focuses on self-compassion as a resource
associated to resilience to adversity and is inspired by over a decade of expe-
rience working to advance health equity via direct-service, coalition building,
and community-engaged action research.
Jia Wei Zhang, Ph.D., earned a bachelor's degree in Psychology from San
Francisco State University and his Ph.D. in Social/Personality Psychology
from the University of California, Berkeley. He is currently Assistant
Professor of Psychology at the University of Memphis. His scholarship takes
a multimethod and reproducible approach to address emotion, emotion regu-
lation, well-being, mental health, resilience, education, ethnic, and diversity
topics. For instance, one line of his research has shown that self-compassion,
a sympathetic reaction extended toward ourselves when we are faced with
difficult experiences, is an adaptive psychological tool that can help people
respond to difficult experiences in ways that can protect and enhance their
well-being.
Contributors xxiii
Kathryn Ziemer, Ph.D., is a licensed clinical psychologist and the clinical

director of Old Town Psychology, a psychology practice that provides evi-
dence-based therapy. She received her Ph.D. in Counseling Psychology from
the University of Maryland. She has conducted research at the National
Institutes of Mental Health, the Social and Decision Analytics Lab at Virginia
Polytechnic Institute and State University, and the research firm Ipsos Public
Affairs. Her research interests include attachment, self-compassion, meaning
in life, brief psychological interventions, and the promotion of positive psy-
chology. She has over 10 years of experience providing psychological ser-
vices, including evidence-based therapy, to clients experiencing depression,
anxiety, chronic health conditions, infertility, relationship issues, and life
transitions. She has previously provided psychological services at the DC
Veterans Affairs Medical Center, the University of Maryland Counseling
Center, and the George Mason University Cognitive Assessment Program.
Self-Compassion: Theory
and Measurement 1
Kristin Neff
Introduction The Elements of Self-Compassion
Self-compassion can be defined as compassion According to my model (Neff, 2016), self-

turned inward. In order to understand what self- compassion forms a bipolar continuum ranging
compassion is, therefore, it helps to consider from uncompassionate to compassionate self-
what occurs in the experience of compassion responding in moments of suffering. It is com-
more generally. Goetz et al. (2010) define comprised of overlapping but conceptually distinct
passion as “the feeling that arises when witness- elements that can be loosely organized into three
ing another’s suffering and that motivates a broad domains – how people emotionally respond
subsequent desire to help” (p. 351). Note that we to suffering (with kindness or judgment), cogni-
must be present with the suffering of others, as tively understand their predicament (as part of
uncomfortable as it might be, in order for feel- the human experience or as isolating), and pay
ings of care and concern to arise. This requires attention to pain (in a mindful or overly identified
mindfulness so that we can turn toward and be manner).
aware of pain rather than avoiding or resisting it.
Also central to compassion is a sense of intercon- Self-Kindness vs. Self-Judgment Most of us
nection with others who are suffering (Cassell, try to be kind and supportive toward our friends
2002). Blum (1980) writes “compassion involves and loved ones when they feel badly about them-
a sense of shared humanity, of regarding the other selves or experience life challenges. We may
as a fellow human being” (p. 511). In fact, this is voice words of warmth and understanding to let
what differentiates compassion from pity, or feel- them know we care – perhaps even offering a
ing sorry for someone separate from yourself. physical gesture of affection such as putting a
The experience of compassion is similar when hand on their shoulder. We are often much harsher
applied to our own suffering, whether our pain with ourselves, however, saying mean and judg-
stems from failure, feelings of personal inade- mental things that we would never say to a friend.
quacy, or life distress more generally. With self-compassion, however, we turn this
around. We take a benevolent and supportive atti-
tude rather than condemning ourselves as worth-
less. We acknowledge our shortcomings while
K. Neff (*)
University of Texas at Austin, Austin, TX, USA caring for ourselves regardless. This type of self-
e-mail: [email protected] acceptance decreases feelings of unworthiness.
© Springer Nature Switzerland AG 2023 1

A. Finlay-Jones et al. (eds.), Handbook of Self-Compassion, Mindfulness in Behavioral Health,
https://doi.org/10.1007/978-3-031-22348-8_1
2 K. Neff
Self-kindness involves more than merely end- mutuality in the experience of suffering and
ing self-criticism, however. It involves actively springs from the acknowledgement that the
opening up our hearts to ourselves, showing con- shared human experience is imperfect. When
cern for our distress. We are motivated to try to we’re in touch with our humanity, we remember
ease our struggles if we can – not because we’re that everyone experiences suffering. The triggers
inadequate as we are, but because we care. We are different, the circumstances are different, the
often treat ourselves with cold stoicism rather degree of pain is different, but the experience of
than support when challenged and move straight imperfection is shared. When we remember our
into problem-solving mode without attending to common humanity, we feel less isolated and
our emotional needs. With self-kindness, how- alone.
ever, we are emotionally available when life
becomes difficult. We allow ourselves to be Mindfulness vs. Overidentification In order to
moved by our own pain, stopping to say, “This is have compassion for ourselves, we need to be
really hard right now. How can I care for myself willing to turn toward our own pain, to acknowl-
in this moment?” When we respond to ourselves edge it mindfully. Mindfulness is a type of bal-
with kindness, we feel validated, supported, and anced awareness that neither avoids nor
encouraged, similar to how we feel when receiv- exaggerates the discomfort of our present-
ing kindness from another. This helps us to cope moment experience (Kabat-Zinn, 1994). We
with the challenges we face. can’t show ourselves compassion if we don’t
acknowledge we’re in pain. At the same time, if
Common Humanity vs. Isolation The sense of we fight and resist the fact that we’re suffering,
common humanity that is inherent to self- our attention may become so absorbed by our
compassion helps us to feel connected to rather pain that we can’t step outside ourselves and
than separate from others. When we fail or make adopt the perspective needed to care for our-
mistakes, we tend to irrationally feel like every- selves. We may become overly identified with
one else is just fine and it’s only me who has our negative thoughts or feelings and be swept
blown it. This isn’t a logical process, but an emo- away by our aversive reactions. This type of
tional reaction that narrows our understanding rumination narrows our focus and exaggerates
and distorts reality. And even when our struggles implications for self-worth (Nolen-Hoeksema,
stem from difficult life circumstances that we 1991). Not only did I fail, “I am a failure.” Not
don’t blame ourselves for, we tend to feel that only did something terrible happen, “My life is
somehow everyone else is having an easier time horrific.” Overidentification tends to reify our
of it. We react as if “something has gone wrong” moment-to-moment experience so that we per-
and forget that part of being human means facing ceive transitory events as definitive and
challenges and being vulnerable. This feeling of permanent.
abnormality creates a frightening sense of dis-
connection and loneliness that greatly exacer- With mindfulness, however, we can recognize
bates our suffering. that our negative thoughts and feelings are just
that – thoughts and feelings – which helps us to
With self-compassion, however, we recognize be less absorbed by and identified with them. We
that life challenges are part of being human, an have the perspective necessary to extend compas-
experience we all share. In fact, our struggles are sion for our difficulties. It also provides the space
what make us card-carrying members of the needed to ask “How can I best care for myself
human race. The element of common humanity right now?” It takes courage to turn toward and
also helps to distinguish self-compassion from directly face our pain, but this act of courage is
self-love. While self-love is important, it leaves essential if we are going to alleviate our suffer-
out an essential factor – other people. Compassion ing. For this reason, mindfulness is the pillar on
is, by definition, relational. It implies a basic which self-compassion rests.
1 Self-Compassion: Theory and Measurement 3
The Structure of Self-Compassion Once people have a moderate level of self-

compassion (and are therefore no longer
When we’re self-compassionate, we feel kinder depressed or anxious), becoming even more self-
and less judgmental toward ourselves, more con- compassionate is unlikely to have a strong effect
nected to humanity, and less isolated and adopt a on how depressed and anxious they are. Some
mindful perspective on our suffering while being scholars have proposed that because UCS and CS
less identified with it. The components of self- (often referred to as “coldness” and “warmth”)
compassion overlap and interact. For instance, have different associations with outcomes, they
the accepting stance of mindfulness lessens over- should be conceptualized as two separate and
identification but also helps to soften self- independent constructs (Brenner et al., 2018;
judgment and provides the wisdom needed to Muris & Petrocchi, 2017; Pfattheicher et al.,
recognize our common humanity. Similarly, self- 2017). In fact, Muris and colleagues (Muris et al.,
kindness reduces self-judgment and because it is 2019; Muris & Petrocchi, 2017) have argued that
an affiliative emotion also helps us to feel safer, reduced self-judgment, isolation, and overidenti-
making it easier to be mindful of our pain. fication should be dropped from the definition
Moreover, realizing that imperfection is part of and measurement of self-compassion altogether.
being human lessens feelings of isolation and However, it is common for each end of a bipolar
helps us to take things less personally so that we continuum to differentially predict outcomes.
are less overidentified with and judgmental of our Consider the physical analogy of temperature. If
problems. In this way, self-compassion can be one were to conduct a study asking people how
seen as a dynamic system that represents a syner- warm they are, how cold they are, and how numb
gistic state of interaction between its constituent their hands are, coldness items would predict
elements (Neff, 2016). Research supports under- numbness more than the warmth items. It would
standing self-compassion as a system: a study by be strange to argue that this finding means cold-
Dreisoerner et al. (2021) found that inducing one ness and warmth are independent constructs,
element of self-compassion through a writing however, especially given that the way to make
exercise changed levels of the other elements, your hands less cold is to warm them up! Other
suggesting they mutually engender one another. bipolar continuums such as wet/dry also evidence
The construct of self-compassion can also be differential associations of each end with out-
conceptualized as a bipolar continuum ranging comes. The fact that different poles of a contin-
from uncompassionate self-responding (UCS; uum have different associations with outcomes
self-judgment, isolation, and overidentification) has no bearing on whether or not they can be con-
to compassionate self-responding (CS; self- ceptualized or measured as a unitary construct.
kindness, common humanity, and mindfulness). Most criticisms of self-compassion as a uni-
As people become more self-compassionate, tary construct have been based on cross-sectional
they increase in CS and decrease in UCS. Analyses findings, but an examination of how the compo-
of how the components of self-compassion are nents of self-compassion change in real time
configured within individuals finds three basic using experimental methods can shed more light
patterns (Phillips, 2019; Ullich-French & Cox, on the how the construct operates. Research indi-
2020): low levels of USC and high levels of CS, cates that self-compassion interventions increase
high levels of CS and low levels of UCS, or mod- the three elements representing CS and decrease
erate levels of both, suggesting that these are not the three elements representing UCS simultane-
independent dimensions. ously (Ferrari et al., 2019), suggesting movement
Studies show that variation in UCS is a stron- along a single continuum. This is true for studies
ger predictor of psychopathology than variation using a wide variety of methodologies such as
in CS. This makes sense given that self-judgment, self-compassion mood inductions (Neff et al.,
isolation, and overidentification directly feed into 2021b), self-compassion meditation training
negative mood states like depression and anxiety. (Albertson et al., 2015; Toole & Craighead, 2016;
4 K. Neff
Wallmark et al., 2012), online psycho-education UCS increased activity in the anterior insula,
(Finlay-Jones et al., 2017; Krieger et al., 2016), anterior cingulate, and the amygdala and that CS
compassion-focused therapy (Beaumont et al., suppressed activity in these very same regions,
2016; Kelly & Carter, 2015; Kelly et al., 2017), illustrating how warmth counteracts coldness.
or mindful self-compassion training (Finlay-
Jones et al., 2018; Neff, 2016). Mindfulness-
based interventions also yield a simultaneous Fierce and Tender Self-Compassion
increase in CS and decrease in UCS (Birnie et al.,
2010; Greeson et al., 2014; Raab et al., 2015; Self-compassion is aimed at the alleviation of
Whitesman & Mash, 2016). A study by Mantzios suffering, and this occurs through a process of
et al. (2020) examined the effect of targeting CS both acceptance and change. Sometimes people
and UCS separately through an experimental view self-compassion as merely going easy on
manipulation. Participants were assigned to a oneself, but to alleviate our suffering, we often
brief intervention that either asked them to relate need to work hard or take active steps to protect
to a difficulty they were having with kindness, a ourselves. Recently I proposed the concept of
sense of common humanity and mindfulness fierce and tender self-compassion as a useful
(CS), or else they were asked to relate to the dif- framework for understanding these two sides of
ficulty without judgment, a sense of isolation or self-compassion (Neff, 2021). Although this
overidentification (reduced UCS). Levels of self- framework is used as a metaphor and has not
compassion increased for both groups equally. been examined empirically, it is helpful for
These findings strongly suggest that CS and UCS understanding the expression of self-compassion.
are not independent constructs but instead form a Tender self-compassion involves “being with”
continuum. ourselves in an accepting way. It entails soothing
The fact that CS and UCS operate in tandem and comforting ourselves, reassuring ourselves
may be linked to the functioning of the sympa- that we aren’t alone, and being present with and
thetic and parasympathetic nervous systems validating our pain. This is the healing power of
(Porges, 2007; see Chap. 17). UCS can be seen to self-compassion. When we feel hurt or inade-
reflect sympathetic activity – the stress response quate, we’re there for ourselves in a loving man-
turned inward when our self-concept is threat- ner, acknowledging our pain and embracing
ened (Gilbert, 2000). Self-judgment reflects the ourselves as we are. This nurturing quality allows
fight response in the form of self-criticism and us to be less concerned with what is happening in
self-attack. Isolation represents the flight our experience – whether it’s painful, difficult,
response – the desire to flee from others and hide challenging, or disappointing – and to be more
in shame. Overidentification can be viewed as the focused on how we are relating to it. We learn to
freeze response – becoming getting stuck in a be with ourselves in a new way. Rather than being
ruminative cycle of negative thoughts. CS reflects lost in and engulfed by our pain, we’re compas-
parasympathetic activity, generating feelings of sionate to ourselves because we’re in pain. The
safety that directly counter feelings of threat. care and concern we extend ourselves allows us
Self-kindness involves nurturing and supporting to feel safe and accepted. When we open our
ourselves, counteracting the fight response. hearts to what is, it generates a level of warmth
Common humanity generates feelings of connec- that helps heal our wounds. For instance, self-
tion and affiliation, counteracting the flight compassion helps us recover from trauma
response. Mindfulness provides a sense of per- (Scoglio et al., 2018), promotes self-acceptance
spective and psychological flexibility that coun- (Zhang et al., 2020), and combats shame (Johnson
teracts the freeze response (Creswell, 2015; Tirch & O’Brien, 2013).
et al., 2014). Notably, a recent study by Kim et al. The fierce quality of self-compassion is asso-
(2020) used fMRI imagery to examine reactions ciated with “acting in the world” to alleviate suf-
to negative emotional stimuli. They found that fering. It looks different depending on the action
required but tends to involve protecting our- the same time, when the force of protection
selves, providing for our needs, or motivating arises without access to feelings of tender care,
change. Protecting means saying “no” to others it can turn into hostility and aggression toward
who are crossing our boundaries or standing up others. We may start to see a situation as us ver-
to injustice. Research shows that self-compassion sus them, I’m right and you’re wrong. Self-
helps people feel stronger, more empowered, and compassion is empowered, but it’s not
assertive (Stevenson & Allen, 2017). It enables overpowering. Similarly, trying to meet our
people to be more comfortable standing up to needs without sufficient self-acceptance can
bullies (Vigna et al., 2017) and confronting oth- morph into selfishness, without attention being
ers who threaten harm (Allen et al., 2017). paid to the needs of others. And the desire to
Providing means taking action to give ourselves motivate change that is not in balance with
what we genuinely need. Self-compassionate acceptance of our human weakness can result in
people are more likely to engage in self-care striving or perfectionism. When fierce and ten-
behaviors such as physical exercise (Homan & der self-compassion are in balance, we take
Sirois, 2017). They are more likely to fulfill basic action to make things better – not because we’re
psychological needs for autonomy, competence, unacceptable as we are, but because we care
and relatedness (Gunnell et al., 2017) and to about ourselves. The more secure we feel in this
engage in activities that they truly enjoy and find tender self-acceptance, the more energy
satisfying (Schellenberg et al., 2016). Self- becomes available to fiercely protect ourselves,
compassionate people are also more motivated to fulfill our needs, and achieve our goals.
make healthy changes in their lives (see Chaps.
12 and 18), taking actions that promote learning
(Hope et al., 2014) and personal growth (Breines ow Does Self-Compassion Relate
H
& Chen, 2012). Rather than promoting compla- to Mindfulness?
cency, self-compassion provides the personal ini-
tiative needed to take charge and fulfill one’s Because mindfulness is a core component of self-
dreams (Dundas et al., 2017). compassion in my model, it is worth considering
Like yin and yang (Palmer, 1997), we need how these constructs are similar and how they
access to both tenderness and fierceness for differ (Neff & Dahm, 2014). First, the type of
wholeness and well-being. As people aim to mindfulness that is part of self-compassion is
alleviate their suffering with compassion, some- narrower in scope than mindfulness more gener-
times tender acceptance is called for and at other ally. The mindfulness component of self-
times fierce action is required. In order for us to compassion refers specifically to awareness of
support ourselves in a healthy manner, these two suffering. Mindfulness in general, however,
ways of being must be balanced and integrated. refers to the ability to pay attention to any experi-
If not, they are in danger of becoming what’s ence – positive, negative, or neutral – with equa-
known in Buddhist psychology as a “near nimity. Self-compassion as a total construct is
enemy.” This term refers to a state of mind that also broader in scope than mindfulness because it
appears similar to the desired state – hence it is includes the elements of self-kindness and com-
“near” – but actually undermines it, which is mon humanity: actively soothing and comforting
why it’s an “enemy.” For instance, when accep- oneself when painful experiences arise and
tance occurs without willingness to take action, remembering that such experiences are part of
it can turn into complacency. Although it’s being human. These qualities are not inherently
important to love and accept ourselves as we are part of mindfulness more narrowly defined. We
in the moment, that doesn’t mean we want to can be mindfully aware of painful thoughts and
stay as we are in the moment. If our behavior is feelings without actively soothing and comfort-
unhealthy, we don’t want to only accept our- ing ourselves or remembering that these feelings
selves, but we also want to make a change. At are part of the shared human experience.
6 K. Neff
Another distinction between mindfulness and ter” or “worse” than we are. Not surprisingly, the
self-compassion lies in their respective targets. attempt to maintain self-esteem has been associ-
Whereas mindfulness is a way of relating to ated with narcissism and feelings of superiority
experience, self-compassion is a way of relating (Bushman & Baumeister, 1998), inflated and
to the experiencer who is suffering (Germer, unrealistic self-views (Sedikides, 1993), preju-
2009; Germer & Barnhofer, 2017). While it’s dice (Aberson et al., 2000), and bullying behavior
possible to be mindful of eating a raisin, an exer- (Salmivalli et al., 1999). To the extent that the self
cise commonly used to teach mindfulness (Kabat- is evaluated in distinction to others, one may feel
Zinn, 1990), it wouldn’t make sense to give the need to derogate others to feel better about
compassion to the raisin, because it doesn’t expe- oneself.
rience pain. Mindfulness involves nonjudgmen- Moreover, as William James (1890) proposed
tally accepting the thoughts, emotions, and over a century ago, self-esteem involves evaluat-
sensations that arise in present-moment aware- ing personal performances (how good am I?) in
ness. Compassion involves the desire for sentient comparison with set standards (what counts as
beings to be happy and free from suffering good enough?) in domains of perceived impor-
(Salzberg, 1995). These theoretical distinctions tance (it’s important to be good at this). This
between self-compassion and mindfulness should means that feelings of state self-esteem can be
be made lightly, however, because both are expe- unstable, bouncing up and down according to
riences that cannot be fully captured by language our latest success or failure (Crocker et al.,
or logic. At some level, both refer to a state of 2003). Self-esteem is a fair-weather friend, there
open heart and mind and cannot be fully for us in good times, deserting us when our luck
disentangled. turns.
Self-compassion is different from self-esteem.
Although they’re both strongly linked to psycho-
How Does Self-Compassion Relate logical well-being, self-esteem is a positive eval-
to Self-Esteem? uation of self-worth, while self-compassion isn’t
a judgment or an evaluation at all. Instead, self-
When I first operationally defined self- compassion is way of relating to the ever-
compassion (Neff, 2003b), I contrasted it with changing landscape of who we are with kindness
self-esteem and proposed that it was a healthier and acceptance – especially when we fail or feel
alternative (also see Chap. 3). Self-esteem refers inadequate. Self-compassion doesn’t require
to how much one likes or values the self, based feeling better than others, but it simply requires
on congruence with personal standards or on acknowledging the shared human condition of
comparisons with others (Harter, 1999). There is imperfection. This means that we don’t have to
general consensus that self-esteem is essential for feel better than others to feel good about our-
good mental health, while the lack of self-esteem selves. Self-compassion also offers more emo-
undermines well-being, fostering depression, tional stability than self-esteem because it is
anxiety, and other pathologies (Leary, 1999). always there for you – when you’re on top of the
There are potential problems with high self- world and when you fall flat on your face. Self-
esteem, however, not in terms of having it, but in compassion is a portable friend we can always
terms of getting and keeping it (Crocker & Park, rely on, in good times and bad.
2004). In many ways, self-compassion can be seen as
High self-esteem requires standing out in a a healthy way to value oneself. My research sug-
crowd – being special and above average (Heine gests that self-compassion and self-esteem are
et al., 1999). This is a problem, because it’s logi- strongly correlated (Neff & Vonk, 2009) but that
cally impossible for everyone to be above aver- once their overlap is accounted for, self-
age at the same time. Self-esteem is often compassion is not linked to social comparison,
evaluated in comparison with those who are “bet- narcissism, and contingent self-worth the way
global self-esteem is and offers greater stability Perhaps the biggest block to self-compassion
in self-worth over time. is the belief that it will undermine our motivation
to improve. We think that self-criticism is neces-
sary to reach our goals. In this case, there is con-
ommon Misgivings About
C fusion between harsh self-judgment and
Self-Compassion constructive criticism. Harsh self-judgment
motivates through fear of inadequacy, whereas
There are many blocks to self-compassion in constructive criticism motivates through care
Western culture, often resulting from miscon- and the desire to learn and grow. Because self-
ceptions about its meaning and consequences compassion makes it safe to fail, people are more
(Robinson et al., 2016). One common miscon- able to learn from their failures and try again.
ception is that self-compassion is selfish. Many For this reason, self-compassion is a more effec-
people assume that spending time and energy tive motivator than harsh self-criticism and pro-
being kind and caring toward themselves auto- vides grit and focus as we work toward our goals
matically means spending less time helping oth- (see Chap. 12).
ers. But research indicates that self-compassion
leads to more caring relationship behavior and
actually helps us sustain helping others without The Measurement
burning out (see Chaps. 14, 15, and 16). Another of Self-Compassion
common misconception about self-compassion
is that it means feeling sorry for yourself – that The majority of studies on self-compassion have
it’s just a dressed-up form of self-pity. In fact, been conducted using the Self-Compassion Scale
self-compassion is an antidote to self-pity and (SCS; Neff, 2003a), which has been translated
reduces the tendency to wallow in suffering. into at least 22 different languages (Neff & Tóth-
Self-compassion allows us to kindly acknowl- Király, 2021). The SCS is a 26-item self-report
edge difficult feelings without becoming lost in measure that is designed to measure self-
them. It also reduces self-focus by framing suf- compassion as I have defined it (Neff, 2003b).
fering in the context of the shared human It’s a straightforward assessment of how often
experience. people engage in the various thoughts, emotions,
Some people fear that self-compassion will and behaviors that align with the different dimen-
make them weak and that harsh self-judgment is sions of self-compassion. It measures self-
needed to be tough. In this case, feelings of com- compassion as a general construct but has six
passion are confused with “being nice” all the subscales which can be used to individually to
time. However, compassion can be fierce, taking examine the constituent components of self-
a strong and resolute stand against anything that compassion. Sample items are self-kindness (“I
causes harm. It also leads to incredible strength try to be loving toward myself when I’m feeling
and resilience in difficult circumstances (see emotional pain.”), self-judgment (“I’m disap-
Chap. 10). Another common misgiving about proving and judgmental about my own flaws and
self-compassion is that it will lead to self- inadequacies.”), common humanity (“When
indulgence. Doesn’t being kind to yourself mean things are going badly for me, I see the difficul-
giving yourself whatever you want? It must be ties as part of life that everyone goes through.”),
remembered that self-compassion has its eye on isolation (“When I think about my inadequacies,
the prize – the alleviation of suffering. Self- it tends to make me feel more separate and cut off
indulgence, on the other hand, involves giving from the rest of the world.”), mindfulness (“When
oneself short-term pleasure at the cost of long- I’m feeling down, I try to approach my feelings
term harm. Research shows that self-compassion with curiosity and openness.”), and overidentifi-
increases health promoting behaviors (see Chap. cation (“When something upsets me, I get carried
18) rather than self-indulgence. away with my feelings.”). Self-judgment,
8 K. Neff
i solation, and overidentification items are reverse The SCS demonstrates known groups validity:
coded so that higher scores indicate a relative undergraduate and community adults have signifi-
lack of UCS. cantly lower scores on the SCS than individuals
There is a large body of research indicating who practice Buddhist meditation, as would be
that scores on the SCS are associated with well- predicted given the Buddhist roots of the construct
being, constituting construct validity. For exam- (Neff, 2003a; Neff & Pommier, 2013). Similarly,
ple, higher scores on the SCS have been linked to clinical populations have lower levels of self-com-
greater levels of happiness, optimism, life satis- passion than nonclinical populations (e.g., Castilho
faction, body appreciation, perceived compe- et al., 2015; Werner et al., 2012), which is also to
tence, and motivation (Hollis-Walker & be expected given that a lack of self-compassion is
Colosimo, 2011; Neff et al., 2005, 2007a, b, seen as a transdiagnostic feature of clinical popu-
2008, 2018a, b) and lower levels of depression, lations (Schanche, 2013). The scale demonstrates
anxiety, stress, rumination, self-criticism, perfec- good convergent validity as well. For instance,
tionism, body shame and fear of failure (Breines therapists’ ratings of how “self-compassionate”
et al., 2014a, b; Finlay-Jones et al., 2015; Neff, individuals were (using a single item) after a brief
2003a; Neff et al., 2005, 2018a, b; Raes, 2010), interaction significantly correlated with self-
and healthier physiological responses to stress reported SCS scores (Neff et al., 2007a, b), and
(Breines et al., 2014a; Friis et al., 2016). There is there was a strong association (.70) between self-
also evidence for predictive validity. Longitudinal reported and partner-reported scores on the SCS
studies have found that self-compassion levels among couples in long-term romantic relation-
predict stress, depression, anxiety, suicidality, ships (Neff & Beretvas, 2013). Similarly, high lev-
and coping over time (Stefan, 2019; Stutts & els of agreement (.77) were found between
Blomquist, 2018; Stutts et al., 2018; Zeller et al., independent coders using SCS items to rate the
2015; Zhu et al., 2019). level of self-compassion displayed in brief verbal
The SCS demonstrates good discriminant dialogs (Sbarra et al., 2012). These findings sug-
validity. First, it is not significantly associated gest that the SCS measures behaviors that are
with social desirability (Neff, 2003a). Self- clearly observable by others.
compassion can also be empirically differenti-
ated from self-esteem, and the SCS demonstrates
incremental predictive validity with regard to the Factor Structure of the SCS
construct (Krieger et al., 2015; Neff & Vonk,
2009) including in longitudinal research Neff (2003a) originally used confirmatory factor
(Marshall et al., 2015). In addition, self- analysis (CFA) to examine the factor structure of
compassion can be differentiated from self- the SCS and found adequate fit for a higher-order
criticism. Although a key feature of model and a six-factor correlated model, justify-
self-compassion is the lack of self-judgment, ing use of the SCS as a total score or else six
overall SCS scores still negatively predict anxiety subscale scores. Since then, several other valida-
and depression when controlling for self-criticism tion studies have been carried out on the SCS (for
and negative affect (Neff, 2003a; Neff et al., an overview, see Neff et al., 2019). While the six-
2007a, b). Neff et al. (2007a, b) found that the factor correlated model has generally been repli-
SCS predicted significant variance in positive cated, findings of a single higher-order factor
well-being after controlling for all the Big Five have been inconsistent. Some studies have found
personality traits. Moreover, Neff et al. (2018b) support for a higher-order model (e.g., Benda &
established incremental validity with neuroticism Reichová, 2016; Castilho et al., 2015; Dundas
in three separate studies, and Stutts et al. (2018) et al., 2016), but others have not (e.g., Brenner
found that self-compassion predicted depression, et al., 2017; Costa et al., 2015; López et al., 2015;
anxiety, and stress while controlling for neuroti- Montero-Marín et al., 2016; Neff et al., 2017;
cism in a longitudinal study. Williams et al., 2014).
As mentioned earlier, certain researchers have analyses to determine their differential associa-
argued that the SCS should not be measured with tion with outcomes. Given the deep intertwining
a total score representing a general construct of of the various components in the definition, oper-
self-compassion but should instead be measured ation, and measurement of self-compassion, and
with two factors representing CS and UCS (e.g., given that almost all of the reliable variance in
Brenner et al., 2017; Costa et al., 2015; López item responding on the SCS is explained by a
et al., 2015; Muris & Petrocchi, 2017). Support general self-compassion factor, separating out
for a two-factor solution to the SCS has also been the shared variance of the six subscales could
inconsistent, however (e.g., Cleare et al., 2018; change their meaning in a way that may under-
Neff et al., 2017). We have argued that a bifactor mine the interpretability of findings.
approach combined with Exploratory Structural
Equation Modeling (ESEM) offers the most the-
oretically consistent way to examine the SCS, Other Measures of Self-Compassion
given that the six components are thought to
operate as a dynamic system (Neff & Tóth-Király, There are different formats of the SCS that are
2021). Bifactor ESEM is increasingly popular for available to researchers. A 12-item short form of
analyzing multidimensional constructs (Morin the SCS exists and is frequently used in research
et al., 2016; Morin et al., 2020). The approach given its shorter length and strong correlation
allows for the explicit expression of item cross- with the long form (SCS-SF; Raes et al., 2011).
loadings as opposed to the overly strict confirma- Recently, we have created a 17-item youth ver-
tory factor analysis (CFA) which doesn’t allow sion of the SCS designed for middle school-aged
for any cross-loadings. Given that the compo- populations (Neff et al., 2021a), which can be
nents of self-compassion mutually engender one used to measure total levels of self-compassion
another (Dreisoerner et al., 2020), some cross- or else the six subscales. Additionally, we have
loadings between factors should be expected. created a state Self-Compassion Scale (S-SCS;
And like CFA, this approach can confirm the fit Neff et al., 2021b) designed to measure feelings
of a priori models. In a large international col- of self-compassion in the present moment (e.g.,
laboration (Neff et al., 2019), we used bifactor “I’m being supportive toward myself”; “I’m tak-
ESEM to examine the factor structure of the SCS ing a balanced view of this painful situation.”)
in 20 diverse samples (N = 11,685), and support There is an 18-item-long version that can mea-
was found in every sample for use of 6 subscale sure state levels of the 6 components of self-
scores or a total score, but support was not found compassion, as well as a 6-item short version that
separate scores representing CS and measures global levels of state self-compassion
UCS. Moreover, 95% of the reliable variance only. Although not strictly another format of the
could be attributed to a general factor. This pat- SCS, we have also created a 16-item measure of
tern of results has been replicated in other studies compassion for others with a similar structure to
(Neff et al., 2018a, b; Tóth-Király, et al., 2017). the SCS (Pommier et al., 2020). Compassion was
For researchers who are primarily interested operationalized as experiencing kindness, a sense
in the benefits of self-compassion in terms of of common humanity, mindfulness, and lessened
implications for intervention, use of a total SCS indifference toward the suffering of others.
score is probably most appropriate given that the It should be noted that we are in the midst of
elements of self-compassion operate in tandem creating a revised version of the SCS (Neff &
as a system. For those more interested in unpack- Toth-Kiraly, in preparation). Currently the SCS,
ing the mechanisms of how self-compassion at 26 items, is too long for many researchers who
enhances well-being, however, it may be useful often need to create shorter surveys for their par-
to examine the six constituent components sepa- ticipants. Also, one potential problem with the
rately. However, one should use caution if enter- SCS is that some items are more focused on gen-
ing the six subscales simultaneously in regression eral life suffering and others are focused on mis-
10 K. Neff
takes and failures, adding a source of variance to Self-Compassion Across Groups

items that is independent from self-compassion
itself. Items in the revised version mention both An important question concerns whether there
personal and general life suffering. The revised are differences in the prevalence or functioning
SCS will have an 18-item-long version that can of self-compassion across groups. Recently, we
measure each of the 6 subscales and a short examined the generalizability of the SCS via tests
6-item version (with 1 item from each subscale) of measurement invariance across a wide range
that can be used to measure the general construct of populations, including student, community,
of self-compassion. The data we have collected and clinical samples, and also varying by gender,
so far provides strong evidence for the psycho- age, and culture (Tóth-Király & Neff, 2021). Our
metric validity of both scales. data set (n = 10,997) included a total of 18 sam-
Of course, other measures of self-compassion ples from 15 countries (Australia, Brazil, Canada,
exist in the literature based on different conceptu- France, Germany, Greece, Hungary, Iran, Italy,
alizations of the construct. For instance, Gilbert Korea, Norway, Portugal, Spain, United
and colleagues created the Forms of Self- Kingdom, United States) in 12 languages.
Criticism and Self-Reassurance Scales (Gilbert Overall, findings demonstrated a striking degree
et al., 2004) to measure these two ways of relat- of invariance in the reliability and factor structure
ing to oneself. These correspond loosely to the of the SCS across groups. Although the SCS
self-kindness and self-judgment subscales of the functioned the same way in all groups, there were
SCS and are typically used separately. More differences in mean levels of self-compassion
recently, Gilbert et al. (2017) developed the displayed between groups.
Compassion Engagement and Action Scales In terms of gender, females reported slightly
(CEAS), based on the broadly used definition of lower levels self-compassion than males. This
compassion as sensitivity to suffering with a result aligns well with a prior meta-analysis,
commitment to try to alleviate it (Goetz et al., including a total of 88 study samples, showing
2010). The CEAS includes a self-compassion that males reported slightly higher levels of self-
subscale with items tapping into two elements: compassion than females (Yarnell et al., 2015).
engagement with distress (e.g., tolerating and This gender difference may be because females
being sensitive to distress) and the motivation to tend to be more self-critical and judge themselves
alleviate that distress (e.g., thinking about and more negatively than males (Leadbeater et al.,
taking actions to help). Notably, the CEAS does 1999). They also feel less entitled to meet their
not include warmth, kindness, concern, or feel- own needs (McGann et al., 2006). However, these
ings of shared humanity as a feature of compas- gender differences appear to be less a function of
sion. Gu et al. (2020) have created a measure of sex and more a function of gender role socializa-
self-compassion that assesses five elements: rec- tion which emphasizes self-sacrifice for females
ognizing suffering, understanding the universal- and entitlement for males. Self- compassion
ity of suffering, feeling moved by suffering, involves meeting one’s needs in order to alleviate
tolerating uncomfortable feelings aroused in suffering, so norms of self-sacrifice work against
response to suffering, and the motivation to alle- this process while norms of entitlement encour-
viate suffering. Garnefski and Kraaij (2019) have age it. Research demonstrates that sex differences
created a measure of self-compassionate coping are negligible once gender roles are taken into
that focuses mainly on self-kindness. Of all these account (Yarnell et al., 2019).
measures, however, the SCS is most commonly Our results also indicated that people become
used, and its psychometric validity has been more self-compassionate as they become older,
examined most extensively. consistent with past research (Homan, 2016; Neff
& Pommier, 2013; Neff & Vonk, 2009). In fact, Other Methods of Researching
the increasing self-acceptance experienced by the Self-Compassion
elderly (Ardelt, 1997, Erikson, 1968) is probably
bidirectionally linked to increasing self-The majority of research on self-compassion has
compassion with age (Neff et al., 2007a, b). The used the SCS to examine trait levels of self-
wisdom that comes from maturity and experience compassion and its relationship to other psycho-
allows for a kinder and more balanced stance logical traits. This approach, however, limits
toward oneself that recognizes that shared nature researchers’ ability to make causal inferences. To
of human suffering and the ability to relate to life address this limitation, there is an increasing
difficulties and personal imperfection with mind- trend toward experimental research that exam-
fulness and compassion enhances life satisfaction ines how change in self-compassion impacts out-
and acceptance. The fact that self-compassion comes (Ferrari et al., 2019). Some scholars have
increases with age is good news for the elderly, examined the efficacy of self-compassion inter-
given the many benefits that self-compassion ventions such as the mindful self-compassion
provides in terms of mental and physical well- training (Germer & Neff, 2019; Neff & Germer,
being (Allen et al., 2012; Perez-Blasco et al., 2013) or compassion-focused therapy (Gilbert,
2016). 2010; Sommers-Spijkerman et al., 2018) to deter-
Our results also found cultural differences in mine how such interventions change well-being
self-compassion. Among undergraduates, we over time. Another promising methodology
found that Korean students reported the highest involves inducing a self-compassionate state of
level of self-compassion. This is somewhat sur- mind. One of the first studies to attempt to induce
prising, given the influence of Confucianism in a self-compassionate mind state was conducted
East Asian cultures which is thought to promote by Leary et al. (2007), who asked participants to
self-criticism as a means of achievement (Heine, recall a past event that made them feel badly
2003). Of course, caution should be used in inter- about themselves and then guided them through a
preting results given that they may have been series of writing prompts designed to evoke self-
sample-specific, and a great deal of more research compassion. The study found that compared to
will be needed to determine if these findings rep- control conditions, those in the self-compassionate
licate. For community adults, it was found that writing condition experienced a greater decrease
Spanish, Italian, Hungarian, Brazilian, and in negative affect. Several researchers have used
Australian participants had the highest level of this induction in experimental studies of self-
self-compassion. We found that those from the compassion (e.g., Blackie & Kocovski, 2018;
United Kingdom, France, and Greece tended to Odou & Brinker, 2014). Other researchers have
have the lowest levels, with Americans and used variations on this writing task or different
Germans in between. Of course, the fact that approaches such as guided meditation (e.g.,
comparisons were confounded by age composi- Breines & Chen, 2012; Kirschner et al., 2019) to
tion and gender renders findings somewhat diffi- determine if changes in state self-compassion
cult to interpret, and these variables will need to impact well-being.
be disentangled in the future. A few things are As part of establishing the validity of the
noteworthy about the findings, however. First, state SCS (Neff et al., 2021b), we created a self-
English speaking countries differed in level of compassion mind state induction (SCMI) that is
self-compassion, indicating that culture may be based on a practice known as the Self-
more important than language in relative impact Compassion Break found in the MSC program
on self-compassion. Also, there did not appear to (Germer & Neff, 2019). The induction first asks
be a general trend for more economically pros- individuals to think of a situation they are strug-
perous nations to have more self-compassion, gling with and then to write mindfully about the
suggesting that healthy self-attitudes are not feelings evoked by a difficulty, so they can
merely a product of standard of living. accept and validate their painful feelings.
12 K. Neff
Examples of self-compassionate language are Conclusion

given such as “this is really hard right now.”
They are next instructed to write about their The field of self-compassion research is growing
common humanity, recognizing that they are not exponentially, as the chapters in this handbook
alone in their struggle. Examples are given such will attest. Even more important than self-
as “everyone is imperfect, I’m not alone.” They compassion theory, measurement, or research,
are then instructed to write to themselves with however, is practice. Self-compassion isn’t just a
kindness, giving themselves the type of care, good idea; it’s something you do. Self-compassion
understanding, and support they would nor- transforms lives. It’s a learnable skill that radi-
mally show to a good friend. Examples are cally improves our ability to cope with painful
given such as “I’m here for you.” Finally, par- experiences without becoming overwhelmed.
ticipants are invited to reflect on what they have Although it’s directly aimed at suffering, the feel-
written so that the message of self-compassion ings of warmth, connection, and presence entailed
can be absorbed and integrated. There is a con- by self-compassion provide satisfaction and
trol condition that asks participants to first write meaning.
about a difficult situation in a descriptive man- In 2010 my close colleague Chris Germer and
ner (parallel to mindfulness), then to indicate I created an eight-week training program to
who was involved in the situation (parallel to teach self-compassion called Mindful Self-
common humanity), next to describe any words Compassion (MSC; Germer & Neff, 2019; Neff
spoken in the situation (parallel to self-kind- & Germer, 2018). A few years later we founded
ness), and finally to reflect on what they had a nonprofit called the Center for Mindful Self-
written. The parallel nature of the control condi- Compassion (CMSC) to train teachers, and since
tion helps to ensure that participants in both then MSC has been taught to hundreds of thou-
conditions are focused on the difficult situation, sands of individuals around the globe, meaning
with only participants in the self-compassion that self-compassion training is scalable. This has
condition actively changing their responses to far-reaching implications for countries and
it. It is hoped that the availability of this SCMI regions where mental health professionals are in
and also the newly created S-SCS will help short supply. Although the MSC program isn’t
facilitate more experimental research on self- therapy, it is highly therapeutic and is an impor-
compassion in the future. tant mental health resource for those needing
So far, research on self-compassion using effective ways to cope with their distress. In addi-
experimental methods has yielded findings that tion to the MSC program, CMSC has been work-
converge with cross-sectional studies using the ing to develop self-compassion training programs
SCS such as increased happiness, life satisfac- for young adults, teens, children, parents, cou-
tion, body appreciation, motivation, and less ples, healthcare providers, psychothera-
depression, anxiety, stress, and shame (e.g., pists, businesspeople, and athletes. As research-
Albertson et al., 2015; Breines & Chen, 2012; ers continue to examine the benefits of
Diedrich et al., 2014; Johnson & O’Brien, 2013; self-compassion in more realms of life, and as
Leary et al., 2007; Neff & Germer, 2013; Odou & more people begin to experience its benefits first-
Brinker, 2014; Shapira & Mongrain, 2010; hand, we are likely to see impacts in the larger
Smeets et al., 2014). Taken as a whole, therefore, culture. Instead of being distrustful of self-
findings obtained in the field of self-compassion compassion, hopefully it will be widely recog-
research appear to be robust. nized as an essential skill for living a healthy life.
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Self-Compassion and Mindfulness
2
Shauna Shapiro and Anna Fitch
Introduction society with the intent of monetizing wellness

and offering mindfulness training without con-
The word mindfulness—Sampajañña in Pali— text or nuanced content. This watered-down,
means clear comprehension. Mindfulness helps amorphous version of mindfulness limits its full
us to see clearly, so we can make wise choices potential and can lead to discouragement and,
and respond to life’s challenges effectively and worse, iatrogenic effects.
with a clear mind. Awareness of the present Self-compassion, at its most basic level, is the
moment inhibits the automatic biases that fre- ability to show yourself kindness in the face of
quently dominate cognitive processing, such as suffering. Mindfulness is considered founda-
attention to perceived threat or negative thoughts tional to self-compassion: we cannot be kind to
about oneself or the world. In doing so, mindful- ourselves unless we first have the awareness and
ness is thought to facilitate more impartial inter- acknowledge we are in pain. Mindfulness helps
pretation of reality, giving rise to “clear seeing” us see suffering clearly. Self-compassion adds:
or “clear knowing” (Analayo, 2019). From this “Be kind to yourself in the midst of suffering”
place of clarity, one is given the opportunity to (Germer & Neff, 2013, p. 861). Accordingly,
consciously discern what the present moment self-compassion also has the potential to facili-
requires and respond in a proper and practiced tate and deepen mindfulness, by supporting us to
way (Shapiro & Carlson, 2009). Thus, mindful- stay present with difficult experiences. Indeed,
ness can both reduce maladaptive and habitual many scholars and practitioners emphasize that
cognitive, emotional, and behavioral patterns and self-compassion is inherent within mindfulness
also mitigate the impact of these patterns on dis- practice. In this way, mindfulness and self-
tress and well-being (Verplanken & Fisher, compassion are distinct constructs that mutually
2014). Although research has demonstrated the engender each other.
myriad benefits of mindfulness (Grossman et al., This chapter closely examines the relationship
2010; Leyland et al., 2019), the recent interest between mindfulness and self-compassion, illus-
has often led to its oversimplification and over- trating both the overlap and fundamental differ-
commodification. As a result, mindfulness bears ences. We aim to provide a comprehensive and
the danger of becoming a buzz word of modern clear understanding of mindfulness, explicitly
highlighting its three components: intention,
S. Shapiro (*) · A. Fitch attention, and attitude. As mindfulness and self-
School of Education and Counseling Psychology, compassion are inextricably linked, the purpose
Santa Clara University, Santa Clara, CA, USA of this chapter is to unravel their integral aspects,
e-mail: [email protected]; [email protected]

https://doi.org/10.1007/978-3-031-22348-8_2
20 S. Shapiro and A. Fitch
examine how they interact, and help to articulate (2013), self-compassion practice and the Mindful
the utility of both mindfulness and self- Self-Compassion (MSC) program were devel-
compassion to support health and well-being on oped to cultivate self-compassion more explic-
an individual and collective level. Throughout itly. Current research shows the benefits of a
this exploration, questions arise: What are the direct approach of training in MSC (Neff &
constructs of mindfulness and self-compassion Germer, 2013). This program utilizes compas-
and how are they defined? What are the funda- sion and lovingkindness meditations, as well as
mental components and practices of each? Where integrating dyadic, group, and individual activi-
are they similar and where do they differ? How ties designed to cultivate these constructs. In
can mindfulness and self-compassion be inte- addition to the focus on one’s cognitive, sensory,
grated in order to bring about the greatest health and affective experience that is characteristic of
and healing, and which populations would this mindfulness meditation, loving-kindness and
integration be most effective? compassion practices focus specifically on intra-
and interpersonal experiences. In lovingkindness
mediation, for example, one practices sending
Distinguishing Mindfulness compassion to oneself, loved ones, and all beings
and Self-Compassion Practices who suffer (Hofmann et al., 2011). In compas-
sion meditation, through the awareness of our
To begin, we need to understand mindfulness and own suffering or the suffering of others, one can
self-compassion as separate practices. While cultivate the inherent compassion that naturally
mindful awareness is a state of being, mindful arises. While compassion meditation facilitates
practice is the mechanism through which consis- recognizing and alleviating suffering, loving-
tent mindfulness is achieved (Shapiro & Carlson, kindness mediation focuses on wishing others
2009). Just as patterns of cognitive distortion unconditional well-being (Hofmann et al., 2011).
such as worry and rumination can become a In Neff and Shapiro’s theoretical framework
“default” through repeated use (McEvoy et al., of general state mindfulness, four distinct ele-
2013), mindfulness too can become an integral ments of mindfulness are identified (Neff &
habit, becoming both a way of being and a formal Shapiro, 2019): (1) paying attention to present-
practice. Focused-attention meditation is one moment experiences, (2) how we relate to experi-
mindfulness practice that specifically aims to cul- ences, (3) how we relate to the experiencer, and
tivate selective attention on a specific object (e.g., (4) the wisdom to see both the experience and
the breath). To do so, one must also simultane- experiencer with clarity. Self-compassion pre-
ously monitor one’s attention to identify when it dominantly focuses on the third element, how we
has wandered away from the chosen object, dis- relate to the experiencer. Additionally, while gen-
engage one’s attention from any distractions, and eral state mindfulness can be applied to all life’s
return one’s attention to the attentional object experiences, mindfulness within self-compassion
accordingly (Lutz et al., 2008). Open monitoring focuses primarily on how we relate to the experi-
meditation builds on focused attention, with the encer (ourselves) in moments of suffering. When
aim of remaining in a state of monitoring any- suffering arises, we utilize the practice of mind-
thing that occurs in one’s present-moment expe- fulness to become aware of our pain and identify
rience, without focusing on an attentional object the experience as suffering. When suffering has
(Lutz et al., 2008). been identified, we include the explicit practice
Traditionally, self-compassion was incorpo- of self-compassion to actively soothe and support
rated in compassion and lovingkindness practices ourselves. The practice of self-compassion is a
of Buddhism and has been implicitly taught crucial ancillary to mindfulness in times of suf-
through the practice of mindfulness-based interfering; it directly responds to the emotional need
ventions (MBIs; Rudaz et al., 2019). However, that is present with support and comfort.
with the pioneering work of Neff and Germer
2 Self-Compassion and Mindfulness 21
he Three Pillars of Mindfulness

T mindfulness active rather than passive. They con-
Practice nect us with our personal visions, aspirations,
and motivations. Our intentions keep us on
Whether through focused attention or open moni- course, reminding us again and again of what is
toring, the practice of mindfulness is made up of most important. Research on the role of intention
three essential pillars: intention, attention, and in mindfulness is limited; however, an early study
attitude (Shapiro & Carlson, 2009). Intention found that intentions underpinning meditation
underpins why we pay attention. It helps to estab- practice shift over time and are associated with
lish the purpose of our practice and keeps our outcomes of practice (Shapiro, 1992). In their
focus on what we wish to achieve through mind- classification framework of mindfulness prac-
fulness, thereby guiding the practice in a deliber- tices, Levit-Binnun et al. (2021) outline four dis-
ate and purposeful direction. Attention helps us tinct intentions: (1) to gain insight into the way in
train and stabilize our focus in the present which how we relate to our experience influences
moment. Attention permits us to discern when our well-being or distress; (2) to gain insight into
and what to practice. Since the only constant is the changing nature of our internal and external
change, attention allows us to perceive the cur- world; (3) to gain insight into how our sense of
rent moment with clarity. By utilizing attention, it self influences our distress and well-being; and
is possible to become aware of what practice the (4) to gain insight into how positive and prosocial
present moment necessitates. This awareness mental states influence well-being. Intentions
provides the ability to select the most beneficial 1–3 are based on the characteristics of experience
practice. Attitude guides how we pay attention— considered fundamental to understanding and
specifically, with kindness and curiosity. alleviating mental distress in the Buddhist tradi-
This third pillar of mindfulness—attitude—is tion, while the fourth intention reflects the
perhaps the most important and often overlooked. Brahmaviharas (i.e., “loving kindness,” “com-
Too often, we practice mindfulness with an atti- passion,” “sympathetic joy,” and “equanimity”).
tude of judgment—judging ourselves when our In practice, intentions can take the form of man-
mind wanders, judging ourselves for not doing it tras, phrases, or even a single guiding word, such
right. This “judging” attitude, however, limits the as “see clearly,” “respond with kindness,” or sim-
ability to fully benefit from mindful practice. ply “peace.”
Researchers Heatherton and Wagner (2011) have
studied the brain’s response to an attitude of self-
judgment. Using fMRI scanning, their research Attention: Training and Stabilizing Our Focus
purports that shame diminishes the activity of the in the Present One of the core tenets of mind-
prefrontal cortex (PFC) and the communication fulness practice is that we pay attention to our
between the amygdala and the PFC, thereby lim- present-moment experiences to truly experience
iting the ability to self-regulate, make informed the essence of life. Mindfulness supports the abil-
decisions, and adaptively learn from experience ity to be attentive and aware in the present
(Heatherton & Wagner, 2011). Further research moment. As mindfulness practice trains and sta-
conducted by Pulcu et al. (2014) found that bilizes attention, we begin to see that which is
shame not only dampens activation of the PFC unfolding before us more clearly. Indeed,
but also increases amygdala activity, which elic- research supports the assertion that present-
its a fear response. Thus, judgment and shame moment attention is associated with more adap-
initiate a fear response, which then subsequently tive stress responses over time (Donald et al.,
reduces the activity in the PFC responsible for 2016), whereas less awareness of the present
acquiring new insights and learning. moment is associated with lower psychological
well-being (Stawarczyk et al., 2012).
Intention: Why We Pay Attention Intentions Killingsworth and Gilbert (2010) found that, on
establish an objective and keep the practice of average, our minds wander 47% of the time. This
means that our attention to the present moment is related to attention. For example, Carter et al.
only fully engaged for approximately half our (2005) found that Tibetan Buddhist monks per-
lives. The phenomenon of the wandering mind formed significantly better on a task of sustained
has been colloquially termed “monkey mind” attention following focused-attention meditation,
because our mind behaves like a monkey, con- but not following compassion meditation. In a
stantly swinging from thought to thought. Swept series of studies, Yordanova and colleagues
into future fears or lost in ruminations of the past, (2020, 2021) found that among experienced med-
we miss the present moment. When our minds itators, focused attention, open monitoring, and
wander, we often miss important details of the lovingkindness meditation had both shared and
present moment and construct inaccurate narra- distinct neural patterns. Specifically, focused-
tives about what is happening, often based on our attention meditation was associated with
previous conditioning instead of the reality of the increased beta connectivity in the right hemi-
present. Thus, the monkey mind may cling to sphere of the brain, whereas open monitoring
inaccurate stories which can cause an incorrect was associated with beta connectivity in the left
forecasting and subsequent behavioral responses hemisphere. The authors proposed that these pat-
in the future. terns represented differences in the type of atten-
tion (i.e., narrow versus wide) or the amount of
In support of the assertion that mindfulness is information attended to (i.e., small versus large).
associated with more adaptive attentional out-
comes, numerous studies have demonstrated Attitude: How We Pay Attention Of the three
improved attentional processing and differences pillars of mindfulness, attitude is perhaps the one
in associated brain structures related to both trait most often overlooked and the most relevant for
mindfulness and mindfulness practice (Yordanova this discussion. While intention reminds us what
et al., 2021; Malinowski, 2013; Allen et al., is most important and attention stabilizes our
2012). In a recent series of meta-analyses, mind in the present, our attitude affects how we
Verhaeghen (2021) examined (a) the effects of pay attention. How we pay attention determines
mindfulness training, relative to control condi- our ability to see clearly, to learn effectively, and
tions, on attention outcomes; (b) attentional to respond wisely and compassionately. To ben-
capacities in long-term meditators compared to efit from mindfulness, an attitude of kindness and
those who have never meditated; and (c) the rela- curiosity is essential (Shapiro et al., 2006). If
tionship between trait mindfulness and attention. intention and attention are met with a cold and
The first meta-analysis demonstrated that mind- critical attitude, the practice may have contradic-
fulness training had significant, small to medium tory consequences (Shapiro et al., 2006; Kabat-
effects on several components of attention, Zinn, 2003). This could result in a practice that is
including inhibition, working memory, attention condemning or judgmental of inner experience,
shifting, and sustained attention, with more train- further cultivating neuronal pathways of judg-
ing sessions associated with greater effects. The ment and shame instead of compassion and
second meta-analysis found that across studies, acceptance. An attitude of kindness and curiosity
long-term meditators reported significantly better enables the learning and information processing
performance on attention tests than those who areas of the brain to function more effectively,
have never meditated, again with small to medium resulting in being able to more objectively evalu-
effects. Finally, the third meta-analysis docu- ate our situation so that we can effectively
mented a small but significant association respond. In fact, the bringing together of these
between trait mindfulness and attention across two elements—kindness and presence—is
studies (Verhaeghen, 2021). reflected in the Japanese character for mindful-
Some studies provide insights into the differ- ness which is comprised of two interactive fig-
ential impacts of mindfulness- and compassion- ures: one is presence; the other is heart or mind
based practices on brain structure and function (Santorelli, 1999). Therefore, an equally accurate
translation of mindfulness is heartfulness findings emerged. Firstly, each kindness group

(Shapiro & Schwartz, 2000). This underscores demonstrated a significant increase in happiness
the importance of cultivating and including open- and well-being compared to the control, and the
hearted qualities during the practice of mindful- number of kind acts was positively correlated
ness. It is important to note that this “attitude” of with happiness. This further substantiates the
kindness is central to the practice of MSC. benefits of kindness found by previous research.
Secondly, no significant difference was identified
One misconception in the current mindfulness between kindness groups. In other words, direct-
“revolution” is that it often neglects this impor- ing kindness toward oneself was just as beneficial
tant pillar of attitude (Shapiro, 2020). People as directing kindness toward others (Rowland &
often think of “kindness” as a side note, or, worse, Curry, 2019).
they mistakenly believe it will make them soft An attitude of kindness and self-kindness has
and cause them to lose their edge. However, the also been found to support personal performance
opposite is true; an attitude of kindness and curi- and motivation levels. In one report, researchers
osity is directly linked to performance and well- conducted two studies to measure the effective-
being (Hanson et al., 2021). In support of this ness of a lovingkindness meditation (LKM)
assertion, research has found that an attitude of training program on motivational states (Masters-
kindness may elicit and strengthen positive well- Waage et al., 2021). Using a randomized con-
being. Symeonidou et al. (2019) examined the trolled trial, the first study split participants into
effects of participant kindness on their subjective three groups (LKM, general mindfulness, and
well-being. Participants were asked to keep a waitlist control). After completion of the pro-
daily record of their kind actions for a week, gram, analysis revealed longitudinal increases in
while those in the control condition were asked to affect and motivation for those in the LKM inter-
simply record their typical daily actions. vention when compared to general mindfulness
Measurements of subjective well-being were and the control condition. Further, the second
administered pre, post, and at 1- and 2-month study reported on a weeklong study to identify
follow-ups. A significant small-to-medium posi- the effects of LKM on workplace motivation.
tive correlation was found between the number of Participants were split into three groups (LKM,
kind actions undertaken and participant well- formal meditation practice, and informal mind-
being (Symeonidou et al., 2019). What is more, fulness practice). Each of these groups was
those in the kindness intervention showed instructed to actively practice mindfulness, but
increases in well-being during follow-up mea- the LKM group was explicitly directed to prac-
surements. This suggests that well-being is not tice kindness toward themselves and others.
static and can be positively infused through self- Researchers found that those in the LKM condi-
recognition of one’s kindness. tion reported increased daily motivation levels
Additionally, research has found similarly after meditation practice. While workplace per-
promising results for those who also practice formance was not significantly different between
self-kindness. Rowland and Curry (2019) con- groups, this research provides evidence for the
ducted a randomized and blind study to deter- efficacy of multiple meditation practices, both
mine the effect of numerous kindness formal and informal (Masters-Waage et al.,
interventions. Participants were split into four 2021).
kindness groups as well as a control group. Each Establishing an attitude of kindness and curi-
group directed kindness to a different receiver osity toward our inner experience is not sugar-
(family and friends, strangers, self, or observa- coating our emotions or trying to suppress or
tional), except for those in the control who were change them, but rather allowing us to experience
not directly instructed to engage in acts of kind- our emotions in a safe and courageous way. An
ness. After pre and post measurements for happi- attitude of kindness and curiosity activates the
ness and well-being were analyzed, two important relaxation response in the brain, which releases
neurotransmitters such as acetylcholine, endor- on awareness of all experience, both pleasant and
phins, and oxytocin which activate the parasym- unpleasant.
pathetic branch of the autonomic system
(Uvnäs-Moberg et al., 2014; Gerritsen & Band,
2018). Rigoni et al. (2015) found that enacting an Self-Kindness Kindness is the mechanism used
attitude of kindness during a meditation practice to actively comfort and support when we are suf-
initiates a release of dopamine—one of the fering. It is important to note that we are not
brain’s neurotransmitters responsible for learning soothing ourselves to make the pain go away or
and rewards and associated with feelings of plea- as an act of avoiding the pain. Rather, we are
sure and motivation. soothing ourselves because we are suffering due
Mindfulness is the awareness that arises when to pain. The existence of pain, and the resultant
all three elements—intention, attention, and atti- experience of suffering, is the reason we call
tude—synergistically arise to meet the present upon the practice of self-compassion.
moment. This mindful awareness allows us to see Mindfulness without kindness can lead to the
the present moment clearly and respond produc- resistance of pain and inadvertently increase suf-
tively. By bringing an attitude of kindness and fering. It is necessary here to distinguish the dif-
curiosity, we can practice genuine heart- ference between pain and suffering. Pain is a part
mindfulness. This is where self-compassion and of life; it exists regardless of our reaction to it.
mindfulness overlap, and the two practices work Suffering, however, is optional and is dependent
together to improve overall well-being. on how strongly we resist the pain. This can be
explained by the equation, suffer-
ing = pain × resistance (S. Young, personal com-
Defining Self-Compassion munication, 2000). Pain is inevitable, and
suffering increases depending on the degree to
The formal definition of self-compassion is artic- which we resist pain.
ulated by Kristin Neff as a dynamic interplay of
compassionate self-responding components of In this way, mindfulness, or being aware of
mindfulness, self-kindness, and common human- pain, does not actively alleviate suffering, but
ity and uncompassionate self-responding compo- rather it makes the experiencer acutely aware of
nents of overidentification, self-judgment, and what they are feeling in relation to the pain. At
isolation (Neff, 2003). By clearly defining the times, the experiencer may realize that, in fact,
construct of self-compassion, we can more fully pain is not as persistent or intense as previously
understand the need for the explicit practice of thought, and therefore there may be some
self-compassion. The components of self- moments of alleviation of the pain. Alternatively,
compassion as defined by Neff (2003) are mind- being aware of pain with openness and curiosity
fulness, self-kindness, and common humanity. may make the experiencer more overwhelmed by
the pain when the pain is great. In either case,
Mindfulness Mindfulness is the foundation for adding self-kindness because one is in pain
self-compassion. We must have the awareness begins the process of soothing suffering.
that we are in pain before we can soothe the pain. Mindfulness facilitates awareness of the pain,
Within the construct of self-compassion, mind- while self-compassion provides the experiencer
fulness is defined as having a balanced perspec- with the opportunity to alleviate the pain. When
tive specifically when faced with challenges, practiced in this manner, self-kindness allows the
without exaggerating or evading difficult emo- experiencer to be more intimate with the pain
tions or potential negative consequences (Neff, rather than detach from it (Shapiro et al., 2006).
2003). This is contrasted with the more general Self-compassion offers an alternative coping
definition of mindful awareness, which focuses mechanism to avoidance. While it may seem
intuitive to distance ourselves from pain, research
has found that acknowledging pain with an atti- of kindness we have available for others (Gilbert
tude of kindness offers more benefit (Costa & et al., 2012, 2011). However, as was previously
Pinto-Gouveia, 2013). In a study of over 100 discussed, self-kindness has been shown to
patients with chronic pain, Costa and Pinto- increase personal motivation (Masters-Waage
Gouveia (2013) analyzed the relationship et al., 2022). Additionally, those who practice
between experiential avoidance, self-compassion, self-kindness have been found to be more emo-
and psychological distress. Hierarchical regres- tionally available to offer kindness to others
sions were conducted after self-report measures (Waytz & Hofmann, 2020; Hashem & Zeinoun,
were completed, and the results speak to the ben- 2020).
efits of self-compassion in times of suffering. A Waytz and Hofmann (2020) examined the
significant positive correlation was identified prosocial benefits of self-kindness in comparison
between patients who practiced avoidance and with kindness shown toward others. In a random-
psychological distress (depression, anxiety, and ized study, participants were separated into three
stress). Alternatively, those who engaged in self- distinct groups to perform one of three kindness-
compassion and approached their pain with kind- related activities. The first group was tasked with
ness showed significantly less psychological acting out kindness, such as donating to charity
distress (Costa & Pinto-Gouveia, 2013). Despite or helping a coworker. The second group was
seeming contradictory, when an attitude of self- asked to think moral thoughts, such as hoping for
kindness is present, being with physical pain someone’s success or thinking kindly about a
decreases overall suffering, while detachment friend. The final group was tasked with engaging
from pain may lead to increased psychological in acts of self-kindness, for example, taking time
suffering. to relax, making a nice meal, or speaking to
Of course, being kind to oneself in the face of themselves with nonjudgment. All groups dem-
suffering can be challenging, and it may even feel onstrated an increase in well-being, gratitude,
contradictory to our nature. When things go and elevation (feeling inspired to spread kind-
wrong, we often try to suppress the pain, berate ness). Interestingly, however, the researchers
ourselves, or leap into problem-solving mode. found that those who practiced self-kindness
Whether through reliance on primitive survival experienced significantly less burnout (Waytz &
instincts, or cultural influences, this is how we Hofmann, 2020). People who took the time to
often treat ourselves (Lu et al., 2021). bring kindness to themselves were less emotion-
Interestingly, we do not treat others this way; ally exhausted and therefore more available for
when friends are facing challenges, we readily others. While all forms of kindness were shown
respond with kindness and compassion. Why to lead to increased kindness toward others, self-
would we so readily offer a friend this benevo- kindness demonstrated the unique benefit of pro-
lence yet are so hesitant to extend the same com- tecting against burnout.
passion to ourselves? Further, given the These results have been replicated, with
aforementioned research and the pitfalls of researchers finding that healthcare workers who
shame, why would we not cultivate an inner envi- practice self-kindness tend to experience less
ronment that is best able to promote productive emotional exhaustion (Hashem & Zeinoun,
growth and meaningful change? 2020). While burnout was highly prevalent in the
The concept of self-kindness, particularly sample, those who measured high in self-kindness
within the practice of self-compassion, is largely demonstrated adaptive coping in times of stress
misunderstood in Western culture. Self-kindness and were readily able to help and offer kindness
is often perceived as indulgent, selfish, or permis- to patients. Thus, self-kindness has the potential
sive. The misconception asserts that directing to increase one’s desire and availability to be kind
kindness to the self is an overall weakness. to others, making it an important complement to
Primarily, the concern is that self-kindness may other-focused kindness and compassion.
result in laziness or could diminish the quantity
Common Humanity Common humanity is the use of mindfulness in other workplaces to

understanding that we are not alone in our suffer- increase employee health and overall perfor-
ing. When we struggle, we often feel that this is mance (Good et al., 2016). For example, mind-
“my” personal problem and that we are the “only fulness programs have been utilized in the
one” suffering. This way of perceiving leads to military, and findings have demonstrated that
the conclusion that we are alone in our pain, mak- mindfulness programs help soldiers make wiser
ing us feel isolated and separate. Understanding choices during high-stress situations (Jha et al.,
that suffering is part of the human experience 2015). In another example, mindfulness pro-
allows us to not feel isolated from others, and we grams have been shown to result in a decrease of
may experience an easing of a sense of despair. post-traumatic stress symptoms while increasing
By reframing our relationship to suffering in resiliency among veterans (Davis et al., 2019).
terms of a common human experience, we are
more able to be in touch with the pain of the pres-
ent moment. We are able to see suffering not as a Benefits of Self-Compassion Training The
result of something that we have done wrong, for practice of self-compassion—cultivated and
example, but as a fundamental and shared aspect taught through various inductions, short pro-
of life. It is important to note that although com- grams, as well as eight-session established train-
mon humanity and interdependence are founda- ing programs such as Mindful Self-Compassion
tional themes in mindfulness practice, they are developed by Neff and Germer (2013)—has
not explicitly included in the instructions of demonstrated positive outcomes in a vast array of
mindfulness practice, another important distinc- domains, including depression, eating behavior,
tion between self-compassion and mindfulness anxiety, stress, and self-criticism (Ferrari et al.,
practice. 2019). Current research has found comparable
benefits to mindfulness practice, with an addi-
tional focus on benefits that are specifically tar-
nique and Overlapping Benefits
U geted by self-compassion practice, such as
of Mindfulness and Self-Compassion increased self-worth and psychological well-
being (Neff et al., 2005; Baer et al., 2012; Dundas
Decades of research demonstrate the link between et al., 2017).
mindfulness practice and better mental health
and overall well-being, including psychological, Research shows that self-compassion inter-
cognitive, and physical domains (Shapiro & ventions are beneficial, leading to significant
Walsh, 2003), for both clinical and nonclinical improvements in rumination, stress, self-
populations (Donald et al., 2019; Fjorback et al., criticism, and anxiety (Ferrari et al., 2019) and
2011; Ni et al., 2020; Lomas et al., 2018). For there are certain populations for whom this con-
example, mindfulness has been shown to increase sideration could be especially important.
a sense of meaning and life satisfaction (LeBlanc Researchers have found that a lack of self-
et al., 2021; Aşık & Albayrak, 2021), aid in cre- compassion may be a factor of vulnerability for
ativity and problem solving (Henriksen et al., developing symptoms of depression (Krieger
2020), and improve sleep and chronic pain et al., 2016) and could possibly predict psycho-
(Doorley et al., 2021). pathology, such as anxiety and depression
(MacBeth & Gumley, 2012). Self-compassion
Benefits of Mindfulness Training In health- has been shown to elicit adaptive coping skills
care, mindfulness interventions have shown a (emotion regulation, acceptance, and self-
decrease in healthcare worker stress as well as an soothing) and could act as both a preventative
overall increase in well-being and positive patient defense to psychopathology and a mediator to
evaluations (Lomas et al., 2018; Irving et al., recovery (Finlay-Jones, 2017). Regarding the lat-
2009). Likewise, research has exemplified the ter, populations that lack self-compassion may
considerably benefit from direct self-compassion suffering and is therefore the foundation of self-
training. For example, individuals who are overly compassion. Self-compassion entails the ability
harsh and critical toward themselves seem to to be aware of suffering (mindfulness), be kind to
benefit more from explicit self-compassion train- yourself in the face of this suffering (self-
ing (Rudaz et al., 2019). Due to intense feelings kindness), and recognize that you’re not alone in
of shame, guilt, and unworthiness that individu- your suffering (common humanity). Without the
als with anxiety, depression, and PTSD face, awareness that mindfulness brings, it is difficult
mindfulness practice may be difficult, and begin- to clearly discern one’s emotional needs and is
ning practice with self-compassion may be more therefore impossible to engage in self-
accessible (Van Dam et al., 2010). In people who compassion, as self-compassion practice
are highly self-critical, mindfulness practice may responds to the question “What do I need?”
inadvertently deepen the pathways of self- Mindfulness provides the nonjudgmental “wit-
criticism, and explicitly beginning with self- ness state” of consciousness that helps us see our
compassion may be a more effective way to suffering clearly. This provides the opportunity to
intervene (Gilbert & Procter, 2006; Smeets et al., choose to comfort and meet suffering with kind-
2014). ness instead of succumbing to habitual reactions
of shame or avoidance.
Similarly, self-compassion is integral to the
Mechanisms of Mindfulness nonjudgmental component of mindfulness.
and Self-Compassion Mindfulness allows us to discern the present
moment with clarity, while self-compassion pro-
One fundamental factor that relates to how both vides us with the resources to respond with kind-
mindfulness and self-compassion practice ness. When suffering arises, the need for explicit
achieve positive outcomes is that both these prac- self-compassion practice is discerned through
tices depend on neuroplasticity, that is, that our our mindful awareness. In this way, mindfulness
brain structure can be modified through repeated and self-compassion can work synergistically to
practice. Neuroplasticity refers to the way that strength and inform each practice. In summary,
the brain and other aspects of the nervous system while mindfulness and self-compassion overlap,
can change in structure and function in response they are two distinct constructs that work together
to internal and external stimuli (Cramer et al., to support the experiencer during times of suffer-
2011). Contrary to previously held beliefs in neu- ing. Mindfulness provides the clarity of mind to
roscience, brain development does not stop at a recognize the experience of suffering and
certain age with recent findings demonstrating approach it with an attitude of nonjudgment.
that the brain can change both structurally and Self-compassion focuses explicitly on the experi-
functionally across the entire lifespan (Toricelli encer’s reaction to themselves, promoting an
et al., 2021). Neuroplasticity affirms this capacity active role of kindness and ameliorating feelings
for the brain to continue to adapt and grow of isolation due to an understanding of common
(Grafman, 2000; Voss et al., 2017). humanity.
Research also suggests that self-compassion is
an integral component of mindfulness, and great
hen Mindfulness and Self-
W success has been observed by implementing
Compassion Meet explicit self-compassion practice with a founda-
tion of mindfulness (Neff & Germer, 2013).
Available evidence suggests that self-compassion Although it is a distinct practice, self-compassion
and mindfulness are overlapping constructs builds the quality of kindness, which is essential
which complement each other (Bluth & Blanton, to the attitude component of mindfulness prac-
2013). At the most basic level, mindfulness sup- tice. In fact, some studies suggest that self-
ports the present-moment awareness that we are compassion is the key mechanism through which
mindfulness interventions achieve outcomes Methodologically, there is a need for much

(Kuyken et al., 2010; Rowe et al., 2016; Galla, greater care in the design of studies. This includes
2016, 2017). Two studies conducted with adoles- such elements as grounding research in theory to
cent participants during weeklong mindfulness guide the development of research expectations;
meditation retreats reported that while both selecting participants in a way that ensures suffi-
mindfulness and self-compassion increased well- cient power and generalizability of findings and/
being, within-person changes in self-compassion or allows for detailed examination of theoreti-
predicted beneficial outcomes more constantly cally relevant mechanisms, processes, and out-
than within-person changes in mindfulness comes; utilizing study designs that permit the
(Galla, 2016, 2017). These findings indicate the examination of changes and effects both cross-
importance of self-compassion as a potential way sectionally and longitudinally; and resisting the
in which mindfulness achieves beneficial tendency of over-relying on a single methodol-
outcomes. ogy (e.g., self-report measures, translational
While mindfulness training teaches the impor- imaging technologies).
tance of observing nonjudgmentally, it does not Rigorously designed RCTs with large sample
explicitly provide an active way to provide com- sizes and diverse populations are needed to eluci-
fort to oneself when pain is encountered. It date the potential of combining mindfulness and
assumes that when observing painful experi- self-compassion practices. In particular, there is
ences, thoughts, or emotions nonjudgmentally, very little research on young kids, and future
compassion for the self will naturally emerge, work needs to be done in both clinical and non-
and does so for many practitioners. However, clinical youth. Finally, future research needs to
perhaps due to the extensive messaging that we determine how to best integrate these practices
get from our culture about not being “good into complimentary interventions, to produce
enough,” many are challenged with accessing positive synergistic benefits. The collaboration of
compassion for the self, and explicit self- mindfulness and self-compassion intervention is
compassion practice can be enormously helpful. still in its infancy, yet it seems clear that if han-
Teaching self-compassion explicitly provides dled skillfully, this integration may prove enrich-
participants with tools so that they can learn to be ing for both, enabling them to become partners in
kind to themselves in a more direct way. As the the understanding, healing, and enhancement of
behavior of supporting oneself is practiced, neu- the human mind and heart.
ronal pathways are established and being self-
compassionate becomes more of a habit.
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To Be Compassionate and Feel
Worthy: The Bidirectional 3
Relationship Between
Self-Compassion and Self-Esteem
Madeleine I. Fraser, Joseph Ciarrochi,

Baljinder K. Sahdra, and Caroline Hunt
Introduction case that many internal psychological barriers to

self-compassion are related to a belief of being
Some appear to easily adopt a self-compassionate unworthy of such compassion. It is of interest to
way of relating to themselves, that is, they can both self-compassion researchers and clinicians
extend to themselves the same supportive kind- to better understand how these constructs interact
ness as they would a good friend. However, many and relate to each other.
more appear to be more likely to be resistant to Self-compassion and self-esteem are interre-
accepting the rationale for self-compassion, for lated constructs. Self-compassion refers to a ten-
example, “it sounds nice, but it’s not for me,” or dency to relate to oneself with unconditional
they may engage with self-compassion on a support and a desire to help, rather than be self-
superficial level, for example, “I’m hard on critical (Gilbert, 2014; Neff, 2003a). Relatedly,
myself only when I need to be.” Measuring and self-esteem generally refers to global appraisal of
understanding concerns about self-compassion one’s self-worth that is positive (Rosenberg,
and a reluctance to adopt this framework are not 1965a, b; Rosenberg et al., 1995). When both
new; indeed, there is a validated measure of fears constructs are high in an individual, they are
of compassion (Gilbert et al., 2011). What has likely to present in a similar fashion. Illustratively,
been less closely examined is the potential rela- a psychological flourishing individual, that is,
tionship between difficulties embracing self- someone who engages in a rich, meaningful, and
compassion and a lack of self-esteem or sense of value-driven life (Ryan & Deci, 2000), is likely
self-acceptance and self-worth. It may be the to be high in both self-compassion and self-
esteem. They can be psychologically flexible and
acknowledge and address their own needs with
M. I. Fraser (*) kindness and respect. In addition, they hold a
School of Behavioural Health Sciences, Australian generally positive global view of their identity
Catholic University – Strathfield Campus,
Strathfield, NSW, Australia and sense of self while also acknowledging and
e-mail: [email protected] accepting imperfections that make them human.
J. Ciarrochi · B. K. Sahdra Clients seeking psychological support are likely
Institute of Positive Psychology and Education, to present to therapy with low self-compassion
Australian Catholic University – North Sydney and low self-esteem. They may treat themselves
Campus, North Sydney, NSW, Australia with harsh self-criticism and be uncomfortable
C. Hunt with or even despise the person they see them-
School of Psychology, University of Sydney, selves to be. In these clients, the subtle d ifferences
Camperdown, NSW, Australia

https://doi.org/10.1007/978-3-031-22348-8_3
34 M. I. Fraser et al.
and relationships between self-compassion and of the definition is a judgment of self-worth and
self-esteem become important and raise several self-acceptance (Kernis, 2002; Eromo & Levy,
questions. Is there a difference between self- 2017; Deci & Ryan, 1995; Rosenberg 1965a, b).
compassion and self-esteem? Is one construct Thus, the self-esteem construct is an affectively
more important than the other? Should these con- laden self-evaluation (Leary & Tangney, 2003),
structs be treated as identical and targeted based on one’s own values, attributes, and accom-
together through intervention? Does improving plishments. Self-esteem has conceptual similari-
one construct through psychological intervention ties to constructs such as self-worth or positive
naturally lead to improvement in the other? self-regard. Self-esteem is generally conceptual-
While much about the relationship between ized as a global or trait construct (i.e., people’s
self-
compassion and self-esteem remains general evaluations of their self-worth), a state
unknown, a growing body of research offers construct (i.e., more temporary feelings of self-
valuable clinical and research insights. esteem), or a domain-specific self-evaluation
This chapter seeks to summarize what is cur- (i.e., the way that people appraise their perfor-
rently known about these constructs, why they mance or worth in a particular domain) (Brown
are important, and the nature of their interactive & Marshall, 2006). Further, it has also been pro-
relationship with each other. Specifically, we posed that self-esteem can be conceptualized
explore different versions of self-esteem and how both as a belief and as a motive (also referred to
they interact with self-compassion. This chapter as conscious and nonconscious self-esteem;
will draw together and review a diverse body of Epstein, 2006), with research demonstrating that
studies which has examined self-compassion and humans are motivated to create and maintain a
self-esteem constructs as targets for psychologi- positive self-image across the lifespan (James,
cal intervention. As a result, we will propose that1890; Macdonald, 1994).
intrinsic self-esteem has a bidirectional relation- A considerable body of research supports the
ship with self-compassion. Thus, a sense of self- psychological benefits of maintaining high self-
worth and self-acceptance (intrinsic self-esteem) esteem. Theorists have proposed that high self-
influences our capacity to relate to oneself with esteem may serve several functions, such as
compassion and a motivation to help, not harm maintaining well-being and positive affect, pro-
(self-compassion), and visa-versa. Extending this viding feedback about coping efforts, reflecting
description of a bidirectional relationship, this status in social hierarchies, facilitating self-
chapter will also propose the two constructs can determination, and providing vital information
be thought of as being in an interactive network, about eligibility for social inclusion and exclu-
with their relationship being highly idiosyncratic sion (Leary & MacDonald, 2003). High self-
and dependent on the individual and context. The esteem is consistently linked with healthy
implications of the available evidence and some functioning (Leary, 1999) and a range of positive
directions for future research will be discussed. psychological constructs, such as coping with
emotional stressors and encouraging develop-
ment of one’s skills and capacities (Pyszczynski
Self-Esteem: Definition, et al., 2004). Conversely, low self-esteem pre-
Consequences, and Measurement dicts psychopathology symptoms (Zeigler-Hill,
2011), including loneliness (Brighi et al., 2012),
Historically, researchers and practitioners have peer rejection (Ammerman et al., 1993), and sui-
argued almost universally for the value of self- cide ideation (Harter, 1993). Furthermore, low
esteem to psychological well-being (Lyubomirsky self-esteem has also been consistently linked
et al., 2006), yet there remains controversy in with poor health behaviors such as cigarette
how the construct is defined (Levy, 2019; Eromo smoking during adolescence (Carters & Byrne,
& Levy, 2017). While self-esteem is generally 2013) and illicit substance use (Donnelly et al.,
regarded as a multifaceted construct, at the core 2008). The apparent benefits of having high
3 To Be Compassionate and Feel Worthy: The Bidirectional Relationship Between Self-Compassion… 35
self-esteem have led to the development of tar- comparison with others, successful performance,
geted psychological interventions, particularly in and perceived success. Contingent self-esteem is
schools (Dalgas-Pelish, 2006; Lai et al., 2009; a form of self-esteem which emphasizes this
Thijs & Verkuyten, 2017). problem. Contingent self-esteem refers to the
Despite the documented benefits of self- degree that one feels accomplished and worth-
esteem, there also appear to be costs to pursuing while in relation to others (Harter, 1999) and
high self-esteem. Crocker and Park (2004a) involves making a judgment of one’s place in a
reviewed some of the detrimental effects of pur- social hierarchy. For example, “I have worth,
suing high self-esteem, including heightened because I am better than you.” Contingent self-
negative emotions such as shame and sadness esteem also involves evaluation of how one is
when failure is encountered, anxiety at having to perceived by others. Accordingly, those who pur-
“prove” one’s self-esteem, and engaging in activ- sue contingent self-esteem may be preoccupied
ities that boost self-esteem yet are ultimately with others’ opinions and may experience inse-
self-defeating (e.g., negative gossip, self- curity or worthlessness when others’ views of
deception). Kernis (2003) explains that high self- them are unfavorable (Deci & Ryan, 1995).
esteem can be damaging for one’s mental health Contingent self-esteem is also referred to as frag-
if characterized by defensiveness, contingence on ile or unstable self-esteem because feelings of
performance, and instability. Illustratively, high self-worth may fluctuate markedly depending on
self-esteem may involve positive feelings of self- whether or not one is successful and on the feed-
worth; however, these feelings may also be frag- back received by others. Furthermore, to create a
ile and highly vulnerable to the environmental favorable comparison, people with high contin-
context. Engaging in such self-esteem boosting gent self-esteem may engage in belittling others
behavior results in interference with activities (Crocker et al., 1987), defending against negative
that satisfy the needs for competence, related- feedback (Fitch, 1970), and convincing them-
ness, and autonomy that are considered core to selves that they are entitled to special treatment.
well-being (Ryan & Brown, 2003). Ryan and In other words, contingent self-esteem can result
Brown (2003) explain that the pursuit of high in a “zero-sum game” whereby some win and
self-esteem often leads to behavior which the others lose.
individual may not value but is seen as worthy by Given that contingent self-esteem is based on
others, thus leading to greater conformity or in judgment and comparison of self to others
some situations greater risk-taking or self- (Eromo & Levy, 2017), the social context is of
compromising choices. great importance. This constant comparison to
Different outcomes associated with self- others is problematic, as one’s sense of self-worth
esteem have led researchers to consider whether is almost entirely shaped by who is selected as
there are certain facets of self-esteem that are the comparator. For example, a student attending
more adaptive than others (Crocker et al., 2003; school X has put in great effort and produced a
Kernis, 2003; Kernis et al., 1993). This had led to high-quality piece of work. This same student is
the identification of several important dimen- told their grade for the work was the highest in
sions of self-esteem, such as contingent self- the class and, as a result, is likely to feel very
esteem and intrinsic self-esteem, that appear to proud of their accomplishments and experiences
have important implications for psychological high self-esteem. Let’s say that same student
well-being. completes the same work with the same effort
and receives the same grade but is attending
school Y with different students and thus is told
Contingent Self-Esteem they ranked 50th in the class. In this scenario, the
same student may be at risk of feeling less accom-
A core problem with self-esteem is the degree to plished and less proud of their work and perhaps
which one’s positive self-evaluations involve not experiencing the same bolstering effect of the
feedback on their self-esteem. This hypothetical fragile and encounters many unwanted and unin-
example illustrates that effort and the quality of tended consequences when rigidly pursued.
work produced can be almost irrelevant to self-
esteem. Instead, the comparison to other students
in one’s immediate context determines the level Intrinsic Self-Esteem
of pride and subsequent self-esteem felt. In other
words, your level of self-esteem depends on In contrast to contingent self-esteem, intrinsic
whom you are standing next to. Also referred to self-esteem refers to a form of self-evaluation
as the “big fish, little pond” effect, this tendency that is relatively independent of comparison with
for a student’s academic self-concept to be based others. For example, the statement “I am inher-
on their standing in comparison with their school ently worthwhile and deserve to be treated fairly”
peers has been measured internationally (Loyalka enables one’s sense of self-worth to be main-
et al., 2018). tained regardless of environmental context or
Threats to fragile self-esteem can trigger social comparison. This sense of self-worth is
strong defenses, as if something precious is being likely to be preserved no matter whom the person
taken. For example, attempts to protect one’s compares themselves to. Core to intrinsic self-
self-esteem when experiencing social criticism esteem is an acknowledgement of one’s inherent
may trigger arrogance or aggression (Walker & self-worth, independent to accomplishments and
Bright, 2009). In other words, a high value is comparisons to others, and resulting in self-
placed on perceived self-esteem, and threats to acceptance and self-liking (Kernis, 2002; Leary,
this are viewed as grave. Sedikides and Alicke 1999). Self-acceptance is a powerful mindset; to
(2012) further explain that we all routinely be self-accepting means to be acknowledging and
engage in self-enhancement and self-protection not merely tolerant of but also open and nonresis-
behaviors to manage threats to self-esteem. Self- tant to one’s flaws. Intrinsic self-esteem also does
enhancement encompasses efforts to maximize not incur the same costs as the pursuit of high
positive views of ourselves, for example, the self- contingent self-esteem and may serve as a helpful
serving bias involves attributing success to our and a strong predictor of psychological well-
own internal traits and attributing failures to being (Crocker & Park, 2004a, b; Ryan & Brown,
external forces such as an unfair judge, faulty 2003; Kernis, 2002).
equipment, or poor instruction. Self-protection Intrinsic self-esteem has long been acknowl-
motives refer to attempts to reduce or minimize edged as important. For example, references are
negative self-views, for example, the selective made to this concept in the philosophical argu-
self-memory bias may result in systematic fail- ments of the enlightenment period, proposing
ures to recall negative information about oneself. that all people are born equal and deserving of
Such processes which seek to preserve one’s dignity and respect (Rousseau & May, 2002).
sense of self-esteem inevitably incur a degree of Similar concepts to intrinsic self-esteem have
dishonesty or incorrect information. Yet these been studied using a range of different labels. For
same processes can, albeit superficially, maintain example, Deci and Ryan (1995) coined the term
self-esteem and thus become heavily reinforced “true self-esteem” to reflect an autonomous way
as they serve to support the pursuit of one’s goals of judging oneself which is not a result of achiev-
(Sedikides & Alicke, 2012). Such trends have led ing outcomes nor social approval. Ryan and
to lively debate in the literature questioning Brown (2003) refer to “noncontingent self-
whether the benefits of pursuing self-esteem out- esteem” as the experience of oneself as funda-
weigh the costs (Crocker & Park, 2004a, b; mentally worthy of esteem and love. Thus,
Pyszczynski & Cox, 2004). In summary, when noncontingent self-esteem serves a protective
contingent self-esteem is high, an individual may role, existing distinct from, and thus not depen-
be high functioning and experience a positive dent on, both successes and failures (Ryan &
self-view; however, this form of self-esteem is Brown, 2003). Similarly, Kernis (2003) proposes
that distinct from high self-esteem which may be peers, parents, school, and personal interests. The
fragile and defensive, “optimal self-esteem” Social Self-Esteem Scale (Ziller et al., 1969)
incorporates qualities such as genuine authentic- measures stability of self-esteem, especially
ity, stability, and noncontingent self-evaluations. when placed under strain. In contrast, the
More recently, Eromo and Levy (2017) propose a Contingencies of Self-Worth Scale (Crocker
broader conceptualization of self-appraisal, dis- et al., 2003) assesses seven sources of contingent
tinguishing between accurate and distorted self-esteem including academic, appearance,
forms. This broader proposal enables further approval from others, competition, family sup-
acknowledgement of different forms of self- port, God’s love, and virtue.
esteem across this continuum of accuracy, for The most commonly used measure of global
example, positive versus negative forms of self- self-esteem is the brief ten-item Rosenberg Self-
appraisal (which may have varying levels of Esteem Scale (Rosenberg SES; Rosenberg,
accuracy) and stable (consistent across time) or 1965a, b). The Rosenberg SES measures one’s
unstable (high fluctuation; Eromo & Levy, 2017). general feelings of self-worth as a person using
The current chapter focuses on a parsimonious items such as “On the whole, I am satisfied with
distinction between intrinsic self-esteem, a con- myself” on a four-point Likert scale from Strongly
cept encapsulating these prior definitions of other Agree to Strongly Disagree (Rosenberg, 1965a,
forms of healthy self-esteem, and more tradi- b). The Rosenberg SES measures a generalized
tional conceptualizations of contingent self- and global assessment of one’s feelings of self-
esteem, which are based on a judgment of worth as a person. A closer examination of the
self-worth based on comparison to others. ten items suggests this scale may reflect intrinsic
Intrinsic self-worth suggests that all people self-esteem rather than the comparative elements
could be considered worthwhile, thus removing of self-esteem, albeit imperfectly. Items such as
the need for a zero-sum game involving a judg- “I take a positive attitude toward myself” and
ment of better versus worst. An additional benefit “On the whole, I am satisfied with myself”
of intrinsic self-esteem is its stability. A key fea- (Rosenberg, 1965a, b) may arguably reflect a
ture of intrinsic self-esteem is stability in that sense of self-worth with reduced dependency in
sense of self-worth across time and context comparison with others or context. While there is
(Kernis, 2005). Intrinsic self-esteem is inherently no specific measure of intrinsic self-esteem,
portable and carried by the individual regardless global measures such as the Rosenberg SES may
of who may be available for social comparison or tap into a sense of self-worth that is global, non-
other feedback in the immediate social context. contingent on comparison, and enduring, which
Strong intrinsic self-esteem is more likely to more closely resembles intrinsic self-esteem than
withstand the pressures of daily life and endure contingent self-esteem.
instances of failure or shame. Thus, a review of
the literature overwhelmingly suggests there are
greater benefits and fewer harms to pursuing Self-Compassion: Definition,
intrinsic self-esteem in comparison with contin- Consequences, and Measurement
gent self-esteem for psychological well-being.
Gilbert (2009) developed a framework of “com-
passion” based on evolutionary and attachment
Measurement of Self-Esteem theory (see Chap. 4). Gilbert’s model proposes
there are three types of emotion regulation sys-
A diverse range of measures of self-esteem exist tems which constantly interact: the self-soothing,
(Blascovich & Tomaka, 1991), reflecting the safe system; the threat and protection system;
multifaceted nature of this construct. For exam- and the drive, excitement-seeking system
ple, the Self-Esteem Inventory (Coopersmith, (Gilbert, 2009, 2014). Gilbert (2009) conceptual-
1967) measures positive self-regard in four areas: izes both compassion for self and other as part of
the self-soothing, affect regulation system. The Form (SCS-SF; Raes et al., 2011). Newer ver-
threat and protection system evolved to enhance sions of this scale have also been developed for
our threat-detection abilities and to quickly mobi- specific populations including early adolescence
lize us to act with the goal of self-preservation. (SCS-Y; Neff et al., 2021) and adults diagnosed
Strong emotions linked to this system include with diabetes (SCS-D; Tanenbaum et al., 2018).
anxiety, anger, and disgust. The drive and excite- A state-based version of the scale has also been
ment system are activated when engaging in developed to capture self-compassion in the
behaviors that strive to accomplish rewards and moment, likely to be of interest in experimental
resources. Based on an evolutionary perspective, studies and when examining changes in self-
these resources can include food, alliances, sex- compassion across time (Neff et al., 2021). The
ual opportunities, achievements, and validation scale has also been translated into many different
or territories. Importantly, the self-soothing sys- languages including Japanese (SCS-J; Arimitsu,
tem is triggered during contentment, when an 2014) and Iranian (Azizi et al., 2013) and
individual is not perceiving threat or engaging in Brazilian (de Souza & Hutz, 2016).
resource-seeking. This system is associated with Research has consistently found that higher
feelings of securing, peacefulness, well-being, levels of self-compassion are robustly associated
and safety (Gilbert, 2010). with a plethora of benefits across the lifespan,
In a complementary approach, Neff (2003b) such as greater psychological well-being (Zessin
developed a framework for self-compassion et al., 2015), decreased symptoms of psychopa-
based on Buddhist concepts. This framework thology (MacBeth & Gumley, 2012; Marsh et al.,
comprises a bipolar continuum ranging from 2018), and increased health-promoting behaviors
uncompassionate to compassionate self-(Sirois et al., 2015). Furthermore, meta-analyses
responding. Compassionate self-responding have consistently found support for the efficacy
involves self-kindness or being supportive and of self-compassion-based interventions for
caring toward oneself during times of difficulty; improving psychological well-being outcomes.
common humanity, or an acknowledgement of Self-compassion-based interventions can
the imperfect nature of being human; and mind- enhance one’s ability to be self-compassionate
fulness, which in this context refers to a healthy (Kirby et al., 2017; Ferrari et al., 2019) and lead
detachment from one’s thoughts and feelings. to other beneficial psychological outcomes such
Conversely, uncompassionate self-responding as reduced anxiety and depression (Ferrari et al.,
involves self-criticism or a tendency to be harsh 2019; Kirby et al., 2017) and improvements in
and judgmental toward one’s perceived flaws; rumination, eating behaviors, mindfulness, and
isolation, or feeling separate to others and alone; life satisfaction (Ferrari et al., 2019).
and overidentification which is characterized by
feeling fused and stuck with our thoughts and
feelings, especially those which cause distress. Are Self-Compassion and Self-
Initially framed as a healthy alternative to self- Esteem Distinct Concepts?
esteem, Neff (2003b) argued that self-compassion
does not come with the same costs attached to the Self-compassion and self-esteem, particularly
pursuit of contingent self-esteem, such as the intrinsic self-esteem, are psychological con-
development of narcissistic traits, self-structs which are closely related and overlap. At
centeredness, and a lack of concern for others. high levels of self-compassion and intrinsic self-
The exponential growth in self-compassion esteem, the differences between these constructs
research has largely been unified through use of are less clear. Individuals high in both constructs
the Self-Compassion Scale (SCS), a 26-item are likely to present in a similar way: psychologi-
measure of the different facets of self-compassion cally flourishing with a sense of purpose, mean-
as conceptualized by Neff (2003a, b). Most self- ingful relationships, and a generally positive
compassion research utilizes the SCS or its Short attitude to their sense of self. Indeed, research
suggests there is a strong correlational relation- SES and SCS-SF measures, were positively mod-
ship between self-compassion and global mea- erately correlated. Neff and Vonk (2009, Study 1)
sures of self-esteem, which may more accurately surveyed a large adult community population
reflect features of intrinsic rather than contingent from the Netherlands using a battery of self-
self-esteem (Souza & Hutz, 2016; Stephenson report measures of varied psychological out-
et al., 2018; Neff & Vonk, 2009; Eller et al., 2014; comes. The authors examined correlations of the
Pohl et al., 2021; Holas et al., 2021; Thoma et al., SCS total score with different forms of self-
2021). In contrast, contingent self-esteem appears esteem in a large cross-sectional community
more likely to have a very weak relationship with sample. They found significant, positive, and
self-compassion given its outward focus on social moderate correlations between self-compassion
comparison (Eromo & Levy, 2017), fragility and global self-esteem (measured by Vonk et al.’s
(Walker & Bright, 2009), and propensity toward (2008) scale, deemed equivalent to Rosenberg
artificial self-enhancement (Sedikides & Alicke, SES), which were significantly and negatively
2012). correlated with contingent forms of self-esteem
The following section of this chapter will con- including a focus on social approval, appearance,
sider the research comparing self-compassion performance, and social comparison.
with different forms of self-esteem. We will argue Theoretically, the negative correlation between
that contingent self-esteem is not likely to be self-compassion and contingent self-esteem found
positively related to self-compassion, but intrin- in Neff and Vonk’s (2009) study can be explained
sic self-esteem (meaning an acceptance of self) is with reference to Neff’s (2003a) self-compassion
likely to have a bidirectional relationship with model. Contingent self-esteem contrasts to each
self-compassion. This section will build toward of the three components. Instead of self-kindness,
the proposal that self-compassion and intrinsic contingent self-esteem is associated with aggres-
self-esteem can be thought of as constructs con- sive competitiveness (Koivula et al., 2002);
nected in an interactive network (Ciarrochi et al., instead of mindfulness, it encourages overidentifi-
2021), with improvements in one leading to cation and fusion with one’s self-evaluation
improvements in the other, and vice versa. (Rohmann et al., 2019); and instead of common
humanity, it encourages comparison with – and
potentially devaluation of – others (Schütz &
elf-Esteem and Self-Compassion Are
S Tice, 1997) or devaluation of self (Alfasi, 2019).
Correlated According to Gilbert’s compassion model, high
levels of contingent self-esteem may also act as a
Research suggests there is a meaningful relation- barrier to self-compassion. This is because the
ship between self-compassion and global mea- competitive focus of self-esteem, based on com-
sures of self-esteem, such as the Rosenberg SES parisons to others, is likely to be related to the
(Souza & Hutz, 2016; Stephenson et al., 2018; threat and drive/excitement systems (Gilbert,
Neff & Vonk, 2009; Eller et al., 2014; Holas 2015). The drive/excitement system may encour-
et al., 2021; Thoma et al., 2021). As argued age a sense of competitiveness and focus on one’s
above, global measures of self-esteem may more place within a social hierarchy, attempting to rank
readily reflect features of intrinsic self-esteem as superior to others (Gilbert, 2015). Similarly,
than contingent self-esteem and be related to the threat system may also encourage a sense of
self-compassion. Illustratively, a study of 432 competitiveness with others: competition over
Brazilian citizens reported a moderate positive resource security or safety (Gilbert, 2015). Thus,
correlation between the Rosenberg SES and the the sense of comparison which self-esteem often
SCS (Souza & Hutz, 2016). Similarly, in a study encourages is likely to activate the systems which
involving 184 US undergraduate students, undermine one’s ability to engage in
Stephenson et al. (2018) found that self-esteem self-
compassion and activate the self-soothing
and self-compassion, using the same Rosenberg system.
Further research has examined the relation- bility, global self-esteem contingency, specific
ship between self-esteem measures and the areas of self-esteem contingency (social approval,
subscales of the SCS in more detail. Eller et al. performance, and appearance), and social com-
(2014) studied self-report data collected from parison. Self-esteem stability refers to daily fluc-
participants diagnosed with HIV across the tuations in feelings of self-worth, while global
United States, Puerto Rico, Canada, Namibia, self-esteem contingency refers to self-esteem that
China, and Thailand. The authors found a significant, is contingent on outcomes such as receiving
small, and negative correlation between higher social approval from others, performing to a high
levels of self-esteem (as measured by the standard, and having an appearance which is cul-
Rosenberg SES) and lower levels of self- turally understood to be attractive. The authors
judgment (negative subscales of the SCS) but suggest this predictive strength of self-
reported no significant correlation with self- compassion may be a result of self-compassionate
kindness (positive subscales of the SCS). Thoma individuals embracing all aspects of themselves,
et al. (2021) reported in a supplementary table the good and the unpleasant, with an open-
attached to their paper that in adults who had hearted awareness. In comparison, high self-
been maltreated as children, self-esteem (as mea- esteem may encourage a focus on the positive
sured by a German version of the Rosenberg and desirable aspects of self and an avoidance of
SES) did not significantly correlate with the self- the undesirable. The exception to this was narcis-
kindness nor self-judgment subscales of the SCS sism, which was predicted by global self-esteem
(German translation) but positively correlated but not self-compassion, potentially supporting
with the Common Humanity and Overidentified the argument that pursuing and maintaining self-
subscales and negatively correlated with Isolation esteem may incur unwanted consequences such
and Mindfulness subscales. Taken together, such as extreme self-involvement. Yet in further analy-
cross-sectional research suggests that although ses, Neff and Vonk (2009, Study 2) found self-
self-compassion and self-esteem are related, cor- compassion and self-esteem were equivalent
relations across different measures and subscales predictors of positive mood states including hap-
tend to vary, suggesting these constructs are dis- piness, optimism, and positive affect.
tinct from each other. Authenticity refers to a sense of alignment
with one’s true or genuine self and is a construct
of interest because it is associated with greater
Self-Compassion and Self-Esteem psychological well-being, life satisfaction, and
Differentially Predict Outcomes positive affect (Kernis & Goldman, 2006; Toor &
Ofori, 2009). Across five studies, Zhang et al.
Self-compassion and intrinsic self-esteem are (2019) found self-compassion was a stronger
significantly correlated and may be considered predictor of authenticity than self-esteem. Zhang
related constructs (Souza & Hutz, 2016; Neff & et al. (2019) found a positive correlation between
Vonk, 2009; Eller et al., 2014; Thoma et al., self-compassion (measured by the SCS-SF) and
2021), yet clearer differences between these con- authenticity when controlling for self-esteem in
structs emerge when we examine research find- university students (measured by Rosenberg
ings about their predictive relationship with other SES; Study 1), which was replicated using a daily
psychological outcomes. Some studies support diary method of data collection to test the eco-
self-compassion as a more stable predictor of logical validity of the finding (Study 2). Study 3
self-worth (Neff & Vonk, 2009) and authenticity experimentally induced a state of self-compassion
(Zhang et al., 2019) than self-esteem. Further in participants and found this resulted in higher
analyses reported by Neff and Vonk (2009, Study self-reported authenticity than a self-esteem con-
1) found self-compassion had a stronger predic- dition and a control group. This predictive
tive relationship compared to global self-esteem relationship was further replicated across Iranian,
with several outcomes including self-esteem sta- Malaysian, Turkish, and American populations
and longitudinally (Study 4 and 5). Study 4 and the older population assessed by the study, the
Study 5 also found the link between self- nature of the challenges they faced as children, a
compassion and authenticity could be explained result of the method of retrospective data collec-
by reductions in fear of negative evaluation and tion, or a genuine reflection of the importance of
heightened optimism. Taken together, this cumu- self-esteem over self-compassion. Thus, although
lative series of studies demonstrates that self- some research found self-esteem a stronger pre-
compassion is a stronger predictor of authenticity, dictor of mental health symptoms compared to
over and above self-esteem (Zhang et al., 2019). self-compassion (Thoma et al., 2021), a larger
Additionally, some studies have found that body of research supports self-compassion as a
self-compassion shares stronger associations stronger predictor over self-esteem for a range of
with mental health outcomes than self-esteem. psychological outcomes. Such outcomes are
For example, for males living with a positive HIV diverse and include self-worth (Neff & Vonk,
status, uncompassionate self-responding as mea- 2009), authenticity (Zhang et al., 2019), depres-
sured by the SCS (all negative items summed to sion (Eller et al., 2014), and BPD symptoms
create a composite score) was a stronger predic- (Pohl et al., 2021).
tor of depression symptoms than self-esteem,
self-efficacy, HIV symptoms, and demographic
variables (Eller et al., 2014). Pohl et al. (2021) elf-Compassion May Mediate
S
examined self-compassion and self-esteem in the Beneficial Impact of Self-Esteem
adults with borderline personality disorder (BPD)
who had experienced childhood trauma. In this Neff (2003b) acknowledged there are benefits
group, self-compassion moderated the positive that come with high self-esteem, however, at
correlation between childhood trauma and BPD times individuals can use unhealthy methods to
symptom severity, but self-esteem did not. These obtain it, and that self-esteem may have unhealthy
findings suggest that higher self-compassion may consequences. Neff (2003b) proposed that self-
weaken or reduce the negative psychological compassion can overcome many of the shortcom-
consequences of childhood trauma, but self- ings associated with the pursuit of self-esteem.
esteem does not offer the same protection. In For example, the pursuit of high self-esteem may
addition, Stephenson et al. (2018) found that self- lead to an inflated sense of self which seeks to
esteem did not predict irrational beliefs, such as artificially elevate oneself and disparage others
unrealistic personal standards, after accounting (since one’s value is defined in relation to others).
for level of self-compassion, thus suggesting that Such elevated self-esteem may leave one to be
many benefits of having high self-esteem can be underprepared for times of struggle or failure and
accounted for by self-compassion. unable to have empathy for others. In contrast,
In contrast, a smaller number of studies have self-compassion is not contingent on such artifi-
found support for self-esteem as a stronger pre- cial judgments. Instead, core to the self-
dictor of psychological well-being outcomes, compassion model is an acknowledgement of the
over and above self-compassion. One such study, natural imperfections and failings of common
Thoma et al. (2021) found that self-esteem, but humanity, encouraging compassion to these
not self-compassion, mediated the effect of child- aspects of ourselves rather than using denial or
hood abuse on mental health. Of note, this study suppression to avoid them. Thus, self-compassion
was based on a sample of Swiss older adults may be beneficial for individuals with high self-
(mean age 70 years) who were identified as hav- esteem as they not only have a positive sense of
ing been affected by compulsory child welfare self-worth, but this is based on a more grounded
services as children, and the data were collected and realistic acceptance of the imperfections of
retrospectively. It is not clear why this study dif- being human. Such individuals may also be bet-
fers in finding support for self-esteem over ter equipped to cope in times of error or
self-compassion. Potential explanations include
embarrassment, being open and accepting to verbal analogy test. As anticipated, those who
one’s flaws while retaining a sense of self-worth. received the self-compassion induction did not
A recent study which empirically supports the perform poorly on the test after exposure to the
notion that self-compassion may explain the ben- threat. Those who received the threat and did
eficial impacts of self-esteem, especially intrinsic not receive the self-compassion induction had a
self-esteem, was conducted by Holas et al. much poorer performance on the difficult test.
(2021). The authors found a moderately strong This experiment supports the role of self-com-
and significant correlation between self-passion in serving as a buffer against threat
compassion (SCS total score) and self-esteem effects on performance.
(Rosenberg SES) in socially anxious adults.
While low self-compassion and low self-esteem
significantly predicted more problematic anxiety A Comparison of Self-Compassion
symptoms, self-esteem was a stronger predictor and Self-Esteem Focused
compared to self-compassion. In addition, self- Interventions
compassion partially mediated the relationship
between self-esteem and social anxiety. The The nature and effects of self-compassion and
authors interpret these findings to suggest that self-esteem are further explored in experimental
self-compassion can buffer the negative effects of trials which compare psychological interventions
contingent features of self-esteem, such as a developed to target these constructs. Most such
sense of self-worth contingent on competition studies have focused on similar outcomes (body
and appearance. In other words, the presence of image related concerns) and adopt a similar psy-
self-compassion contributes protective features chological intervention (brief writing tasks).
to one’s sense of self-worth. Based on these find- Understanding how self-compassion- and self-
ings, Holas et al. (2021) propose that self- esteem-based interventions compare in their
compassion may involve additional benefits over effectiveness and whether there are meaningful
self-esteem such as facilitating a more balanced differences provides valuable insight to the nature
and rational stance toward life adversities, result- and effects of these constructs. A recent meta-
ing in less unhelpful anxiety and greater accep- analysis of CFT and other compassion-based
tance that imperfections are part of being human. interventions (k = 8) found that, notwithstanding
Convergent findings by DeLury and Poulin considerable heterogeneity, these interventions
(2018) suggest that self-compassion buffers the had a medium positive effect on self-esteem
effect of a self-esteem threat on academic task (Thomason & Moghaddam, 2021). This meta-
performance. The authors conducted an experi- analysis noted that brief self-compassion-based
ment where first year psychology students were interventions tended to show little improvement
randomly allocated to a self-esteem threat, in self-esteem or reported large confidence inter-
where participants were asked to write in detail vals indicating poor reliability. Thomason and
about a negative academic event in their past Moghaddam (2021) propose these results reflect
that caused shame or to describe their travel to the need for sufficient time within an intervention
campus that morning (control). Subsequently, (at least 20 hours) to overcome discomfort and
participants were randomly allocated to a neu- distress reactions to self-compassion, especially
tral writing task or a self-compassion writing when early childhood experiences may lack the
task. The self-compassion task prompted par- opportunity to develop a soothing emotion regu-
ticipants to consider that everyone has experi- lation system. The small number of studies
enced something similar (common humanity), included in the review calls for further research in
consider how they’d treat a friend in the same this area to consolidate and extend on these
situation (kindness), and describe triggered promising findings. To the best of our knowledge,
emotions in an accepting fashion (acceptance). there has not yet been a review of the effective-
Finally, all participants completed a difficult
ness of self-esteem-based interventions for self- participant to a self-compassion, self-esteem, or

compassion outcomes. control writing group. The self-compassion
Several papers compare the effectiveness of group was given writing prompts that were
self-compassion- and self-esteem-based inter- designed to encourage the core elements of self-
ventions. Moffitt et al. (2018) compared self- compassion. For example, to induce self-
esteem, self-compassion, and positive distraction kindness, participants were instructed “Write a
writing tasks and measured their effects on reduc- letter to yourself expressing understanding, kind-
ing state body dissatisfaction. One hundred forty- ness, and concern. Write in a way you might
nine female undergraduates (mean age 22 years) express concern to a close friend who experi-
spent 15 min looking at and rating a series of 16 enced a similar event.” In comparison, the self-
magazine advertisements on a computer which esteem group was given prompts such as
featured thin, young women. This task was “Describe why an unflattering photo of yourself
designed to trigger body dissatisfaction in the does not really indicate anything about the kind
participants. Subsequently the participants were of person you are” and asked to list their compe-
asked to write a paragraph to themselves for tent characteristics. The control group was given
3 min according to instructions. They were ran- prompts about irrelevant information such as
domly allocated to one of three intervention “List the subjects you did in your final year of
groups with self-esteem, self-compassion, or high school. Which did you like or dislike and
positive distraction instructions. The self-esteem why?” After the intervention, both the self-
group was asked to write a description of their compassion and self-esteem groups showed
positive qualities such as personal attributes and higher body satisfaction than the control group.
accomplishments. The self-compassion group The benefit of self-compassion was evident in the
was asked to express kindness, compassion, and difference in body appreciation scores, which
understanding toward their weight, shape, and were higher than both the self-esteem and control
appearance. In contrast, the positive distraction groups after the intervention. These effects, how-
group acted as a control comparison and was ever, were not sustained at the 2-week follow-up
asked to write about an enjoyable hobby. As (Seekis et al., 2017). Like the findings of Moffitt
anticipated, the self-compassion group reported et al. (2018), this study provides support for the
significantly lower dissatisfaction with weight benefit of targeting self-compassion over self-
and appearance, as well as significantly higher esteem to improve body satisfaction; however,
self-improvement motivation compared to the these benefits appeared to be short term and not
self-esteem and positive distraction groups. In sustained at a 2-week follow-up.
addition, participants with high trait body dissat- Barbeau et al. (2021) also found support for
isfaction, independent of the experiment, bene- targeting self-compassion to address body appre-
fited the most from the self-compassion ciation and healthy eating in women. They ran-
intervention. Moffitt et al. (2018) concluded that domly allocated university and community
these findings provide robust support for the recruited women (mean age 29 years) to one of
effectiveness of self-compassion, over and above three writing groups; each was required to record
self-esteem interventions and controls, for body daily writing activities for 7 consecutive days.
dissatisfaction. The self-compassion and self-esteem groups
Seekis et al. (2017) used a 15-minute writing wrote a journal recount via email on a moment
task to trigger body image concerns in female over the last 24 hours when they felt self-
university students. Ninety-six female university conscious about their body, exercise, or eating
students (mean age 19 years) were asked to read habits. After this journal recount, they were given
a hypothetical scenario and imagine they were either a self-compassionate or self-esteem
the protagonists who had unflattering photos of focused prompt to reflect on the event. The same
themselves posted on social media by a friend. procedure was carried out for the control group
The researchers then randomly allocated each but focused on a particular event, not related to
self-consciousness. Comparing the three groups closures than the control condition which
after the intervention revealed the self- involved writing about the event in a nondirective
compassionate group experienced clinically sig- way. The self-compassion group had a slight
nificant changes in bulimic symptoms while the advantage in producing lengthier written
other two groups did not. responses than the self-esteem group, while there
Similarly, Albertson et al. (2015) also found was no significant difference in depth of content.
support for self-compassion training in reducing Dupasquier et al. (2020) concluded that engaging
contingent self-esteem based on appearance. in a self-compassion exercise and repairing self-
Women with body image concerns were recruited esteem are both effective in encouraging disclo-
through social media (N = 238) and randomized sure of distressing information, with
to a 3-week self-compassion meditation group self-compassion offering a slight advantage
(Mage = 38.42) or a waitlist control (Mage = 36.42). through promoting lengthier responses. Such
The intervention included access to podcasts responses allow greater opportunity for individu-
containing a 20-minute self-compassion medita- als to access social support to protect long-term
tion which participants were asked to practice psychological well-being.
once a week, such as the Compassionate Body Psychological intervention studies which
Scan and a variant of the Loving-Kindness compare self-compassion- with self-esteem-
Mediation. Participants reported practicing the based interventions consistently demonstrated
podcasts 3.6 days each week, demonstrating rea- support for self-compassion over self-esteem
sonable intervention adherence. The intervention approaches (Moffit et al., 2018; Seekis et al.,
group demonstrated significantly greater gains in 2017; Barbeau et al., 2021, Alberston et al.,
self-compassion (as measured by SCS) and 2015). There were strong commonalities between
greater reductions in contingent self-worth based these intervention studies in relation to the popu-
on appearance (CSW, Contingent Self-Worth lation studied (young, university female students)
subscale). These results were maintained at a and the outcomes targeted (related to body image
3-month follow-up, suggesting that self-concerns); therefore, it is not clear whether these
compassion practice can significantly improve findings readily generalize to other populations
appearance-based self-worth and that such effects or psychological processes. Despite these limita-
are sustained with time. tions, these intervention studies show growing
In addition to body image concerns, a willing- support for the clinical utility of self-compassion-
ness to disclose self-esteem threatening events to based interventions. Specifically, self-
others is a behavior which relates to psychologi- compassion- based writing tasks were more
cal well-being and may increase opportunity for efficacious compared to self-esteem-based writ-
an individual to receive required support or assis- ing tasks for improving body dissatisfaction, self-
tance. Dupasquier et al. (2020) found that prac- improvement motivation, and clinical symptoms
ticing self-compassion promotes the disclosure of bulimia (Barbeau et al., 2021; Moffitt et al.,
of self-esteem threatening events. Disclosing 2018; Seekis et al., 2017). In addition, self-
such information which would typically trigger compassion practice also seems to weaken con-
shame and social withdrawal is an important and tingent forms of self-esteem (Albertson et al.,
helpful behavior. Participants were asked to write 2015) and offer a slight advantage to disclosure
in detail about an event that occurred in the past of distressing information compared to self-
5 years and made them feel bad about themselves esteem (Dupasquier et al., 2020). Self-
at present. Participants were then randomly allo- compassion interventions also tend to contribute
cated to an experimental writing manipulation to improvements in self-esteem (Thomason &
that used writing prompts to promote self- Moghaddam, 2021). Such research confirms that
compassion, self-esteem, or free writing (control increasing self-compassion compared to increas-
group). The self-esteem and self-compassion ing self-esteem through psychological
conditions both led to deeper and lengthier dis-
intervention results in meaningful psychological that high levels of self-esteem in grade 9 were
differences. related to better mental health in grade 10, regard-
less of one’s level of self-compassion. Self-
compassion became important, however, when
How Self-Compassion and Self- an adolescent reported low self-esteem. In these
Esteem Interact: Longitudinal instances, low self-compassion appeared to exac-
Research erbate the negative effects of low self-esteem. In
contrast, those who were also high in self-
Longitudinal research which measures self- compassion experienced a protective buffer
compassion and self-esteem over an extended which weakened the link between low self-
time period provides further insight to the poten- esteem and subsequent poor mental health. This
tial bidirectional and causal relationship between robust study found that self-compassion and self-
these constructs. Using experience sampling via esteem have independent longitudinal effects on
mobile phone, Krieger et al. (2015) examined changes to adolescent mental health. In addition,
self-compassion and self-esteem in relation to an ability to practice self-compassion and accept
positive and negative affect over a 2-week period personal failings as normal appears to protect
in a community sample (n = 105). They found against negative self-judgments and thus weaken
that both self-compassion (using a German trans- the negative consequences of low self-esteem.
lation of the SCS) and self-esteem (a German Thus, while similar, the self-compassion con-
translation of the Rosenberg SES) were posi- struct appears to offer additional psychological
tively correlated with positive affect and nega- benefits which mitigate the harms of low
tively correlated with negative affect and self-esteem.
perceived stress. Interestingly, after controlling Examining changes in self-compassion and
for the effect of self-esteem, self-compassion self-esteem over time can also provide insight
continued to predict both positive and negative into how these constructs might engender each
affect. When the influence of self-compassion other. To explore this, Donald et al. (2018) col-
was controlled, however, self-esteem no longer lected data from 2809 Australian school students
predicted these outcomes. This longitudinal spanning 17 schools (Mage = 14.7 years,
study lends further support to the understanding SD = 0.45). Consistent with prior research
that while both self-compassion and self-esteem (Marshall et al., 2015; Krieger et al., 2015),
are helpful for cultivating good mental health, Donald et al. (2018) used the SCS-Short Form
self-compassion may have a greater effect, inde- and the Rosenberg SES. Across 4 years, from
pendent of self-esteem. In addition, the authors grade 9 to 12, students completed surveys at the
found that beneficial effects of self-esteem on same time each year. Using autoregressive cross-
positive and negative affect are largely explained lagged modeling, the study found high self-
by self-compassion. esteem consistently predicted improvement in
A pivotal study which may inform our under- self-compassion, yet self-compassion did not
standing of self-compassion and self-esteem’s predict self-esteem. These findings suggest that
bidirectional relationship was a longitudinal developmentally, self-esteem may be an anteced-
study of 2488 high school students conducted by ent of the development of self-compassion, but
Marshall et al. (2015). The authors collected self-compassion is less important as a foundation
measures of self-compassion (SCS-SF) and self- to develop self-esteem. Based on these findings,
esteem (Rosenberg SES) in grade 9 and 10 and Donald et al. (2018) suggested that a positive
measured general mental health in grade 10. The self-evaluation, or sense of self-worth, may more
authors used structural equation modeling to readily give rise to self-compassionate responses
assess how the two constructs interacted and pre- when an individual is faced with difficulty. Thus,
dicted general mental health. This study found the presence of negative self-evaluations, or a
lack of a basic sense of self-worth, may encour- matches the diagnosis. In contrast, an interactive
age the perception of self-compassion as model approach asks, based on this specific cli-
threatening and not deserved. Donald et al.
ent, their circumstances, at this stage of interven-
(2018) argue that during the vulnerable time of tion, what biopsychosocial processes should be
adolescence, the types of self-evaluations that targeted and how? Illustratively, Ciarrochi et al.
arise appear to have a critical influence on natu-(2021) use the example of a depression diagno-
rally developing a self-compassionate response. sis. Rather than conceptualizing depression as a
The longitudinal studies reviewed in this list of distinct symptoms such as depressed mood,
chapter (Donald et al., 2018; Krieger et al., 2015;
significant weight change, sleep disruption, and
Marshall et al., 2015) suggest that there is a bidi-
recurrent thoughts about death, it may be more
rectional relationship between self-esteem and helpful to think of depression as a series of pro-
self-compassion. Krieger et al. (2015) found in cesses in an interactive network. For example,
community adults that the link between self- depression may represent a cyclical interactive
esteem and mental health disappeared when con- network of hopelessness, rumination, sadness,
trolling for self-compassion. Similarly, Marshall and low behavioral activation which feeds into
et al. (2015) found that across time, adolescents and amplifies itself. This reframing as a dynamic
who were high in self-compassion were protected interactive network rather than a list of symptoms
from the poor mental health effects of low self- may be more useful for understanding the devel-
esteem, whereas Donald et al. (2018) found that opment, maintenance, and exacerbation of symp-
self-esteem predicted self-compassion in adoles- toms, in addition to formulating and sequencing a
cents, but not vice versa. Taken together, research
treatment plan.
suggests that feelings of unworthiness (low self- The interactive model also provides a useful
esteem) often lead to poor mental health, but thisframework for tailoring psychological treatment
link is weakened by high levels of self-compassion
to the needs of the individual. Continuing with
(Marshall et al., 2015; Krieger et al., 2015), while
the example of a depression diagnosis, evidence-
in other studies, self-esteem is a predictor of self-
based treatment packages for depression may
compassion but not vice versa (Donald et al., include cognitive-behavioral therapy which tar-
2018). These findings may suggest the two con- gets automatic negative thoughts and dysfunc-
structs can be thought of as being in an interactional beliefs, acceptance and commitment
tive network, the relationship between constructs therapy which targets psychological flexibility, or
changing in an interactive way across different compassion-focused therapy which develops the
individuals in different contexts. self-soothing emotion regulation system. Such
treatment packages are overlapping, often com-
plex, and target multiple processes that will influ-
The Self-Compassion and Self- ence different people in different environmental
Esteem Interaction: Application and cultural contexts differently. Adopting an
of the Interactive Network Model interactive network approach (Ciarrochi et al.,
2021) encourages clinicians to focus on pro-
This conceptualization of self-esteem and self- cesses of change which target the idiosyncratic
compassion as part of an interactive network, presentation of the individual rather than treat-
rather than distinct and entirely separate con- ment packages. Such processes of change may
structs, aligns with a bigger movement in psy- include components of these treatment packages
chology to consider mental health diagnoses and such as cognitive restructuring to target hopeless-
psychological interventions as processes rather ness, mindfulness to target rumination, emotional
than distinct packages (Ciarrochi et al., 2021). acceptance to target sadness, and behavioral acti-
Traditional psychological models tend to ask vation to target inactivation. Within the interac-
which diagnosis best fits the presenting symp- tive network model, clinicians begin with a
toms and which evidence-based treatment best detailed formulation of the processes involved in
client’s presenting problem and select processes and/or via other variables differently in different
of change to target each, rather than following a people across different contexts. The studies
treatment package and tweaking all components reviewed in this chapter indicated some variation
to fit the client. in the relationship measures between self-esteem
Applied to self-esteem and self-compassion, and self-compassion, and these differences were
an interactive network model suggests the prac- present despite analyses being conducted on
tice of self-compassion is likely to also increase larger groups of participants; no studies reported
one’s feelings of worthiness and acceptance of data or results on an individual basis. The net-
flaws or imperfections. At the same time, a sense work approach supports the need for more
of self-worth is likely to make it easier to accept person-centered and highly tailored interventions
feelings of compassion and acceptance to one- for promoting self-compassion rather than one-
self. While this reciprocal relationship has not size-fits-all treatment protocols.
directly been tested through intervention studies,
this is supported by longitudinal research (Donald
et al., 2018; Krieger et al., 2015; Marshall et al., Conclusion
2015). From a treatment perspective, intervention
research reviewed in this chapter overwhelm- The aim of this chapter was to review research
ingly supports self-compassion-based interven- which provides insight to the relationship
tions as more effective than those focused on between self-compassion and self-esteem. This
self-worth across a number of psychological out- chapter identified a version of self-esteem, intrin-
comes (Barbeau et al., 2021; Moffitt et al., 2018; sic self-esteem, which is likely to be beneficial to
Seekis et al., 2017; Albertson et al., 2015; the development and maintenance of self-
Dupasquier et al., 2020). In addition, self- compassion. Intrinsic self-esteem contrasts to
compassion interventions result in modest contingent self-esteem, which refers to a focus on
improvements in self-esteem (Thomason & thinking positively and boosting your self-worth
Moghaddam, 2021). It may be the case that the in comparison with others. Attempts to pursue or
practice of self-compassion and acceptance of maintain contingent self-esteem frequently incur
humanity’s natural flaws may intuitively encourage negative consequences and are likely to be unre-
an individual to further develop a sense of self- lated to self-compassion (Crocker et al., 1987;
worth. Yet the interactive model suggests that the Loyalka et al., 2018; Walker & Bright, 2009).
relative importance or focus on one’s self-worth This chapter has reviewed empirical research
and ability to practice self-compassion are likely which suggests that intrinsic forms of self-esteem
to be dynamic and change constantly rather than be and self-compassion are significantly correlated
fixed. Further intervention research would benefit and there is likely overlap between these con-
from examining changes in self-compassion and structs (Souza & Hutz, 2016; Neff & Vonk,
self-esteem across time and in relation to each other, 2009; Eller et al., 2014), yet there are also
particularly as longitudinal research (Donald important differences. These differences are
et al., 2018; Krieger et al., 2015; Marshall et al., reflected by findings that self-compassion is a
2015) suggests these constructs are best under- stronger predictor of psychological outcomes
stood within an interactive network. than self-esteem including a more stable predic-
A key advantage of the network approach is tor of self-worth (Neff & Vonk, 2009), authentic-
that it is naturally ideographic, i.e., it draws atten- ity (Zhang et al., 2019), and BPD symptoms
tion to the fact that different individuals may have (Pohl et al., 2021). A much smaller body of
different configurations of the network. As a research found the reverse, that self-esteem was a
result, it may not be just a matter of self- stronger predictor of mental health outcomes
compassion and self-esteem influencing each than self-compassion, specifically the effect of
other more or less similarly for most people, but involvement of child welfare services on poor
rather the two may be linked to each other directly mental health later in life (Thoma et al., 2021).
In addition, self-compassion can buffer or comparison on state self-esteem and depression.

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Self-Compassion: An Evolutionary,
Biopsychosocial, and Social 4
Mentality Approach
Paul Gilbert
recognition of suffering, understanding its univer-

Introduction sality; feeling sympathy, empathy, or concern for
those who are suffering (which we describe as
emotional resonance); tolerating the distress asso-
This chapter offers an evolutionary and biopsy- ciated with the witnessing of suffering; and moti-
chosocial approach to self-compassion. It consid- vation to act or acting to alleviate the suffering.
ers the evolution of compassion as emergent (Strauss et al., 2016, p. 25)
from mammalian caring behavior (Gilbert,
1989/2016, 2000, 2020) regulated via the evolu- A different evolutionary approach which is com-
tion of a range of human cognitive competencies plementary has been to track the phylogeny of
that enable us to reason, mentalize, and have motivations like care and compassion and iden-
mindful consciousness of consciousness (Gilbert, tify their basic if A then do B algorithm.
2019, 2020). These competencies are also the Algorithms underpin most functioning systems.
basis for self-awareness, which has positive and For example, air-conditioning systems work on
useful effects, but can also have harmful ones, the principle that if temperature goes below a cer-
such that Leary (2004) calls it “the curse of the tain level, then the air-conditioning will automat-
self.” ically turn off and if the temperature goes above a
Before exploring how compassion is applied certain level, then the air-conditioning will auto-
to “the self,” it is important to explore the concept matically turn on. All it needs is a temperature
of compassion in general because it has been detector that is linked to an output system. A
defined in different ways (Gilbert, 2017; Mascaro human body example is if temperature goes too
et al., 2020). One approach is to explore what low, we then shiver; if it goes too high, we then
clusters of psychological phenomena that charac- perspire. Behavioral algorithms for threat can be
terize compassion. In a major review of the litera- as follows: if confronted by a threat (stimulus),
ture, Strauss et al. (2016) suggest compassion is then a defensive behavior (response) becomes
made up of five components: activated and engages in fight or flight. For eat-
ing, it would be as follows: if stimulus indicates
food, then approach, salivate, and eat. If stimulus
indicates sexual opportunity, then approach and
P. Gilbert (*) engage in courting. Clearly, these motive-based
Centre for Compassion Research and Training, algorithms depend on key feature detectors that
College of Health and Social Care Research Centre, are linked into physiological systems that then
University of Derby, Derby, UK
support specific actions. For example, the amyg-
The Compassionate Mind Foundation, Derby, UK dala and sympathetic nervous system are
e-mail: [email protected]

https://doi.org/10.1007/978-3-031-22348-8_4
54 P. Gilbert
important for detecting and responding to threat. (Cassidy & Shaver, 2016). In the case of a human
Damage to the amygdala can mean that animals mother caring for her infant, she will supply
may not detect threats in their environment and/ many different resources for that infant, provid-
or not respond to them if they are detected. These ing not only for their physical needs but also for
algorithms can also be attuned through learning. their psychological developmental needs. For
In humans, the cognitive interpretation of a stim- example, she will play with her infant, share pos-
ulus can trigger the threat response (e.g., a rise in itive emotions of joy and love, encourage her
heart rate triggers fear of a heart attack). However, infant to take risks, and teach, mentor, and dem-
it is the linkage of stimulus-detector response onstrate so her infant learns life skills (Cassidy &
that is crucial to the algorithm. Shaver, 2016). In addition, parental caring
The algorithm for caring is if encountering involves mentalizing (see below) the child and
signals of distress and need then activate a range validating the child’s experiences (Luyten et al.,
of physiological systems that have evolved for 2020). In close states of connectedness, mother
caring behavior. Looked at this way, a derivative and infant can be in physiological synchrony,
of caring, compassion, can be seen to have meaning that their interactions are maturing
evolved from (among other routes; Kessler, 2020) physiological profiles that underpin the develop-
mammalian caring behavior, friendship forma- ment of compassionate motivations in the infant
tion, and concerns to make a useful contribution (Feldman, 2012; Lunkenheimer et al., 2018;
to the lives of others (Carter et al., 2017; McFarland et al., 2020). This is partly because
Mikulincer & Shaver, 2017, 2014; Gilbert, providing care and receiving care operate through
1989/2016, 2009; Gilbert & Simos, 2022; similar physiological systems; for example, oxy-
Mayseless, 2016; Goetz et al., 2010). It is useful tocin is triggered when we receive care and sup-
to be able to identify the algorithm (the stimulus port from others, but it is also a hormone that
that needs to be detected and the appropriate supports our interest in being caring (Carter,
response) of the caring motive because then we 2014). What “offspring” require from their
can identify the physiological infrastructures on mother changes significantly as they mature into
which it rests. In fact, a good deal is now known a child, proceed into adolescence, and continue
about the evolution of the physiological pro- into adulthood.
cesses of caring behavior. Especially important None of this can even begin without a preex-
ones are hormones such as oxytocin, vasopressin, isting motivation to care. In contrast, callousness
and endorphins (Brown & Brown, 2015; Carter, can be defined as a lack of motivation and an
2014; Carter et al., 2017); changes in the auto- indifference to the needs and suffering of self and
nomic nervous system, especially the vagus nerve others. Caring then involves being motivated to
(Porges, 2007, 2017); and specific neurocircuits notice; being sensitive and attuned to signals of
(Kim et al., 2020a, b; Singer & Engert, 2019). distress, need, or suffering; and then switching
Although the “if encountering signals of dis- attention to what is required to help the one being
tress and need (e.g., in offspring), then act to alle- cared for. This may be providing nutritious foods,
viate and prevent suffering and distress” appears shelter, and warmth; appropriate education; and
simple, there are many subroutines within it. For loving, playful, affectionate interactions that
example, a mammalian parent, usually the stimulate a range of psychophysiological systems
mother, must be able to identify a particular kind that are conducive to well-being. There is now
of “distress signal/call and need” to identify the considerable evidence that the caring we experi-
appropriate action that will alleviate the distress. ence in childhood has profound effects on our
The caring action may be to rescue or protect the sense of ourselves and whether we are prone to
infant, keep the infant warm, feed the infant, and, self-criticism or self-acceptance and self-
more generally, provide a secure base and safe compassion (Music, 2016; Cassidy & Shaver,
haven for the infant’s development into maturity 2016). Whether we are loved, neglected, or
4 Self-Compassion: An Evolutionary, Biopsychosocial, and Social Mentality Approach 55
harmed can have a major impact on our epigene- suffering must be part of self-compassion. Hence,
tic profiles (Cowan et al., 2016; Slavich, 2020) recognizing that smoking or drinking too much
and brain maturation (Lippard & Nemeroff, and eating the wrong foods are damaging to one’s
2020), which in turn have profound impacts on health, and changing one’s behavior, would be
the organization of motives and emotions and examples of self-compassion.
sense of self. Hence, when working clinically, This implies another key principle of compas-
helping people develop more accepting, self- sion which is that we become aware how we may
reassuring, and compassionate orientations to easily and inadvertently cause harm to ourselves
themselves may require considerable work, as and others. We can be callous in pursuing our
experiencing care and support in this way might own needs at the expense of others’ needs. For
be unfamiliar or frightening to them. This may example, we know that many children die every
also involve working through early traumas and day through lack of clean water, insufficient food,
multiple fears and resistances to compassion and poor-quality medicines, yet we spend more
(Gilbert, 2022a). money on feeding our pets and on our gardens
What the mother (i.e., care provider) must also than we do in addressing this tragedy. Vegetarians
do is to keep track of the infant’s development argue that meat eaters are callous to the suffering
and be alerted if problems are arising which will of their food. We can also show a certain callous-
require a change of action. In essence, she must ness “as indifference to the suffering we cause
be alert to signals of distress and also the signals ourselves” through our pursuit of pleasures as in
of deviation from expected developmental trajec- smoking, drinking too much alcohol, and eating
tories which indicate unmet needs. Hence, care- too many chips and pizzas. We can also be very
compassion can be defined as a sensitivity to self-harming, both literally and in the way we
suffering in self and others with a commitment to think about and treat our own minds. For exam-
try to alleviate and prevent it. In other words, ple, there is a large literature showing that harsh
whether we are talking about compassion to oth- forms of self-criticism are associated with many
ers or being compassionate to ourselves, both are forms of mental health difficulty (Werner et al.,
rooted in a motivation to pay attention to suffer- 2019; Gilbert, 2022c).
ing (not turn away from, dissociate, or deny) and Therefore, care and compassion require us to
then find the appropriate wisdom to know what to be attentive to our potential to cause harm to self
do and, if not known, then be motivated to find and others and adopt a motto of life which is
out. “may I live to be helpful not harmful to self and
The concept of prevention of suffering is others.” Helpfulness and harmfulness can also be
implicit in Buddhist definitions of compassion. applied to our mental lives, and indeed most dis-
For example, in a collection of lectures, the Dalai courses on self-compassion tend to focus on
Lama (1995) explains that compassion is the mental life. A holistic, biopsychosocial approach
motivation to try to alleviate suffering and the to self-compassion requires us to be aware that
causes of suffering in all sentient beings. Hence there are many sources of harmfulness to the self,
Gilbert and Choden (2013) highlighted that the including, for example, diet, lack of exercise,
element of prevention is essential for the full defi- overworking, and staying in toxic relationships.
nition of compassion. In addition, we highlighted This is particularly true when we recognize that
that adding the concept of prevention has signifi- our diets can have a significant impact on a whole
cant implications for how we think about com- range of physiological systems including the
passion because it requires us to be vagus nerve which plays an important role in
forward-thinking and address needs to prevent well-being and compassionate behavior (Breit
suffering in the future. When it comes to self- et al., 2018; Di Bello et al., 2020). In compassion
compassion, therefore, understanding what focused therapy (CFT) (Gilbert, 2020), mind
enables us to flourish and how to prevent future awareness is cultivated alongside body aware-
56 P. Gilbert
ness and body cultivation. Hence, some of the in the form of imagery) plays a key role in our
compassionate mind training exercises that are functioning. Sometimes we experience intrusive
part of CFT offer insight and guidance into how imagery as in trauma flashbacks, finding our-
to train/use the body to support the mind. For selves going over an argument we have had, or
example, the importance of developing vagal worrying. However, we can also knowingly and
tone, how to use breathing exercises to settle and purposely use imagery to problem solve. We can
ground the body and mind, how to use posture imagine and run “what if…” and “suppose
and exercise, and paying attention to diet which that…” and “imagine this…” simulations in our
can influence the vagal nerve have been devel- mind. We can also run imaginary simulations in
oped in compassion focused therapy (CFT) our mind deliberately to stimulate physiological
(Gilbert & Simos, 2022) and by Porges and col- systems, as in sexual fantasy. Compassion
leagues (Porges & Dana, 2018). focused visualizations take advantage of this link
between our imagined experiences and our phys-
iological responses (Gilbert & Choden, 2013).
From Caring to Compassion Together, with other competencies, these enable
us to form complex mental representations of the
Although many animals care for their young, and world. Among these representations are the rep-
at times each other, compassion is not a term we resentations we have of ourselves in relationship
would typically use to refer to these behaviors. In to others – particularly whether we are cared for,
CFT, compassion requires certain types of cogni- can contribute, and are valued. This is important,
tive competencies to direct our caring motives because these interpersonal representations play
and with knowing intentionality. These cognitive an important role in our mental well-being.
competencies have been evolving over the past Accordingly, a key component of self-compassion
few million years or so on our journey to becom- is about addressing the need for
ing Homo sapiens and have impacted how interconnectedness.
motives and emotions are activated and regu- Cognitive therapists (Beck, 1987; Beck et al.,
lated. They are also responsible for making us the 1985) highlight the importance of understanding
dominant species that we are. There are at least how people consciously reason, how they come
three types of competencies that underpin com- to the conclusions they do, and how they form
passion: nonsocial reasoning, social reasoning, expectations and derive attributions. These cog-
and consciousness of consciousness (Gilbert, nitive dimensions are extremely important for
2019, 2020, 2022b). our ability to understand suffering and needs in
self and others and, by forming mental represen-
tations in our minds, work out what is likely to be
Nonsocial Reasoning helpful, either immediately or at some point in
the future. The way we think about the nature of
Humans have evolved extraordinary competen- suffering and the causes of suffering can help us
cies for reasoning. Byrne (1995) called humans deal with suffering or can make it much worse. In
the thinking ape and more recently drew attention the Buddhist traditions, this is called the sutra of
to the evolution of insight (Byrne, 2016). Baron- the two arrows. If we are shot by an arrow, the
Cohen (2020) called us the pattern seekers, that first pain is from the arrow itself, while the sec-
is, a fundamental attribute of our intelligent mind ond is our reactions to it, of wondering how this
is to seek “if-and-then” patterns. We have evolved could have happened, who did it, and what does
competencies for language and symbol use and it mean for the future. Crucial to how we deal
thinking in time (i.e., I can act now because of with life setbacks, disappointments, and failures
what I want my future to be; study for a career). are the thoughts and feelings we have about our-
The use of internal representations (which can be selves. We may experience shame-based self-
criticism. Self-criticism is typically linked to be that good with mentalizing the mind of self or
monitoring some standard ideal or outcome we others (Baron-Cohen, 2020). The essence of
failed to achieve. Even when we are trying to be mentalization is therefore the ability to under-
“mindful,” we can have a stream of self-critical stand the nature of a mind as motivated, intend-
thoughts such as that we are not doing it cor- ing and feeling. Caring behavior is greatly
rectly, other people can do it better than us, or we advanced in humans because we can mentalize
will not be able to achieve what we want to and are able to understand both the nature of
achieve and be rejected. There is a complex rela- mental states (which can include suffering) and
tionship between the fear of failing, fear of being what will help the one who is suffering.
rejected/excluded and self-criticism (Gilbert, Importantly, self-mentalization is the ability for
2022c). We may also label ourselves as stupid, us to understand our own mental state and minds,
pathetic, and incompetent. While some people to have insight into what motivates us, and why
self-criticize because they feel they could and we feel what we feel and think what we think
should do better, others have a more pathogenic (i.e., metacognition). When helping people with
form which is of self-hatred, commonly linked to mental health problems develop self-compassion,
early abuse. While both are the opposite of self- it sometimes takes a while to help them mentalize
compassion, they require different interventions themselves and really begin to understand the
(Gilbert, 2022c). sources of their suffering. In a way, that is one of
the main functions of psychotherapy – to help
people understand their mind. Therapists have
Social Reasoning highlighted the fact that we can dissociate from
pain and deny it if and when we feel overwhelmed
Evolutionary theorists have argued that in addi- by it. Examples may be that, rather than trying to
tion to using general principles of reasoning, heal trauma memories using compassion, we try
when it comes to social relational events, we have to avoid thinking about them and dissociate from
specialist ways of reasoning. For example, how them. Rather than acknowledge that our mental
do you come to decisions about whether you are pain is causing our alcohol problems, we simply
sexually attracted to somebody and if they are deny we have a problem. Clearly, these defenses
sexually attracted to you? How do you make interfere with our capacities for self-compassion.
decisions about how dominant or controlling Self-compassion can also fail when we have not
somebody seems the first time you meet them or been able to work out what our needs are, because
if this person is somebody you would like to obviously then we can’t do what we need to do to
make friends with and cooperate with or not? sustain ourselves. We may fear compassion
Although there is clear evidence that several spe- because of the pain it touches on, or because we
cies show elements of understanding the emo- feel we do not deserve it.
tions and mind of others of their own kind (De
Waal & Preston, 2017), humans have evolved
extraordinary competencies for what is called Consciousness of Consciousness
mentalization. This is an umbrella term that cov-
ers theory of mind, empathy, perspective taking, Humans are a unique species because we can be
metacognition, and reflection (Fonagy et al., conscious that we are conscious. We not only can
2018; Kim, 2015; Luyten et al., 2020). Broader have a thought, an emotion, or a desire, but we
than empathy, mentalization also takes in our sci- can know that we are having them. We can be
entific understanding about the nature of mind mindful and observe our mind, and deliberately
which helps us to understand and think about our and purposively direct our attention to observe
minds and the minds of others. our mind. Hence, we have self-awareness which
Some people can be extremely talented at rea- comes with the desires for self-identity. Many
soning, making them excellent scientists, but not evolutionists see this as a fundamental distinction
58 P. Gilbert
between humans and other animals (Leary & Knowing Intentionality

Buttermore, 2003). It is not all for good however,
and Leary (2004) highlights how self-awareness These three competencies together give rise to
can be something of a curse because it can drive what one can call knowing intentionality. One
us to overly self-monitor, self-criticize, feel example of this is that lions can intend to chase
shame, and experience depression and suicidal down and kill their prey. However, they can’t do
thoughts and behaviors. It can also drive us to this knowingly; they don’t consciously know that
violence and other defensive and destructive they are engaged in hunting behavior or causing
behaviors when we seek to protect ourselves or suffering, they can’t do it mindfully, and they can’t
take vengeance on those who have attacked or suddenly decide that ripping the throat out of
shamed our sense of self and identity. another animal to eat it is rather callous and it
Nonetheless, self-awareness and being con- might be better to become a vegetarian. Nor can
scious of being conscious are partly what drives they decide to get up in the mornings and go cir-
compassion. For example, we can care for our cuit training on the savannahs to become better
gardens, cars, and houses, but if they become hunters. The fact that we can make these conscious
damaged in some way, we don’t have compas- choices is a game changer in our evolutionary
sion for them. Compassion is reserved for sen- story (Leary, 2004) because it means that we can
tient beings with a type of consciousness. If I choose to direct our motives deliberately and pur-
break my leg, although the pain is in my leg, I posively. This is depicted in Fig. 4.1.
don’t say my leg is suffering. I say I am suffering
because I am experiencing pain. So, compassion Complexities of Knowing Intentionality For
relates very much to the dimension of under- us to develop empathy for others, we need insight
standing the nature of conscious experiencing. into our own minds; the question is, how do we
Other animals can certainly show concern for achieve that? One mechanism is via the activity
each other; for example, there is evidence that of mirror neurons, whereby we can stimulate
rats won’t pull a lever for food if they associate it similar circuits in our brain when we observe
with a cage mate getting an electric shock (De mental states in others (Corradini & Antonietti,
Waal & Preston, 2017). However, this is far from 2013). Another important dimension of knowing
having a conscious awareness of the suffering of intentionality is awareness of what is happening
the cage mate. This awareness of conscious expe- inside our own bodies in relationship to how we
riencing is also part of mentalization and central are interacting with the environment. For exam-
for mindfulness. ple, attention has been directed to what is called
Fig. 4.1 From caring to

compassion: From
Gilbert (2018). Living
Like Crazy. (Reprinted
with permission
Annwyn House)
interoception (Arnold et al., 2019; Khalsa et al., (Gilbert, 2022c). They may also find being open
2018). Nonsocial forms of interoception relate to to the compassionate support and help of others
detecting hunger, thirst, temperature, and various difficult or hard to develop trusting friendships.
aches and pains as guides to taking action. In They may lack insight into what nourishes the
addition, we have awareness of changes in emo- mind and promotes well-being, social connected-
tional state; examples are noticing our heart rate ness, and flourishing.
increases when we become angry or anxious or
becoming aware of the feelings in the body when
we are happy. In addition, there is the question of he Competencies of Human Caring
T
how we link our body experiences when in social and Compassion
interactions. For example, in a potential argu-
ment, we can be aware of a rising heart rate and Our new brain competencies offer new ways to
facial expression changes and sense of threat that approach, activate, and cultivate compassion and
might make us cautious about how we proceed. the two basic elements of its algorithm of (1)
These different areas indicate the complexity of (stimulus) detection and engagement and (2)
self-compassion because we can’t be compas- appropriate (response) action. When using com-
sionate unless we have insight into what we are passion as a guide in therapy, these two elements
feeling, thinking, and experiencing. Hence, of compassion can be broken down into their
before some people can develop self-compassion, sub-skills that recruit our new brain competen-
it will help to have insight into the nature and tex-cies. Over the years, I have suggested six compe-
tures of the mind and their felt experience of dif- tencies for engagement and six for appropriate
ferent affective states. For example, how can I be action but only as guides (Gilbert, 2009, 2020).
compassionate to my depression if I’m dissociat- These are given in Fig. 4.2.
ing from depression or in denial? Starting our exploration at “9:00 o’clock” on
the inner circle, everything begins with concern
and care for our own or others’ well-being. To
Self-Care Versus Self-Compassion engage with the distress in ourselves or others,
we must be motivated to be present and aware
If we distinguish care and compassion in terms of rather than turning away, dissociating, engaging
suffering and having a sentient mind, then we can in denial, or being callous. Then moving around
distinguish between self-care and self-clockwise, we come to sensitivity to the signals
compassion. Self-care is the ability to understand of distress and need. This involves some degree
our needs and to address them in a way that is of mindfulness. If we are not sensitive, we may
helpful and not harmful. For example, keeping not be aware of distress. Being sensitive and
ourselves clean (basic hygiene), keeping fit, eat- noticing distress stimulate a reaction which is
ing appropriate foods, resting appropriately, not called sympathy. Sympathy is related to personal
overworking, and generally looking after our- distress and being moved by the plight of self or
selves are part of self-care. Motivation remains others (Eisenberg, 2003; Eisenberg et al., 2015).
crucial. For example, we may spend a lot of time Often, when we are engaging with distress and
in the gym not because we want to “care and look pain, this can be one of the first exit routes out of
after” our bodies but because we want to look compassion, because we can become over-
attractive or are fearful of being seen as overwhelmed and close down or pull away. Following
weight. Nonetheless, individuals can be keen to logically then, the next competency is called dis-
care for their bodies in relation to their physical tress tolerance. This is a basic skill that many
health but fail to see the same need for care when therapists seek to develop. It typically involves
it comes to their mental health. People can be gradual exposure toward what is feared or
harshly self-critical, even driving themselves into avoided, along with at times cognitive reap-
anxiety and depression in certain circumstances praisal. CFT supports these distress tolerance
60 P. Gilbert
Fig. 4.2 Domains for the therapeutic process. (Adapted from Gilbert (2009). Compassionate Mind. Reprinted with
permission from Little Brown)
interventions by teaching people how to access izing competency of insight into the conse-
grounding and soothing systems through mind- quences or harmful action. Importantly, these
fulness and breathing techniques, among others six competencies are not linear but support each
(Petrocchi & Cheli, 2019). As we develop distress other. For example, imagine how each of these
tolerance, we are likely to be able to mentalize six competencies might be affected if any of the
(Luyten et al., 2020) and empathically engage others were lost.
with the distress and suffering of self and others. The outer circle represents the action-response
Mentalization enables us to have insight into the qualities of compassion. If we go to hospital with
nature of our minds and those of others; we can a broken arm and we experience a very empathic
make sense of what is being experienced. In addi- doctor who shows all the qualities of the first
tion, empathy requires us to keep a clear bound- circle, that will not be enough to help us. We will
ary between self and others so that their pain is also want them to have the wisdom to know how
not mistaken as our pain. to fix the broken arm and take us out of pain.
The final competency in the circle is called Clearly then, intentionality and the abilities to
open non-judgment. It is open because we are not engage with suffering are not enough; we need
closing down around the nature of our own or wise action. Hence, beginning in the outer circle,
other’s suffering, and we are non-condemning. we can start by paying attention not to the suffer-
Non-judgmental does not mean simple accep- ing but to what is likely to be helpful. We can use
tance, because when we recognize distressing images and run simulations in our minds and use
feelings in ourselves, we can take steps to change our new brain reasoning competencies to think
to more helpful ones. In addition, even if we through and problem solve. Our capacities for
enable acceptance, it does not mean that the reasoning will also be linked to the knowledge
actions associated with certain brain states are we have about the nature of suffering and how it
acceptable. In some cases, we will choose not to can be alleviated. So, for example, the doctor can
act on triggered impulses (e.g., vengefulness) but recall his/her training that s/he may have acquired
to act against them because we have the mental- over many years to support compassionate action
toward healing the broken arm. When it comes to making determined efforts to lose weight on
our own mental states then, again the more we health grounds. Clearly then, what links all of
understand about the nature of our brain, and how these different processes is compassion motiva-
it creates the desires, emotions, impulses, fears, tion rather than a specific emotion or skill.
hopes, joys, ruminations, and plans in the way Compassion therefore does not have a particu-
that it does, the more wisdom we can bring to lar emotion when it is engaged in action. In their
generating compassionate ways to help our minds paper Compassion Is Not a Benzo, Di Bello et al.
with the ups and downs of life. The feelings we (2021) highlight the fact that if we are to engage
have when acting compassionately will depend with suffering, then our threat system processes
on what the action is. will be activated, and it is how we tolerate and
At the center of compassion therefore has to encourage ourselves to behave wisely in those
be courage to engage with pain and difficulties situations that is crucial. The misunderstanding
linked to knowing what to do. Wisdom without that we need a calm mind to be compassionate is
courage and courage without wisdom are not clearly incorrect. When we are engaging with
helpful. However, the nature of the courage and compassion, we are not going on our holidays,
wisdom we may need for any particular source of but descending into suffering, pain, and difficulty
suffering will depend on context. For example, a where we need a focused, grounded, courageous
firefighter about to enter a burning house is likely mind, not necessarily a calm or fearless one.
to be anxious and will need ways to contain their Self-compassion is the ability to direct these
anxiety to pursue the intention to rescue. In addi- 12 competencies toward the self. In other words,
tion, they will need particular “wise” skills. In we can be motivated to be self-compassionate
contrast, a counselor counseling a bereaved client and be attentive and sensitive to sources of our
might feel sad and be able to contain sadness to pain and suffering. We can tolerate that distress
provide support; these are very different skills to and begin to empathically attune to understand it
that of the firefighter. In contrast, somebody and its causes without being harshly self-critical
fighting injustice will need to work with different or condemning. When it comes to taking action
themes and different emotions and have different and how to help ourselves, we can use our new
skills. Despite these major differences, what links brain competencies to refocus attention, pull on
them is the motivation to address and prevent suf- our wisdoms, run imaginary scenarios in our
fering. This is what makes motivation, rather than mind, use our abilities to reason and think through
any specific emotion, central to compassion. things, and maybe discuss with, and seek out,
Note, too, that these skills might not be inter- help from friends, mentors or professionals. In
changeable because our brave firefighter might any moment of distress, we can be attentive to the
not make the most empathic or compassionate body and tolerate feelings that arise as we take
parent and our counselor might not make the action.
most courageous firefighter. It is important to see There is also increasing evidence that differ-
that compassion is not one process and varies ent aspects of self-compassion affect us quite dif-
with context. ferently. For example, the three positive
It is the same with self-compassion. What components of Neff’s concept of self-compassion,
self-compassion will involve will depend on the namely, kindness, mindfulness, and sense of
context of our suffering. Trying to be self- common humanity (Neff, 2011), are significantly
compassionate and supportive when we have just linked to measures of well-being and flourishing
been diagnosed with cancer, and going through but less so to measures of mental health diffi-
treatments, requires a very different set of skills culty. In contrast, the three negative factors of
than if we are dealing with depression, coming to self-judgment, sense of isolation, and overidenti-
terms with lose of loved one, addressing trauma fication or absorption are more robustly linked to
memory of past abuse, learning to be assertive in mental health problems (Gilbert et al., 2017;
the face of a bully, leaving a toxic relationship, or Pandey et al., 2021). Related to this is that self-
62 P. Gilbert
reassurance has a greater moderating impact on brief time here, maybe 30,000 days if we are
depression than self-esteem, indicating that all lucky: all of us decay and die, and some of us
positive self-evaluations do not have the same rather painfully and slowly (e.g., cancers and
impact (Petrocchi et al., 2019). Moreover, dementias). All of us become conscious we exist
although measures of self-reassurance and self- in a body and a brain that have all kinds of
compassion are often highly correlated, they are impulses and feelings which have been built for
also different. Self-reassurance is focused on a us not by us. All of us want to be happy rather
sense of encouragement and the ability to remem- than suffer. It is when we personally overidentify
ber one’s strength and abilities in times of diffi- with these algorithms and programs that we can
culty (Gilbert et al., 2017). Self-reassurance, like get into difficulties. The greatest challenge of all
kindness and assertiveness, is a way of being humans is to begin to understand that we are pro-
compassionate but is not compassion itself. grammed beings, but we can also become “mind
aware” of our programming and begin to choose
how to live. We can knowingly and intentionally
Wisdom of the Minds We Have try to live to be helpful not harmful, recognizing
that we have within us the seeds of great harmful-
Understanding the nature of our minds is crucial ness. The point of this is to highlight the fact
for our ability to become self-compassionate. there are many different wisdoms that can orien-
This can take us into difficult territory of under- tate us to a compassionate life.
standing what it is to be a gene-built biological
being with a conscious mind. We are, like all
other species, a biological creation built to sim- Social Mentalities and the Self
ply survive and reproduce. Considering all other
life forms past and present, that is basically all a An important aspect of evolution that can throw
life form does. Hundreds of millions of years, light on the process of self-compassion is social
even before the dinosaurs, it was simply a pro- mentality theory (Gilbert, 1989/2016, 2005,
cess of eating and reproducing before being eaten 2017). This highlights the fact that all social
or decay and death. Indeed, no living thing chose motives must coevolve in the context of dynamic,
that existence or to be what it is. No elephant reciprocal interactions and are therefore attuned
chose to be an elephant, no rabbit a rabbit, and no to such. The evolution of caring behavior is an
human a human. No human chose to be a man or excellent example of a coevolved social mental-
a woman, nor their ethnicity, nor the illnesses ity. Before the evolution of attachment and paren-
they will be vulnerable to, nor where they were tal investment, reproductive strategies were to
born and the families that matured them. We are produce hundreds, sometimes, thousands, of off-
all running the algorithms that nature has set in spring, very few of which would survive until
our brains and our social experiences have fine- adulthood. However, a different reproductive
tuned. Clearly, if we have been brought up in a strategy evolved with parental investment,
violent background or a very loving background, whereby very few offspring are produced but
much of what we become would be different, they are cared for and provisioned during their
even our genetic profiles (Cowan et al., 2016). maturation into adulthood. This means there is a
These are fundamental insights when working carer (usually, but not always, the mother) and a
with clients. They are the root of compassion cared for, i.e., the infant(s). This is evolving as
because it helps us understand the real meaning lock and key because clearly, infants cannot
of common humanity. We are all biologically cre- evolve to be dependent on resources from a
ated in ways we never chose and socially pro- mother if the mother is not also evolving motives
grammed in ways we never chose. All of us are and competencies to be aware of the needs of her
caught up in various traumas and tragedies of infant. The attachment system of mother-infant is
life, some worse than others. All of us have a thus a clear example of a coevolved, co-regulating
process. What is evolving are the physiological A second key resource is called a safe haven,
infrastructures to be able to engage in these which is the ability of the parent to act as a sooth-
behaviors. Species that produce high numbers of ing object and to help regulate arousal and dis-
offspring clearly do not have these physiological tress in the infant. There are various caregiving
systems. Importantly, both giving and receiving behaviors that can achieve this, including sooth-
evolved and involve overlapping physiological ing voice tones, stroking, hugs, and facial expres-
systems such as the vagus nerve, the hormone sions that convey a genuine sense of empathic
oxytocin (Brown & Brown, 2015; Carter et al., connection and concern. As children grow, they
2017; Porges, 2017, 2021), and neurocircuits can develop transitional objects such as teddy
(Kim et al., 2020a, b). bears that have soothing qualities. In addition,
they can develop imaginary friends that can be a
source of support (Taylor et al., 2009). As a result
he Psychological Functions
T of these two core qualities of secure base, that is,
of the Evolved Caring encouraging and guiding, and safe haven, that is,
and Attachment Systems soothing and comforting, the parent and child
have what is called proximity-seeking and main-
As noted above, parental caring relationships tenance systems. This third key resource creates
have a range of functions, from feeding, to pro- motivational orientation such that when the child
tecting, thermal regulation, and supporting psy- is distressed, it will seek out those that can guide,
chophysiological maturation and regulation comfort, soothe, and support him/her.
(Cassidy & Shaver, 2016). The quality of care we Understanding these three core resources of
receive also impacts epigenetic development caring is fundamental to understanding the many
(Cowan et al., 2016). In addition, the evolution of of the functions of all forms of caring and com-
caring behavior provides three main psychologi- passion including to self and to others. It means
cal functions for the developing infant. These that when we are being self-compassionate, we
were identified over 50 years ago by primate can create an inner secure base. We can turn
researchers, developmental psychologists, and within (proximity-seeking to our inner supports)
child psychotherapists (Music, 2016; Cassidy & to find self-reassurance, self-encouragement, and
Shaver, 2016). Attachment theorists (Ainsworth, self-support which enables us to face things that
1969; Bowlby, 1969) highlighted the fact that are difficult. Indeed, self-compassion is not pas-
across species, a caring parent provides key psy- sively reacting, but actively preparing ourselves
chological resources to the infant that impact its for our (heroic) journey through life and to be
subsequent psychosocial maturation. From an able to take on its challenges for growth, setbacks
attachment perspective, these include a secure and traumas, decay, and death.
base, which in the human context provides mul- We can also function as a safe haven for our-
tiple inputs to the child including protection, selves. We have within us the competencies for
encouragement, support, and signals of warmth, self-regulation and self-soothing. These func-
joy, love, and affection along with emotion and tions are originally internalized from early attach-
behavioral guidance. These enable a child to ment relationships, but in some individuals, they
internalize a sense of his/her own acceptability may have to be built and cultivated. In addition, if
and lovability in the eyes of others, which builds clients have toxic experiences of caring, such as
social confidence and emotion regulation (Music, neglect or forms of abuse or criticism, the caring
2016; Cassidy & Shaver, 2016). Children who do system can require work to detoxify it. That can
not receive such inputs are more threat sensitive, require grieving for the love and affection that
vigilant, and less trusting, which can compromise was not present in childhood. In these more com-
well-being (Music, 2016; Cassidy & Shaver, plex cases, it means that self-compassion pro-
2016). They are also prone to be more self-critical vides the courage to work with one’s fractured
and less self-compassionate (Gilbert, 2022c). sense of attachment security. Put another way, we
64 P. Gilbert
can begin to identify the core functions of com- Nonetheless, rather than (imagining) oneself
passion and self-compassion as the ability to be being compassionate to oneself, some people find
encouraging and supportive when facing it easier to start being self-compassionate by
difficulties and to be soothing and containing
imagining what a compassionate other would say
when distressed (Gilbert & Simos, 2022). to them or how an imagined compassionate other
would be with them. The act of imagining what
they would want their compassionate image to be
Compassionate Others and Images like, and how they would like to relate to it, and
be related to by their imagined compassionate
Another key dimension of self-compassion is the other, is part of the work of compassion aware-
ability to reach out to others for help. Hence, ness. This can be a crucial first step into self-
some aspects of self-compassion involve being compassion, particularly for people who have not
courageous enough to ask for help. Psychotherapy received compassionate care in their early lives.
clearly depends on the courage and preparedness These practices can also reveal important fears,
of people to seek and be open to help and reveal blocks, and resistances to compassion.
the nature and extent of their suffering. Indeed, Self-compassion is not a self-contained pro-
there is growing evidence that being open to the cess but one that is aware of our interconnected-
compassion of others is an important buffer against ness, able to feel encouraged, supported, and
mental health problems in contrast to compulsive soothed by others. Indeed, one of the reasons that
self-reliance (Hermanto et al., 2016). Two main low self-compassion has become a major issue in
reasons that people do not seek out the help of oth- the west is partly because of the increase in lone-
ers is due to shame, self-criticism, and social dis- liness and feeling disconnected from caring
trust. Given the importance of “receiving social communities (Becker et al., 2021;
compassion” systems in our brain, CFT tries to Cacioppo & Patrick, 2008). Self-compassion
help people begin to stimulate the experience of should not be seen as a process of compulsive
receiving by generating images of a compassion- self-reliance but one of developing trust in one-
ate other. There is now very good evidence that self and others. Many commentators have noticed
imagined forms of relating can have very powerful that self-criticism is low in supportive communi-
psychological effects (Gleason, 2013). Just as we ties and hunter-gatherer societies partly because
have sexual fantasies that involve imagined inter- individuals are highly socially connected (Ryan,
actions to stimulate an arousal of specific physio- 2019). There is a strong link between low self-
logical systems, we can imagine interacting with a compassion, self-criticism, and a sense of social
compassionate other(s) to stimulate compassion disconnection (Gilbert, 2022c).
systems. Part of the reason for doing this is because
compassion is rooted in a social mentality of send-
ing and receiving. Hence, by developing a com- Compassionate Self
passionate image, and imagining dialoguing with
the compassionate image, we are activating that There are many strategies that can be used for
sending and receiving process. Importantly, some developing a sense of a compassionate mind and
clients have difficulties generating and responding self. One is to help people recognize we are gene-
to their own compassionate images because they built and socially shaped, and much more of what
struggle to imagine receiving compassion and goes on minds is not of our design. Some of these
because compassion feels alien and unfamiliar. are based on cognitive techniques, such as inviting
For others, it is because compassion connects individuals to think in certain ways that could off-
them to memories of losing compassion connec- set feelings of self-criticism or loneliness. CFT
tion via shame, rejection, and feeling sad and iso- also seeks to stimulate the caring mentality as it is
lated. These experiences are worked through in linked to a range of physiological systems such as
the therapy (Gilbert & Simos, 2022). the vagus nerve (Porges, 2017, 2021), oxytocin
(Carter et al., 2017), and various neurocircuits Similarly, practicing positive self-imagery by
(Singer & Engert, 2019). Part of the training is recalling a time when one felt relaxed and posi-
therefore to develop the capacity to use the body to tive was related to higher levels of self-esteem
support the mind, through practicing various pos- and reduced anxiety in response to anxiety-
tures (e.g., yoga), breathing exercises, visualiza- provoking vignettes such as meeting your part-
tions, and behavioral practices and how to create ner’s parents for the first time (Stopa et al., 2012).
compassionate voice tones for self- reassuring Gilbert and Basran (2018) invited people to talk
thinking. The view is that if you want to run a mar- about a minor life difficulty to a partner, who was
athon or climb a mountain, no matter how skilled instructed to simply listen, without saying any-
you are, if you are not physically fit, you will not thing, for 2 or 3 min. The person who shared their
be able to do it. Similarly, no matter the intention, difficulty was then asked to reflect on what it was
if people are not able to regulate their autonomic like to be listened to in such a manner and was
nervous system, for example, and have access to invited to reflect on how they were thinking about
parasympathetic regulation, they may struggle to their difficulty, following the experience of being
engage both the secure base and safe haven func- listened to. They then engaged in a compassion-
tions of compassion (Porges, 2021, 2017). ate mind induction using the soothing rhythm
Compassion is based upon courage and wis- breathing exercise and then to think about the
dom, and both are important when we confront problem again through their compassionate mind
the realities of being a short-lived, vulnerable, state. For the latter part of the exercise, partici-
biological, gene-built and socially constructed pants were asked to imagine having all of the
being. As noted above, on the nature of our characteristics they might have if they were to
“tricky brain,” clients are guided into important embody the qualities of compassion. Participants
evolved constructs (which offer “compassionate experienced the life difficulty quite differently
wisdoms on the nature of tricky mind”). Helping and had new insights as to how they might be
people to envision, create, and begin to enact a able to work with it. Shifting their focus to a
compassionate sense of self can start by inviting compassionate mind state enabled them to
people to imagine particular qualities of a com- develop more empathy for the problem and imag-
passionate person and mind or their ideals of ine different ways of how to cope better. These
compassion, and, then like an actor, imagine kinds of projects reveal that switching mental
becoming them. Asking people to imagine them- states “on purpose” does create different ways in
selves in certain states of minds, such as being which we see the world.
self-critical or self-reassuring, is associated with
important differences in neurophysiological acti-
vation (Longe et al., 2010). Creative imagination Building a Compassionate Mind
of a version of oneself and exploring the impact
that has on coping have been investigated in other To understand any approach to self-compassion
paradigms. For example, thinking about a life requires a clear understanding of that approach’s
problem and then imagining oneself as one’s view of compassion and the competencies that
“best possible self” and exploring it from that support it. Whether compassion is directed
perspective are related to emotional change and toward others or to oneself, it requires a set of
increased optimism (Meevissen et al., 2011; competencies that enable a courageous and wise
Peters et al., 2010). Osimo et al. (2015) created a engagement with suffering. Compassionate mind
virtual reality scenario where participants raised training (CMT) has suggested six competencies
a personal issue and then offered themselves for engagement and six competencies for taking
counseling either as themselves or as (a virtual) action. These were described in Fig. 4.2. There
Sigmund Freud. Giving oneself counseling “as are a range of processes that support these com-
Sigmund Freud” reduced depressed feelings sig- petencies and help build self-compassion. These
nificantly more than as themselves. include the following:
66 P. Gilbert
1. Using the body to support the mind: These to walk in the streets with a friendly face and
practices are designed to help develop a range friendly acknowledgements and to deliber-
of physiological systems that support com- ately think about how you could be helpful to
passion. These can include posture, breathing, people and perform helpful acts to yourself
movement, yoga, acupuncture, diet, fitness, and others. Additionally, there are behavioral
grounding, and settling. There are also practices such as compassionate letter writ-
grounding practices such as safe place and ing, listening to one’s own compassionate
color imagery. These can be also practiced by message from a mobile phone, and asking
listening to music or going into nature. Art- somebody who you think cares about you for
and music-based interventions can help peo- help or support.
ple explore different aspects of compassion 4. Addressing the fears, blocks, and resistances:
(Bennett-Levy et al., 2020). All psychological processes have fears,
2. Using new brain competencies: There are blocks, and resistances. For example, there
many practices to support mind awareness can be certain emotions we are frightened to
that include mindfulness, mentalization, and experience or express. People can be fearful
rational thinking. Figure 4.2 outlines six basic of compassion because of what it stimulates
competencies for engaging with suffering. We in them, such as sadness or anxiety. People
also offered six competencies that are focused may be blocked to compassion because they
on the action aspect of compassion. Intention misunderstand it or would like to be compas-
without wise action is often not helpful. sionate but don’t know what to do, or they
Together they make up the courage and wis- haven’t had a chance to practice. When people
dom elements of compassion. What can help are resistant, it is usually because they see it as
clients engage with these practices is to stimu- too costly or not useful. When we are working
late a sense of play and allow for curious in psychotherapy, working through the fears,
exploration with pleasure from the process. blocks, and resistances to compassion is often
As noted throughout this chapter, there are many the main focus of the work, with specific exer-
practices for reflecting on and internalizing core cises and practices to help clients identify and
qualities of compassion. Two keys ones are: overcome these barriers.
imagining one’s ideal compassionate other and
the experiences of relating to that image,
and imagining one’s own self as having compas- Conclusion
sionate skills, courage and wisdoms. In regard to
the first process, one can imagine compassionate Compassion emerged from the evolution of car-
dialogs and interactions designed to stimulate ing behavior. There is now a clear science of the
specific physiological systems. The principle is physiological systems underpinning caring
no different than any other imaginary relation- behavior and how this motivational system can
ship, be it sexual or imagining an argument with be regulated by more complex cognitive compe-
somebody; how we imagine interactions influ- tencies. Indeed, even having a conceptualization
ences our physiological state. The second is con- of an individualized separate self (which can be
necting to and imagining one’s own core compassionate to itself) is a product of certain
compassionate qualities, embodying them and cognitive competencies. It follows therefore that
regularly, mindfully, remembering to tune into how we use these competencies to direct motives
them and practice thinking and acting from that is fundamental to how we experience ourselves
pattern of self (compassionate mind). in the world. Self-compassion helps us recognize
3. Behavioral practice: Examples of identifying the nature of personal distress and then develop
and engaging compassionate ways of thinking the courage and wisdom to address it. The nature
and behaving each day with compassionate of the compassion we develop and express
practice can include making a deliberate effort depends upon the context and the nature of the
suffering we are experiencing. Self-compassion Frontiers in Psychiatry, 9, 44. https://doi.org/10.3389/

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Attachment and Self-Compassion:
Associations Across the Lifespan 5
Trisha L. Raque, Kathryn Ziemer,
and John Jackson
Introduction they relate to self-compassion, emotion regulation,

and early maladaptive schemas. The importance
Self-compassion has been identified as an impor- of self-compassion as a mediating pathway
tant self-regulation strategy and a general way of between negative early life experiences and well-
relating to the self that is predictive of a wide being will be highlighted. Continuing across the
range of aspects of interpersonal and intraper- lifespan, this chapter will next cover peer attach-
sonal functioning (e.g., Zessin et al., 2015). Early ment and adult attachment before concluding
life experiences, including the development of with a presentation of clinical interventions
attachment to security figures, are key pathways aimed at increasing secure attachment and
for developing high levels of self-compassion, self-compassion.
including how self-compassion relates to self-
concept and emotion regulation. A growing body
of research is establishing the ways in which Self-Compassion
attachment and self-compassion relate to each
other as well as positively predict a wide range of Neff and McGehee (2010) define self-compassion
mental and physical health outcomes across the as “compassion turned inward” (p. 226). More
developmental continuum. This chapter first out- specifically, self-compassion embodies the abil-
lines the construct of self-compassion and then ity to treat oneself with kindness when experienc-
the key tenets of attachment theory before pre- ing struggles rather than judging oneself (i.e.,
senting their associations across the lifespan. self-kindness), to recognize one is not alone in
Beginning with the role of parents in their their struggles and imperfections rather than feel-
children’s development of attachment styles, we ing isolated in their distress (i.e., common
then present information on other salient child- humanity), and to remain present and observe
hood experiences such as trauma and abuse as one’s thoughts and feelings rather than overiden-
tifying with, exaggerating, or avoiding distress
(i.e., mindfulness; Neff, 2003). Broadly, higher
T. L. Raque (*)
University of Denver, Denver, CO, USA
levels of self-compassion have predicted greater
e-mail: [email protected] optimism, happiness (Neff et al., 2007), social
K. Ziemer
connectedness, self-acceptance (Neff, 2003),
Old Town Psychology, Alexandria, VA, USA coping with stress, resilience (Terry & Leary,
J. Jackson
2011), and lower levels of anxiety, depression,
Central Washington University, Ellensburg, WA, USA self-criticism (Neff, 2003), negative affect (Neff

https://doi.org/10.1007/978-3-031-22348-8_5
72 T. L. Raque et al.
et al., 2007), and rumination (Neff, 2009). A Attachment Theory

meta-analysis by Zessin et al. (2015) on the rela-
tionship between self-compassion and well-being The need for interpersonal connection is a funda-
reported medium to large effect sizes, with the mental human motivation (Baumeister & Leary,
strongest correlation between self-compassion 1995), and how we pursue that connection
and psychological well-being (r = 0.62, k = 12, reflects how we relate to the world and ourselves.
n = 1586), then negative affect (r = −0.47, k = 32, Attachment theory has been lauded as one of the
n = 5710), cognitive well-being (r = 0.47, k = 48, broadest, most coherent, well-known, and empir-
n = 11, 181), and finally positive affect (r = 0.39, ically grounded frameworks in the contemporary
k = 32, n = 5779). study of human development and relational func-
Neff (2003) has proposed that self-compassion tioning (Cassidy & Shaver, 2008). Attachment
may be a form of emotion regulation (ER) in styles are hypothesized to develop based on early
addition to referring to how one relates to one- childhood experiences with caregivers and
self. ER embodies the ways that individuals remain relatively consistent into adulthood
experience, respond to, and express their reac- (Bowlby, 1988), with implications for well-
tions to internal and external events (Gross, 1998) being. Mediators between attachment and well-
and may represent a transdiagnostic risk factor being have been explored as potential points of
for many mental health issues (Finlay-Jones intervention, with self-compassion indicated as a
et al., 2015). In regard to ER, self-compassion potentially key pathway through which attach-
has been shown to activate brain regions involved ment relates to mental health (e.g., Raque-
in emotional processing (Hofmann et al., 2011) Bogdan et al., 2011).
and to decrease negative emotions (Arimitsu & The most fundamental construct of attach-
Hofmann, 2017). Among psychologists experiment theory is attachment behavior, defined by
encing stress, self-compassion was associated Bowlby (1969, 1973) as forms of behavior that
with decreased ER difficulties (Finlay-Jones operate to achieve and/or maintain a child’s prox-
et al., 2015). Finlay-Jones et al. (2015) explain imity to a caregiver or attachment figure.
that higher levels of self-compassion may pro- Attachment behavior is primarily influenced by
vide greater emotional acceptance and clarity, the primary caregiver’s sensitivity to the child’s
thereby contributing to healthier ER strategies. behavior as well as the quality of interactions that
Given the strong associations between self- facilitate proximity, help the child feel soothed,
compassion, emotion regulation, and well-being, and promote a sense of inter- and intrapersonal
it is important to unpack how self-compassion security. These interactions are in turn influenced
may be developed. Early caregivers and the ways by the child’s temperament, the caregiver’s own
in which children attach to those caregivers may attachment history, and environmental factors
have profound influences on the development of that can impact caregiving quality, such as family
self-compassion; caregivers may influence chil- stress. Attachment behaviors support individuals
dren’s self-concepts and the ways that they learn, to seek proximity to others in times of danger or
both directly and indirectly, to emotionally regu- potential threat (Bowlby, 1969). Attachment
late. Further, experiences with trauma and/or behavior is evolutionarily adaptive and ultimately
betrayal may impact a person’s ability to practice functions to protect a child from predation and
self-kindness, practice mindfulness as a form of to promote other evolutionarily advantageous
emotion regulation, and feel connected to others behavior, such as feeding, self-regulation, and
(e.g., common humanity). Understanding how social interaction (Cassidy & Shaver, 2016).
self-compassion relates to early maladaptive The quality and form of repeated interactions
schemas and emotion regulation after trauma between a child and an attachment figure give
may offer insight into how to intervene to increase way to the formation of what Bowlby (1973)
self-compassion and decrease the potentially del- termed internal working models. Internal working
eterious effects of trauma. models function essentially as cognitive templates
5 Attachment and Self-Compassion: Associations Across the Lifespan 73
regarding oneself and one’s external world, They may struggle with intimacy in relation-
including one in relation to others. These struc- ships, may suppress their emotions, may strive
tures organize experiences and expectations, for emotional distance from others, and may be
shaping the way a child “…perceives events, rigidly self-reliant when distressed. Withdrawing
forecasts the future, and constructs his [sic] from others may serve to protect them from
plans” (Bowlby, 1973, p. 203). When attachment anticipated disappointment that others will not
figures are consistently responsive and soothing, meet their needs (Mikulincer et al., 2003a, b).
a child develops an internal working model of the High avoidance and high anxiety comprise fear-
self as valued and confident and worthy of having ful attachment, which is characterized by feelings
their needs met by others. When attachment fig- of inadequacy and distrust of others. Together,
ures are inconsistently available and/or respon- high avoidance and low anxiety comprise a dis-
sive, or when they are punitive or abusive in their missive attachment style characterized by inflated
responses to attachment behavior, a child devel- self-worth and minimization of the value of rela-
ops an internal working model of the self as tionships. The combination of low avoidance and
unworthy and/or incompetent and not valued high anxiety constitutes preoccupied attachment,
enough to have others meet their needs. Thus, characterized by neediness, dependence on oth-
experiences with attachment figures throughout ers for validation, and jealousy (Bartholomew &
childhood promote long-standing, sometimes Horowitz, 1991).
rigid expectations about how one will be treated Those low on the dimensions of attachment
by significant others and one’s notions of self. anxiety and avoidance are categorized as securely
Repeated caregiver interactions continue to influ- attached, and this attachment style is character-
ence how close relationships are navigated across ized by the tendency to hold a positive perspec-
the lifespan. tive of oneself and others, higher self-worth,
During adulthood, internal working models greater capacity for emotion regulation, and
serve as the mental representations of caring and higher levels of interpersonal satisfaction and
loving relationships that are activated by the general well-being (Love & Murdock, 2004).
attachment system (Mikulincer & Shaver, 2007a, Secure attachment captures the expectation that
b). Internal working models are characterized by others will be available and respond in a support-
several different ways, often represented as ive manner to one’s needs, with this confidence
dimensions of anxious, avoidant, and secure, offering a foundation for positive psychological
with the taxonomy of fearful, dismissive, and adjustment (Mikulincer & Shaver, 2003a, b). The
preoccupied built upon these dimensions (Shaver majority of the attachment research reviewed in
& Fraley, 2008). Anxious attachment is charac- this chapter identifies styles as either secure, anx-
terized by a positive view of others yet a negative ious, or avoidant rather than as fearful, dismis-
view of the self. Anxious attachment styles mani- sive, or preoccupied.
fest in feelings of unworthiness, clinginess, and For multiple reasons, our overview of attach-
insecurities over the availability and responsive- ment theory would be incomplete without atten-
ness of others. Those with this attachment style tion to the cultural context. Early researchers on
may be hypervigilant to signs of abandonment attachment, Bowlby (1969/1982) and Ainsworth
and rejection and seek ongoing reassurance from (1967) drew attention to the importance of con-
others, in part because they may be self-critical text in influencing how attachment and caregiv-
and doubt whether they are deserving of others’ ing behaviors are expressed and evaluated. For
responsiveness to their needs (Wei et al., 2011). instance, the cultural context influences how we
Avoidant attachment styles are characterized by a assess what is considered “responsive,” “too
fear of being close to others and holding negative responsive,” or “not responsive enough” parental
views of others’ responsiveness to their needs; behaviors to children’s needs for connections
thus, they may suppress or deactivate their needs (e.g., offering too little/too much comfort and
as a form of self-protection (Moreira et al., 2015). protection; Mirecki & Chou, 2013). Mirecki and
Chou (2013) outline the need to explore the func- Accordingly, perhaps we, as attachment research-
ers, are concerned that in the example discussed
tion of a caregivers’ behavior within a cultural we have glimpsed how attachment theory and the
context and address how adaptive that response is knowledge it creates might be unwittingly drawn
within both the cultural context where that behav- into translating the unacceptable into the accept-
ior was developed as well as the current cultural able, in the interests of neoliberalism—but at the
expense of psychological well-being. Perhaps we
context where it is adopted. They noted that are calling for the emergence of a critical con-
“future research directions should examine the sciousness, a critical voice in attachment theory
effectiveness of clinical applications of attach- (and beyond) that seeks to interrogate carefully
ment theory through a multicultural-driven psychological knowledge constructed outside of a
value-neutral framework and in the interests of
approach when working with families of various social justice. (p. 172)
cultures” (Mirecki & Chou, 2013, p. 514).
Additionally, future research should explore They conclude that rather than view attachment
the ways in which structural inequities responsi- avoidance as a way of coping with a neoliberal
ble for sexism, racism, heterosexism, poverty, society, as psychologists, we have a responsibil-
ableism, and other forms of marginalization may ity to recognize the ills in such a society and work
influence the development of attachment behav- to challenge it. As an extension of this view,
ior. For example, being bombarded with societal rather than simply documenting how experiences
messages that one’s needs are unimportant as a with marginalization and oppression may make
marginalized individual (e.g., woman, racial insecure attachment behaviors functional in a
minority, sexual minority, person with disabili- dysfunctional society, we have a responsibility to
ties) may make it challenging not to internalize challenge and work to change that dysfunctional
those messages and not manifest insecure attach- society. In short, the cultural context is a critical
ment behavior. In a special issue of Attachment component in the conceptualization and interpre-
and Human Development focused on attachment tation of attachment behaviors and how we, as
and anti-racism, Stern et al. (2021) outline the psychologists, advocate for societal change to
importance of asking questions such as, “How do enhance well-being. With this lens in mind, we
attachment figures teach their children positive now outline how attachment and self-compassion
racial socialization to help children develop relate over the lifespan.
secure internal working models?” and “How
might avoidant coping styles be adaptive emotion
regulation strategies in the context of predomi- onnections Between Attachment
C
nantly white spaces?” Such inquiries embody the Styles and Self-Compassion
need to account for how power, privilege, and
oppression may influence attachment behaviors. Among adults, higher levels of attachment secu-
In addition to examining the cultural context rity are positively related to a greater ability to
in which attachment behaviors are developed, engage in self-care and thus self-compassion,
Carr and Battle (2015) emphasize the importance whereas those who minimize the value of support
of attending to the cultural context in which provided in relationships (i.e., avoidant attach-
attachment behaviors are interpreted as func- ment style) or exhibit anxiety about whether they
tional or nonfunctional with a social justice lens. are worthy of others’ care (i.e., anxious attach-
In particular, they examine how aspects of attachment style) are hypothesized to have less access
ment avoidance have been interpreted as a to self-compassion (Neff & McGehee, 2010).
strength in a neoliberal society that values self- Individuals who are clingy or dependent on exter-
reliance, independence, hypervigilance for dan- nal sources such as others for validation (i.e., pre-
ger, and minimal need for others (e.g., Ein-Dor occupied) may have less capacity to generate
et al., 2012). After outlining the negative conse- compassion for themselves. Moreover, those who
quences of neoliberalism for psychological well- do not trust others and struggle with self-worth
being, Carr and Battle (2015) express: (i.e., fearful) may not have a strong foundation
for offering themselves acceptance. Mixed find- as having experienced mindful parenting, may
ings have been reported for those with dismissive also influence the development of self-
attachment styles and self-compassion, suggest- compassion as a positive form of ER and way of
ing that those with dismissive attachment may relating to oneself. This next section will work
minimize the importance of relationships and through these various perspectives on how early
thus engage in a form of self-deception that life experiences may affect self-compassion and
affects their accuracy in identifying their levels of attachment and the ways in which self-
self-compassion (Neff & McGehee, 2010). compassion may be protective when facing chal-
Research on compassion training, such as lenging life events.
compassion-focused therapy (CFT; Gilbert &
Procter, 2006), has found that some people strug-
gle to cultivate compassion for themselves and Adverse Childhood Experiences
others, and being prompted to do so triggers
avoidance, fear, or grief reactions (Gilbert, 2010).
Exposure to adverse childhood experiences may
Gilbert (2010) outlines how early life experi- influence how individuals think about and treat
ences with caregivers influence both attachment themselves. For instance, caregivers who are not
styles and affiliative behaviors, with secure emotionally or physically responsive to an
attachment resulting in greater capacity for com- infant’s cry for help may contribute to the infant’s
passion than anxious or avoidant attachment development of an anxious or avoidant attach-
styles. Those who yearned for affection and car- ment style later in life. In turn, attachment style
ing from significant others but failed to receive it
may influence the ability to develop mindfulness
may experience self-compassion as increasing and self-compassion and the formation of early
their awareness of their unmet needs for close, maladaptive schemas. Thimm (2017) defines
validating relationships (Gilbert, 2007). Gilbert early maladaptive schemas (EMSs) as “negative
et al. (2011) developed measures of fear of com- beliefs about oneself and one’s relationship with
passion, including fear of self-compassion, find- others that arise from adverse relational experi-
ing that fear of compassion for self was associatedences in childhood and are associated with a
with fear of compassion for others, and both were broad range of psychological problems” (p. 3).
linked to self-coldness, self-criticism, insecure These beliefs about oneself and others are theo-
attachment, depression, anxiety, and stress. These rized to develop in childhood and adolescence
findings have been replicated elsewhere with fear based on difficulties in having basic needs met
of self-compassion relating to lower levels of (e.g., secure attachment, autonomy) over time
self-compassion (Joeng & Turner, 2015) and and may influence the use of maladaptive coping
self-compassion and fear of self-compassion pre- strategies. Thus, these negative beliefs may
dictive of higher levels of anxiety and depression become internalized into the individual’s sense of
(Joeng et al., 2017). self and may form the way the individual sees
and interacts with themselves and the world.
EMSs emerge from insecure attachment if the
Early Childhood: Development belief that takes hold is that one is not worthy of
of Attachment Styles others’ consistent care and that others are not
and Self-Compassion dependable for meeting their needs (Cecero et al.,
2004; Simard et al., 2011). Further, EMSs may
There are multiple frameworks for unpacking undermine the development of mindfulness and
how early life experiences may influence the self-compassion; in turn, low awareness of one’s
development of attachment styles and self- experiences in the present moment and self-
compassion, including negative life experiences criticism when experiencing struggles may act to
resulting in early maladaptive schemas (EMSs). perpetuate the negative impact of EMSs (Thimm,
Conversely, positive early life experiences, such 2017). In a study with 212 undergraduate
p sychology students (mean age 21.8, psychological distress such as depression and
SD = 4.4 years), participants reported negative substance use. Wu et al. (2018) report that for
associations between EMSs with mindfulness college students, self-compassion mediated the
and self-compassion, with self-compassion and pathways between childhood emotional abuse
mindfulness mediating the pathway between and childhood emotional neglect with depres-
EMSs and psychological distress (Thimm, 2017). sion. Individuals experiencing childhood mal-
Thus, self-compassion and mindfulness represent treatment may be less likely to develop
pathways through which EMSs relate to distress. self-compassion, potentially leading to higher
However, to parse out the causal directions risk for depression in adulthood (Soffer et al.,
between attachment, mindfulness, self-2008). Among youth seeking treatment for sub-
compassion, and EMSs, longitudinal studies are stance use, Vettese et al. (2011) found that child
warranted (Thimm, 2017). maltreatment was associated with lower levels of
self-compassion and emotion regulation difficul-
Childhood Abuse Studies examining EMSs ties. Self-compassion predicted emotion dysreg-
after trauma such as childhood abuse have offered ulation above and beyond problem substance use,
further support for the important role that self- distress, and maltreatment history. Further, self-
compassion may have in mediating between neg- compassion mediated the association between
ative early life experiences and psychological childhood maltreatment and emotion dysregula-
distress (e.g., Zeller et al., 2015). Exposure to tion in adolescence.
childhood abuse has been predictive of forming
insecure attachments to caregivers, negative Bullying Self-compassion may also be an
appraisals such as “I deserved the abuse” (Barlow important buffer for negative early life relational
et al., 2017), and lower levels of self-compassion experiences outside of the family environment,
(Vettese et al., 2011). For instance, Boyraz et al. such as bullying. College students prompted to
(2019) found that participants who reported reflect on their childhood bullying experiences
greater exposure to high betrayal traumas before reported that self-compassion served as a signifi-
the age of 18 also reported lower levels of self- cant mediator between attachment and shame as
compassion and higher post-traumatic stress. Yet, well as between bullying and shame (Beduna &
not all who experience trauma develop distress, Perrone-McGovern, 2019). Children’s attach-
and studies have revealed the importance of indi- ment styles may make them more susceptible to
viduals’ interpretation of trauma as key to the bullying; specifically, those with insecure attach-
risk for post-traumatic stress disorder (PTSD), ment who hold cognitive schemas with expecta-
sometimes above and beyond the trauma expo- tions that others will treat them poorly may be
sure itself (DePrince et al., 2011). In addition to more at risk for being bullied (Walden & Beran,
being predicted by trauma exposure at an early 2010). Thus, self-compassion appears to be help-
age, self-compassion may play a role in recovery ful for responding to bullying experiences with
after trauma (Játiva & Cerezo, 2014). Given that less shame and self-criticism and instead
self-compassion relates to how one responds to approaching the effects of bullying with equa-
oneself and how one copes during and after chal- nimity and self-kindness (Beduna & Perrone-
lenging moments (Germer & Neff, 2015), theo- McGovern, 2019). In summary, research on
retically higher self-compassion may help aversive childhood experiences inside and out-
decrease the development of negative trauma side the family environment has identified self-
appraisals (e.g., shame, self-blame) and PTSD compassion as a malleable point of intervention
symptoms. to decrease distress after negative early life expe-
riences. Self-compassion may be especially use-
In addition to studying PTSD symptomatol- ful when addressing self-beliefs after trauma
ogy, others have examined how exposure to abuse (Boyraz et al., 2019), emotion regulation (Vettese
relates to self-compassion and other forms of
et al., 2011), and decreasing shame (e.g., Beduna ents’ effect on their adolescent’s development of
& Perrone-McGovern, 2019). self-compassion and mindfulness. By observing
their parents practice adaptive coping skills for
difficult life situations, thoughts, and emotions,
The Role of Parents children may learn to relate to themselves in a
similarly adaptive manner. Conversely, children
Mindful Parenting At the other end of the con- who have observed their parents respond to life’s
tinuum of early life trauma experiences, positive challenges with self-criticism, negative emo-
experiences with parents also may represent a tions, or impulsivity may conclude that any of
key influence on how children develop attach- life’s challenges may inevitably create unman-
ment styles and emotion regulation strategies ageable and shameful suffering that they alone
such as self-compassion. How parents respond to experience. Children’s inner dialogs develop in
caregiving challenges is connected to their own part because of family experiences; mindful par-
attachment (Gilbert, 2005). Mindful parenting is enting may result in security-boosting interac-
characterized by bringing awareness, nonjudg- tions that foster children and adolescents’ secure
mental acceptance, and compassion into parent- attachment (Medeiros et al., 2016) thereby fos-
child interactions (Kabat-Zinn & Kabat-Zinn, tering the development of a self-compassionate
1997). It enacts compassion both toward the child self-soothing system (Moreira et al., 2018).
and toward parents themselves and enacts self- An interesting finding from this prior work is
regulation and emotional awareness that prompts that parents’ ability to listen to their adolescent
parents to behave in congruence with their values with complete attention was associated with ado-
and goals (Duncan et al., 2009). Drawing from lescents’ mindfulness. Parents’ ability to convey
attachment theory (Shaver et al., 2017), Moreira compassion, kindness, sensitivity, and respon-
et al. (2018) found that mindful parenting may siveness to their adolescents’ needs indirectly
contribute to children’s development of secure related to adolescents’ well-being through attach-
attachment and self-compassion. In a sample of ment. One explanation is that a secure relation-
563 parent-child dyads (95.6% of which included ship with their parents may allow adolescents to
mothers and 61.5% adolescent girls of mean age have more cognitive resources available for prac-
of 14 years), Moreira et al. (2018) found that ticing mindfulness and that experiencing com-
mindful parenting indirectly related to adoles- passionate parenting contributes to the
cents’ self-compassion and mindfulness through development of attachment security and adaptive
adolescents’ attachment. Mindful parenting also emotion regulation strategies. Moreira et al.’s
indirectly related to adolescents’ well-being (2018) finding of only an indirect association
through the pathways of attachment, self- between mindful parenting and adolescents’
compassion, and mindfulness. Further, adoles- mindfulness and of attachment as the mediator
cents’ attachment was indirectly associated with indicates the crucial role that attachment plays in
their well-being through the pathways of self- how parenting styles may influence their adoles-
compassion and mindfulness. cents’ mindfulness as well as their well-being.
Mindful parenting may result in a less reactive Parents’ Attachment Styles Whether parents
approach that creates flexibility in stopping auto- engage in mindful parenting may be related to
matic and maladaptive parent-child interactional their own attachment styles. Parents’ attachment
cycles, thereby cultivating secure relationships security may affect their caregiving behaviors,
with children and creating conditions that foster including parental sensitivity, responsiveness,
children’s self-compassion and mindfulness. supportiveness, parenting stress, and closeness to
According to Moreira et al.’s (2018) study with children (Jones et al., 2015). Parents’ reports of
adolescents, observational learning and positive their own anxious and avoidant attachments have
family experiences may account for mindful par- been associated with negative caregiving
e motions, cognitions, and behaviors. Compared to more aware of, and kind toward, their wide range
parents with secure attachment, avoidant par- of emotions and thoughts, rather than ruminating,
ents may experience greater ambivalence (Rholes ignoring, or denying them may allow secure
et al., 1995) or less desire for children (Rholes mothers to then self-regulate in their parenting
et al., 1997), struggle to adopt caregiving roles skills.
(Gillath et al., 2005), feel less confident in their Other outcomes for children, such as quality
parenting abilities (Rholes et al., 1995), find par-
of life, also relate to parents’ attachment and self-
enting less meaningful and more stressful (Rholes compassion. Moreira et al. (2015) found that in
et al., 2006), and express less support, closeness,
171 family dyads of children/adolescents aged
and warmth toward their children (Edelstein 8–18 years, the child’s quality of life was indi-
et al., 2004). Anxiously attached parents may rectly predicted by their mother’s attachment to
focus more on their own needs (Mikulincer & their own mother through self-compassion and
Shaver, 2007a, b) and experience distress when parenting stress. In other words, mothers’ higher
others need their help, thereby decreasing their levels of attachment-related anxiety and avoid-
sensitivity to their child’s needs (Mikulincer et al.,
ance were connected to worse children’s quality
2005). Relative to secure parents, anxious parentsof life only through the pathways of mothers’
have also reported greater parenting stress lower self-compassion and higher parenting
(Moreira et al., 2015) and more negative attitudesstress. Interestingly, maternal attachment anxiety
toward parenting (Rholes et al., 1997). and avoidance failed to have direct associations
with children’s quality of life, although both
Building upon the research on parenting directly related to parenting stress. These find-
attachment styles and caregiving behaviors, ings indicate that mothers with an anxious or
Moreira et al. (2016) explored self-compassion avoidant attachment style have difficulty relating
as the mechanism between mothers’ attachment to themselves with warmth and compassion dur-
and mindful parenting. Mothers’ self-compassion ing challenges and experience greater stress with
mediated the pathway between maternal attach- parenting demands. These difficulties with self-
ment anxiety and decreased mindful parenting. compassion and stress are in turn associated with
Additionally, maternal attachment avoidance lower quality of life reported by their children. In
directly predicted lower levels of mindful parent- summary, self-compassion appears to be a criti-
ing, and self-compassion failed to mediate this cal pathway through which attachment may
pathway. They concluded that attachment avoid- influence well-being, both for parents and for
ant mothers appeared to struggle to practice their children; interventions aimed at increasing
mindful attention in their caregiving relation- self-compassion may help parents break cycles
ships with their child, perhaps instead enacting of enactment of anxious or avoidant attachment
emotional suppression or inhibition. Having that may result in lower quality of life for their
experienced their own parents’ model as with- children and may lead children to internalize
holding and emotionally distant, avoidant moth- insecure attachment styles.
ers repeated this pattern with their own children. These studies provide further evidence for the
In contrast, mothers with attachment anxiety importance of attending to individuals’ early
appear to experience emotional activation and caregiving schemas and their relationship with
struggle to implement self-soothing and self- attachment, self-compassion, and well-being.
compassion, thereby lowering their likelihood to Children may develop self-compassionate or
practice mindful parenting. Moreira et al. (2016) self-critical inner dialogs stemming from work-
suggest that secure mothers experience less self- ing models that reflect their family functioning;
criticism about their parenting and greater accep- parents who express caring and warmth may lead
tance of their mothering skills, which is then children to internalize and provide themselves
transposed into how they relate to their children with caring and warmth (Neff & McGehee,
with nonjudgment, caring, and acceptance. Being 2010). Other studies have focused on how young
adults’ recollections of supportive family envi- Kelly and Dupasquier (2016) found that recalled
ronments have been associated with adolescents’ parental warmth related to higher self-
and young adults’ higher levels of self- compassion, lower fear of self-compassion,
compassion, whereas others have outlined how higher received social support, and lower fear of
attachment and self-compassion enacted in cur- receiving compassion via social safeness. Thus,
rent functioning predicts well-being. perceived parental warmth was associated with
In a college student sample (mean age feeling connected and safe with others in other
21.5 years), Pepping et al. (2015) found that ret- relationships, which in turn were associated with
rospective recall of parenting received in child- individuals’ ability to generate compassion
hood was associated with attachment anxiety, toward themselves and receive compassion from
attachment avoidance, and self-compassion. others. Although these findings do not point to
More specifically, attachment anxiety mediated attachment styles as the key theoretical frame-
the pathways between parental warmth, parental work for how parental environments may con-
overprotection, and parental rejection, respec- tribute to the development of self-compassion,
tively, with self-compassion; these models they provide further evidence for the importance
explained between 15.3 and 16.2% of the vari- of parental warmth in how individuals learn to
ance in self-compassion. Parental warmth, over- self-soothe and relate to themselves as a key
protection, and rejection were correlated with emotion regulation strategy.
attachment avoidance and self-compassion, but
avoidance failed to mediate the associations
between poor parenting and self-compassion. For Adolescence: The Role of Peer
college students, memories of parents as reject- Relationships on Attachment Styles
ing, critical, and absent of warmth were con- and Self-Compassion
nected to lower self-compassion through higher
levels of attachment anxiety, but not through Adolescence represents a developmental stage
avoidance. Pepping et al. (2015) suggested that during which self-compassion may be an espe-
recalling warm parental relationships may help cially important protective strategy for emotional
individuals to feel secure and worthy of others’ regulation. In addition to peer relationships tak-
compassion, kindness, and care and not fear ing on increasing importance, adolescents may
abandonment (i.e., low attachment anxiety). In hold the personal fable cognitive schema in
contrast, memories of parents as critical or reject- which they view their experiences as unique from
ing may be internalized into negative self- that of others. The personal fable may lead them
perceptions and self-criticism. Parental to believe that they are isolated in their challenges
overprotection may communicate a lack of confi- and that others cannot understand their experi-
dence in children’s ability to cope with life’s ences (Lapsley et al., 1989). Thus, self-
challenges, hindering opportunities for individu- compassion could be a helpful tool for breaking
als to learn that they can handle difficult life through isolation and managing interpersonal
experiences and cultivate self-compassion in the challenges with peers during adolescence (Neff
process (Pepping et al., 2015). & McGehee, 2010).
Prior work supports the hypothesis that secure
Parental Warmth Rather than examining parental attachments help youth access a self-
attachment as the link between parental warmth compassionate response to personal challenges.
and self-compassion, Kelly and Dupasquier Peter and Gazelle (2017) report how secure
(2016) identified social safeness and affect as key attachment with both parents in early adoles-
mediators. Social safeness is characterized as cence (mean age 10.65 years) moderated associa-
feeling warmth, calmness, and cared for and con- tions between a social withdrawal presentation
nected to other people (Gilbert, 2005). After con- (characterized by anxiety, solitariness, shyness,
trolling for parental rejection and overprotection, and reticence) and self-compassion. Youth who
were securely attached to both parents experi- attachment may take, Neff and McGehee (2010)
enced fewer negative associations between a found that those with a preoccupied attachment
socially anxious interpersonal style and self- style (i.e., characterized by neediness or depen-
compassion. Another study by Jiang et al. (2017) dency) were related to lower levels of self-
focused on how closeness with parents, likely compassion but that a dismissive attachment
connected to attachment styles, related to peer style failed to relate significantly with self-
relationships and self-compassion. They found compassion. They explained this finding as indi-
that for 658 secondary students in China (mean viduals with a dismissive attachment style are
age 13.58 years), self-compassion mediated asso- less likely to consider interpersonal relationships
ciations between closeness with mothers, fathers important and potentially less likely to accurately
(partial mediation), and peers to non-suicidal recognize their levels of self-compassion. After
self-injury (NSSI) (Jiang et al., 2017). Self- controlling for family and cognitive factors, self-
compassion also mediated the pathway between compassion continued to explain significant vari-
attachment with peers and NSSI. By internalizing ance in overall well-being (i.e., lower depression
warm, validating, and accepting parental rela- and anxiety and higher social connection). Thus,
tionships such that they treat themselves simi- associations between self-compassion and well-
larly, young adolescents may be less likely to being were not confounded by family function-
engage in NSSI. Likewise, feeling security and ing and egocentrism. Neff and McGehee (2010)
warmth in their relationships with peers (with note that these findings suggest that self-
these relationships potentially taking on increas- compassion may be a more accessible point of
ing importance at this stage of development) may intervention than attempting to change compli-
help young adolescents practice self-kindness, cated patterns of family functioning. Conversely,
buffer against feelings of isolation, and reduce they note that the reverse may also be true such
risk for NSSI when facing challenges in life. that those higher in well-being may more easily
be able to express understanding, compassion,
and acceptance of their complicated family
dulthood: Link Between
A dynamics; emotional well-being may result in
Attachment Styles greater self-compassion toward one’s family
and Self-Compassion functioning.
Young Adulthood
Adulthood
As one of the first studies examining attachment
and self-compassion in adolescence and young Among adults, self-compassion has partially
adulthood, Neff and McGehee (2010) found mediated associations between attachment and
strong relations between higher self-compassion outcomes such as mental health (Raque-Bogdan
with lower depression, lower anxiety, and higher et al., 2011), depression (Øverup et al., 2017)
levels of positive social connection. In addition, and/or anxiety (Joeng et al., 2017), interpersonal
family functioning (secure attachment, maternal problems (Mackintosh et al., 2017), and subjective
support) and less endorsement of egocentrism well-being (Wei et al., 2011). Multiple studies
predicted self-compassion. In turn, self-have reported differential associations between
compassion partially mediated associations self-compassion and attachment anxiety/avoid-
between family and cognitive variables and ance with several studies finding that attachment
well-being. Adolescents (mean age of 15.2 years) anxiety held the most predictive power for lower
and young adults (mean age of 21.1 years) levels of self-compassion (e.g., Joeng et al., 2017;
reported similar levels of self-compassion, with Øverup et al., 2017; Raque-Bogdan et al., 2011).
self-compassion functioning in the same way in However, most recently, in a sample of adults
relation to well-being across these two samples. receiving psychological therapy in primary care
When differentiating the forms that insecure for anxiety and/or depression, Mackintosh and
colleagues (2017) found that attachment avoid- interpersonal trauma (e.g., abuse, assault, rape)
ance rather than anxiety played a key role in the predicted higher levels of attachment avoidance
connections between attachment, self-compas- and lower levels of self-compassion, which in
sion, and distress. Attachment avoidance, but not turn predicted worse interpersonal skills.
anxiety, along with low self-compassion and high Interpersonal skills then mediated the pathways
interpersonal problems predicted anxiety and between interpersonal trauma, attachment avoid-
depression, with self-compassion mediating this ance, and self-compassion with post-traumatic
relationship. They suggest that although individ- symptoms. They concluded that self-compassion
uals with attachment avoidance may maintain a may be a particularly helpful emotion regulation
positive self-image, avoidant individuals seeking strategy for adults in reducing the distancing,
treatment for anxiety and depression may have detachment, and rigidity characteristic of attach-
difficulty treating themselves with self-kindness, ment avoidance and allowing for affect and
approaching their distress with equanimity, and thoughts to be integrated into one’s self-concept
recognizing that they are not alone in their strug- after interpersonal trauma.
gles. Collectively, these studies indicate the The potential for self-compassion to serve as a
importance of examining attachment anxiety and coping strategy when facing illness has begun to
avoidance for adults separately in the context of be investigated, specifically in cancer survivor-
self-compassion and to be particularly sensitive ship research. Receiving a cancer diagnosis may
to assessing for lower levels of self-compassion represent another form of trauma or threat to
in individuals with avoidant attachment styles safety that may trigger the attachment system to
who are experiencing depression and anxiety. seek care and comfort. Self-compassion has been
Further, self-compassion has been explored as associated with better mental health outcomes for
a mediator along with other positive interper- breast cancer survivors (Pinto-Gouveia et al.,
sonal and intrapersonal factors such as mattering 2014), including less depression, anxiety, stress,
(Raque-Bogdan et al., 2011), belonging (Øverup and body image disturbance (Przezdziecki et al.,
et al., 2017), and empathy (Wei et al., 2011) as 2013; Sherman et al., 2017). In a sample with
well as negative factors such as burdensomeness breast cancer survivors of more than 5 years since
(Øverup et al., 2017) and fear of self-compassion diagnosis, Arambasic et al. (2019) found that
(Joeng et al., 2017). The connections between attachment anxiety and avoidance both predicted
self-compassion and variables such as mattering greater stress, more negative perceived impact of
(r = 0.34; medium effect size; Raque-Bogdan breast cancer on body image, worry, life interfer-
et al., 2011) and belonging (r = 0.46; medium ence (“I feel like cancer runs my life”), and lower
effect size; Øverup et al., 2017) imply that self-compassion. In turn, self-compassion medi-
self-compassion not only connects to how indi- ated the pathways through which attachment
viduals feel toward themselves but also relates to anxiety and avoidance, separately, related to
how they perceive others’ views of them. stress and negative perceived impact of cancer.
Longitudinal and experimental studies can help These findings further replicate conclusions
to parse out any causal pathways between self- drawn about the indirect impact of attachment
compassion and positive aspects of social con- through self-compassion on a wide range of men-
nection such as mattering and belonging. tal health outcomes for healthy youth, adoles-
cent, student, community, and clinical samples.
The Impact of Trauma in Adulthood

Older Adulthood
For adults reporting trauma, connections between
attachment, self-compassion, and stress continue The benefits of secure attachment and its poten-
to remain consistent with research on college stu- tial effects on the cultivation of self-compassion
dent and clinical populations. Bistricky et al. may continue into the later stages of life (Homan,
(2017) reported that higher experiences with 2018). Bowlby (1969/1982) indicated that illness
or loss may represent life circumstances in which Implications for Interventions

attachment styles are especially salient. Given
that older adults tend to experience more illness As the research presented in this chapter indi-
and loss, the salience of their attachment styles cates, attachment and self-compassion are inti-
may be especially relevant for their well-being mately connected. Self-compassion is a
during this stage of life. A growing body of mechanism through which attachment may influ-
research has supported the relevance of attach- ence well-being and other psychological out-
ment theory across the life span (e.g., Lopez comes. Moreover, parenting styles and the family
et al., 2018). Secure attachment in older adult- environment may influence attachment as well as
hood has been connected to higher quality of life self-compassion. As such, early interventions to
(Bodner & Cohen-Fridel, 2010) and marital satis- help parents cultivate secure attachment with
faction (Monin et al., 2014), greater ability to their children and foster self-compassion have
maintain social relationships, fewer depressive the potential to make a large difference in chil-
symptoms (Gillath et al., 2011), and lower pain dren’s development. In adulthood, interventions
perceptions (McWilliams & Bailey, 2010). to foster self-compassion also hold potential to
During the transitions in relationships and physi- correct for insecure attachment styles developed
cal health status experienced by older adults, in childhood. This section will first cover inter-
secure attachment continues to relate to higher ventions focused on parenting in early childhood
quality of life. and then discuss interventions targeting attach-
In one of the few studies to examine attachment and self-compassion in adulthood.
ment and self-compassion jointly for older adults, Mindful parenting, as described earlier in this
Homan (2018) reports that attachment anxiety chapter, has been found to promote positive and
and avoidance were both negatively associated secure parent-child attachment and adolescent
with the well-being dimensions of self- well-being by fostering self-compassion and
acceptance, personal growth, positive relation- mindfulness (Moreira et al., 2018). Early inter-
ships, purpose in life, and environmental mastery, ventions that target parenting styles can help chil-
and attachment anxiety additionally was associ- dren develop healthy attachment styles and
ated with lower levels of autonomy. Self- self-compassion from the start. Coatsworth et al.
compassion mediated the relations between (2010) adapted a Strengthening Families
attachment styles and these aspects of well-being Program: For Parents and Youth 10–14 to incor-
(excluding autonomy) for older adults. In other porate mindful parenting activities with the intent
words, older adults reporting a more secure of fostering more positive adolescent-parent rela-
attachment style also indicated higher levels of tionships and more mindful parenting practices.
self-compassion, and higher self-compassion The adapted program made the mindfulness mes-
served as the pathway through which attachment sages more explicit and included teaching mind-
connected to greater acceptance of themselves, fulness practices (e.g., mindful breathing),
increased engagement in activities that promoted engaging in mindful reflections (e.g., compassion
their growth, more fulfilling relationships with or loving kindness reflections) at the beginning
others, increased sense of purpose in their lives, and end of each session, and providing materials
and greater perceptions that they were living their to practice mindfulness at home. The researchers
lives in congruence with their values. To con- conducted a pilot randomized trial with 65 fami-
clude, attachment research with older adults pro- lies comparing the adapted program with the
vides evidence that attachment exerts its influence original program and a delayed intervention con-
“from the cradle to the grave” (Bowlby, 1979, trol group. Results indicate that the families in
p. 129) and self-compassion may be one impor- the adapted program incorporating mindfulness
tant pathway through which attachment operates demonstrated greater mindful parenting and
on well-being. higher quality parent-youth relationships as com-
pared to families in the original program.
Mediation analyses found that changes in mind- tries. The intervention involves eight sessions,
ful parenting served as the mechanism through each lasting 2.5 h. During the treatment, partici-
which the benefits of the adapted program oper- pants receive and offer compassion to friends,
ated. This suggests that interventions to help par- individuals deemed problematic, unknown indi-
ents engage in mindful parenting practices, viduals, and themselves. They also explore how
including compassion reflections, may be a the parent-child relationship emerged in child-
potential avenue for fostering healthier attach- hood and address maladaptive attachment styles
ments in children. that may have developed.
Cultural context is important to take into In a nonrandomized controlled trial with
account when considering interventions to healthy adults, ABCT demonstrated beneficial
improve parenting practices that foster secure outcomes (Navarro-Gil et al., 2018). Compared
attachment and self-compassion. The Family to the waitlist control group, the participants in
Care Curriculum is a 6-week intervention specifi- the ABCT group significantly increased their
cally developed for families experiencing home- level of secure attachment style, self-compassion,
lessness and includes a culturally sensitive and mindfulness and significantly reduced their
approach to teaching parents positive parenting level of psychological disturbance, anxiety, and
practices (Sheller et al., 2018). The curriculum avoidance. The increase in secure attachment
involves helping parents understand and provide style was mediated by increases in self-
for their children’s emotional, attachment, and compassion. ABCT has also been found to be
developmental needs, as well as understand how effective for adults with fibromyalgia (Montero-
their own experiences contribute to their parent- Marin et al., 2018). Compared to an active con-
ing beliefs and patterns. The program also trol group (i.e., relaxation exercises), the ABCT
explores the impact of racism, classism, and group demonstrated significant improvements in
oppression on the parent-child relationship. their general health status, which was maintained
Research on the outcomes is ongoing, but the at a 3-month follow-up. ABCT participants also
program addresses a much-needed gap in provid- reported improvements in anxiety, depression,
ing a culturally sensitive attachment-based inter- quality of life, and psychological flexibility.
vention to vulnerable populations. Another intervention, secure attachment prim-
Individuals who experienced insecure attach- ing, aims to enhance feelings of security by tem-
ments in childhood can still build secure attach- porarily activating an individual’s mental
ment and self-compassion as adults. The representations of secure attachment figures
following set of interventions are meant to (Mikulincer & Shaver, 2007a, b; Pepping et al.,
address and rectify insecure attachment styles in 2015). Pepping et al. (2015) examined the effect
adulthood and foster self-compassion. The inter- of secure attachment priming by randomizing
ventions include attachment-based compassion undergraduate students to either a 10-min prim-
therapy (ABCT; Garcia-Campayo & Demarzo, ing exercise or a 10-min interpersonal skills
2015; García-Campayo et al., 2016a, b), secure control group. During the secure attachment

attachment priming (Pepping et al., 2015), and priming, participants visualized a person who
self-compassion priming (Rowe et al., 2016). makes them feel comfortable and safe, who is
Attachment-based compassion therapy sensitive and responsive to their needs, and who
(ABCT; Garcia-Campayo & Demarzo, 2015; would help them if needed. They were also asked
García-Campayo et al., 2016a, b) was created to to think about how the person would help them
address maladaptive attachment styles developed and how it would make the participants feel.
in childhood. It is similar to other compassion Results indicate that security attachment priming
interventions in that it includes compassion and increased state attachment security and self-
mindfulness practices, but it differs in that it compassion. This offers evidence that even a
incorporates attachment theory. ABCT also 10-min intervention can enhance attachment
incorporates the cultural values of Latin coun- security, regardless of a person’s attachment
style, and that secure attachment fosters greater impact from the cancer. Moreover, they found
self-compassion. Interestingly, attachment anxi- that insecure attachment style was indirectly
ety and avoidance did not decrease as a result of linked to psychological adjustment via self-
the prime, which suggests that the secure attach- compassion, indicating that breast cancer survi-
ment priming intervention may need to be modi- vors may benefit from self-compassion training.
fied or enhanced in order to fully address insecure For instance, the My Changed Body intervention
attachment. A separate study found that individu- (Przezdziecki et al., 2013; Sherman et al., 2017)
als with higher levels of anxious and avoidant is a writing intervention that has been specifically
attachment styles felt more comfortable engaging developed to foster self-compassion in breast
in a compassion-focused imagery exercise after cancer survivors. The intervention has been found
participating in the secure attachment priming to improve psychological distress and body
intervention (Baldwin et al., 2019). These find- image distress (Sherman et al., 2017). Additional
ings suggest that interventions to enhance attach- studies are needed to explore whether the inter-
ment security may be needed before vention affects attachment style. Overall, these
self-compassion exercises can be effective for studies indicate that interventions to increase
those with insecure attachments. self-compassion can foster well-being, especially
In addition to secure attachment priming, among those with insecure attachment styles.
researchers have also explored self-compassion
priming. Rowe et al. (2016) randomized
meditation-naïve individuals to 10-min self- Conclusion
compassion priming, secure attachment priming,
or neutral priming (i.e., visualizing a shopping Attachment and the development of self-
trip) conditions prior to engaging participants in compassion are closely connected. Early life
a mindfulness meditation exercise. During the experiences influence the development of secure
self-compassion prime, participants were asked attachment and self-compassion through parents’
to visualize and write about being completely own attachment styles, parents’ practice of mind-
compassionate and warm toward themselves. The ful parenting, and individuals’ exposure to early
secure attachment prime was similar to that life trauma inside or outside of the family.
described previously in the Pepping et al. (2015) Further, the impact of attachment and self-
study. Results indicate that both self-compassion compassion is felt across the lifespan, with higher
priming and secure attachment priming increased levels of self-compassion associated with higher
participants’ willingness to engage in further levels of well-being for children, adolescents,
mindfulness training as compared to the control adults, and older adults. Promisingly, self-
group. While secure attachment priming had a compassion is a malleable point of intervention
direct effect on willingness, the self-compassion for parents to potentially influence their c hildren’s
prime operated indirectly through increasing attachment and self-compassion levels, as well as
state of mindfulness during the meditation exer- for adults to increase their ability to be compas-
cise. The results of this study indicate that both sionate toward themselves during times of illness
self-compassion and secure attachment primers (e.g., cancer) and good health.
can help individuals feel more open to pursuing a
challenging exercise.
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https://doi.org/10.1111/aphw.12051
Self-Compassion in Adolescence
6
Karen Bluth and Melissa Clepper-Faith
Introduction tant for adolescents and follow with an overview

of the adolescent research to date. This chapter
Self-compassion, or a way of self-relating that does not provide a comprehensive or systematic
has been described as kindness and compassion review but rather includes a diverse sample of the
turned inward (Neff, 2003), has been associated research studies that have been published and
with better overall emotional well-being in adults suggests ways in which the findings can support
in many studies and confirmed in meta-analyses healthy adolescent functioning.
(e.g., MacBeth & Gumley, 2012; Zessin et al.,
2015). Furthermore, studies demonstrate a lower
physiologic stress response among those who The Need for Self-Compassion
have higher trait self-compassion (Breines et al., in Adolescence
2014; Breines et al., 2015; Svendsen et al., 2016)
or who have been primed with self-compassion Adolescence is a crucial and often tumultuous
inductions (Arch et al., 2014); these are discussed developmental period, during which the main task
in-depth in another chapter in this volume. of teens is to explore and develop their identity
Overall, self-compassion has been associated through negotiating social roles, adapting to
with increased happiness, optimism, connected- changing peer and family relationships, and
ness to others, and curiosity and inversely associ- exploring career and vocational goals (Erikson,
ated with mental health disorders, including 1963; Marcia, 1980). While this exploration of
anxiety and depression in adult clinical and com- identity is taking place, the adolescent brain is
munity samples (Neff, 2009). going through significant restructuring; myelina-
Although research among adolescent population of neurons allows the brain’s processing
tions is newer and therefore not as extensive as speed to increase dramatically, and new neuronal
that of adults, studies indicate that self- pathways are established while unused pathways
compassion has similar beneficial effects on the are pruned away (Giedd, 2008), allowing for more
mental health and well-being of adolescents efficient information processing. Differences in
(Marsh et al., 2018). In this chapter, we will first the rate of maturation of brain systems, such as
describe why self-compassion is critically impor- the prefrontal cortex (or attentional control sys-
tem) and the amygdala (within the limbic system),
K. Bluth (*) · M. Clepper-Faith result in adolescents being more sensitive to emo-
University of North Carolina at Chapel Hill, tional highs and lows without always having the
Chapel Hill, NC, USA advantage of the ability to think clearly about the

https://doi.org/10.1007/978-3-031-22348-8_6
90 K. Bluth and M. Clepper-Faith
consequences of their actions (Keating, 2004). changes were mostly driven by females and
This aspect of the adolescent brain has been com- occurred across all race and ethnicities sampled
monly referred to as “being in a car with a sensi- (Twenge et al., 2018). Mental health disorders in
tive gas pedal and bad brakes” (Steinberg, 2005). adolescence, particularly when unrecognized or
These brain changes are reflected in adolescents’ untreated, can establish a maladaptive develop-
ability to think more abstractly; for the first time, mental trajectory and are predictive of substance
adolescents are able to think about their thinking abuse, poor academic achievement, and mental
or metacognate. Metacognition, although advan- and physical health disorders in adulthood (Patel
tageous in many ways, can also promote greater et al., 2007). According to the 2018 American
self-consciousness which can then lead to greater Psychological Association survey (American
self-criticism. At the same time, changes in sex Psychological Association, 2018), US adoles-
hormones, in particular, estrogen and testosterone cents reported higher stress than any other age
levels in females (Andersen et al., 2022; Copeland group and were least likely to report that their
et al., 2019), result in increases in depression and mental health was either excellent or very good.
anxiety. Notably, 75% of teen respondents cited gun vio-
In addition to the normative ongoing restruc- lence in general, mass shootings, and school
turing of the brain and other physiological shootings as high on their list of stressors.
changes which take place during this period Certain subpopulations of adolescents are at
(Giedd, 2008), this developmental stage may be higher risk for mental health disorders when
complicated by environmental challenges that compared to their peers and are important groups
may have long-term deleterious effects on adult to support through intervention. For example,
health. These challenges often include social studies have shown gender differences exist in
stressors such as transitions to different schools how teens respond to stress, with females being
and peer and academic pressures (Forbes & Dahl, at greater risk of developing and maintaining
2010; Steinberg & Morris, 2001) and may also internalizing disorders such as depression and
include in-person and cyberbullying (Patchin & anxiety. Beginning in early adolescence, females
Hinduja, 2013), exposure to violence (Lambert report more depressive symptoms than males
et al., 2005), structural racism (Lambert et al., (Bennik et al., 2014; Nolen-Hoeksema, 2012;
2009), physical safety concerns, misogyny (Dosil Sontag & Graber, 2010), and this global trend
et al., 2020), inadequate academic resources continues through adolescence until age 16–19
(Crede et al., 2015), food insecurity (Shanafelt when females are twice as likely to be depressed
et al., 2016), homelessness (Wang et al., 2019), as males (Salk et al., 2017). Also, teens who have
and lack of future academic and economic oppor- preexisting health disorders that were diagnosed
tunities (Johnson et al., 2014). Thus, the complex in childhood are faced with the added normative
interaction of various physiological changes tak- stressors of adolescence, coupled with the drive
ing place at this developmental period, combined for independence and desire to self-direct their
with the onslaught of environmental challenges, medical treatment. For instance, teens with
sets the stage for adolescents to be highly self- chronic medical illnesses, (e.g., Type 1 diabetes
critical, anxious, and depressed, particularly for mellitus, eating disorders, cancer) face the added
females. challenges of transitioning to self-care and man-
Although adolescence has always been recog- agement of their medications and treatment regi-
nized as a time of increased vulnerability to men- men (Finlay-Jones et al., 2020). Similarly,
tal health problems, over the last decade, mental adolescents with developmental delays may find
health disorders among adolescents have sky- their health challenges exacerbated by the social
rocketed. For example, between 2010 and 2015, and academic stressors of adolescence (North
high symptoms of mental illness increased by et al., 2013).
33% among a US sample of adolescents aged Furthermore, a past history of physical, sex-
13–18, and suicides increased by 31%; these ual, or emotional abuse is a risk factor for adoles-
6 Self-Compassion in Adolescence 91
cent and adult mental health disorders, including Further, sexual/gender minority (SGM) ado-
anxiety, depression, and suicidality (Lindert lescents experience worse mental health out-
et al., 2014; Lippard & Nemeroff, 2020; Sweeting comes (i.e., greater depression, higher suicide
et al., 2020; Turner et al., 2017). Childhood abuse ideation rates) than their sexual majority peers,
and other adverse childhood experiences are which is likely a result of higher levels of bias-
associated with a higher risk of physical disease based bullying, victimization, and social stigma
in adulthood and adolescence (Felitti et al., 1998; they experience (Gnan et al., 2019; Hatchel et al.,
Herrenkohl et al., 2013; Lippard & Nemeroff, 2019; Vigna et al., 2017). In fact, stigmatized
2020). When adverse childhood experiences SGM youth have two to three times the rates of
occur over a prolonged period, the toxic stress depression, anxiety, self-injury, and suicide rates
which results can cause changes in the develop- relative to their sexual gender majority peers
ing brain that has lifelong impacts (Kuo et al., (King et al., 2008; Zaza et al., 2016).
2012; Shonkoff & Garner, 2012). For example, In addition, other subpopulations of adoles-
childhood sexual abuse has been linked to both cents which struggle with nonnormative stressors
internalizing and externalizing maladaptive that exacerbate the normative stressors of adoles-
behaviors, including depression, and worldwide, cence include youth experiencing homelessness
prevalence for childhood sexual abuse is 18% for or undocumented status (Torres et al., 2018;
females and 8% for males (Kuehner, 2017). Zapata et al., 2016), adolescents in the child wel-
Finding ways to combat the effects of early life fare system (Tanaka et al., 2011), and adolescents
diversity is instrumental to disrupting its long- who were maltreated or victimized as children
term sequelae. (Játiva & Cerezo, 2014; Vettese et al., 2011).
The stressors faced by marginalized popula- Further, youth with multiple marginalized identi-
tions, such as Black, Indigenous, and People of ties, such as those listed above who also struggle
Color (BIPOC), exacerbate the challenges of with experiences of racial discrimination and are
adolescence, and many BIPOC adolescents expe- LGBTQIA+, may face an intersectional or com-
rience greater psychological, academic, and pounding effect of stress on their mental health
behavioral challenges than their White counter- (Vigna et al., 2017).
parts both during and after adolescence (Assari Importantly, the current social climate, char-
et al., 2017; Hughes et al., 2016; Huynh & acterized by political instability, racial protests,
Fuligni, 2010; Paradies et al., 2015; Umaña- the global COVID-19 pandemic, and the result-
Taylor & Updegraff, 2007). For example, a 2015 ing disruption of school and social structures, has
systematic review and meta-analysis found a sig- exacerbated many of these risk factors and has
nificant association between experiencing racism increased the stress level of adolescents. One
and negative mental health outcomes, including recent study reported that compared to pre-
depression, stress, and anxiety, particularly for pandemic measures, adolescents in a large pedi-
Asian-Americans and Latinx-Americans atric primary care network in the Northeast
(Paradies et al., 2015). Additionally, youth who United States had significant increases in depres-
have recently emigrated may experience higher sive symptoms and suicidal thoughts, particularly
risk of depressive symptoms related to their among female, non-Hispanic Black, and non-
immigration status and the perception of being Hispanic White adolescents during the pandemic
regarded as “foreigners” (Davis et al., 2016; (Mayne et al., 2021). Female adolescents in this
Lopez et al., 2016; Sirin et al., 2019). As one study had a 34% increase in suicidal thoughts
example, Latinx youth who recently emigrated to compared to before the COVID-19 pandemic,
the United States experienced ethnic discrimina- 1 year prior (Mayne et al., 2021). Another study
tion in the ninth grade and were more likely to found that the global prevalence of child and ado-
develop depressive symptoms 6 months later lescent depression and anxiety has doubled in the
(Davis et al., 2016). first year of the COVID-19 pandemic, to current
pooled estimate prevalence levels of 25% and research providing evidence for links between
20.5%, respectively (Racine et al., 2021). In fact, self-compassion and various dimensions of well-
Ellis et al. (2020) found that during the COVID-19 being among adolescents is discussed next.
pandemic, 43% of adolescents were “very con-
cerned” about the pandemic, as it related to their
academic success and relationships with friends, ssociations Between Self-
A
and COVID-related stress was associated with Compassion and Well-Being
greater loneliness and depression, particularly for Outcomes
those adolescents who spent more time on social
media. Further, as connecting with peers and The first empirical study on self-compassion and
establishing one’s place in the social network are adolescence was published in 2010; in this study,
critical tasks in adolescent development, and in- Neff and McGehee explored the relationship
person schools and peer interactions have been between self-compassion and psychological
limited during the pandemic, social media use resilience in US adolescents and young adults
among adolescents increased during this time, (Neff & McGehee, 2010). Since then, numerous
with 48% spending more than 5 hours a day on studies have been published, and overall, research
social media since schools closed (Ellis et al., findings mirror that of adults. For example, simi-
2020). Along with the advantages of social con- lar to the meta-analysis on adults that shows a
tact, online social media use during the pandemic large inverse relationship (r = −0.54) between
also may have increased unhealthy social media self-compassion and psychopathology, defined as
interactions, such as cyberbullying, increasing stress, anxiety, and depression (MacBeth &
adolescent mental health challenges (Mayne Gumley, 2012), Marsh et al.’s (2018) meta-
et al., 2021). analysis of adolescent samples demonstrated a
Clearly, there is no magic pill that will allevi- similar magnitude in the relationship between
ate these complex challenges that adolescents self-compassion and psychopathology (r = −
face today. However, building inner resources to 0.55). Supporting this, a systematic review of
contend with these stressors is one important studies on self-compassion and depressive symp-
strategy for helping to modulate adverse impacts. toms in adolescents found that across both longi-
For example, establishing a sense of identity with tudinal and cross-sectional studies,
a community, finding meaning behind struggles, self-compassion was inversely related to depres-
and acknowledging one’s agency (Meyer, 2015) sive symptoms (Pullmer et al., 2019a).
are all internal resources that can be strengthened Similar associations between self-compassion
and have been found to be advantageous in deal- and various domains of emotional health have
ing with minority stressors (Meyer, 2015). They been reported. Specifically, Neff and McGehee
are also all aspects of self-compassion; a sense of (2010) found that self-compassion is positively
common humanity emerges from identifying correlated with social connectedness in adoles-
with a community, finding meaning behind strug- cents; this is noteworthy as establishing healthy
gles is part of growth toward self-kindness (and peer relationships and stable social networks is
taught directly in an exercise in the Mindful Self- critical factor in emotional well-being during
Compassion program), and acknowledging one’s adolescence. Additionally, this study also
agency and purpose is integral to fierce reported positive associations between self-
self-compassion. compassion and secure attachment and negative
As adolescence is a sensitive period for inter- associations between self-compassion and preoc-
vention and often a precarious period for emo- cupied and fearful attachment, suggesting that
tional stability, providing teens with coping tools self-compassion is established in an individual
such as self-compassion can potentially shift through safe and trusting early life relationships.
their mental health and behavioral trajectory to a As there has been a paucity of opportunities to
more positive and salubrious pathway. The develop and cultivate close peer relationships
during the time of the pandemic, the ramifica- can always be present to support oneself (Neff &
tions of isolation during this period may influ- Vonk, 2009).
ence the emotional well-being of adolescents that The relationship between self-compassion and
may not be apparent for some time. self-esteem was investigated further in a study
In understanding the implications of self- which used cross-lagged autoregressive struc-
compassion for adolescent well-being, it is tural equation modeling to determine the tempo-
important to clearly delineate the differences ral order of constructs, i.e., which construct
between self-compassion and self-esteem. Due to predicted the other (Donald et al., 2018). Over
the many physiological, cognitive, and environ- 4 years, self-compassion and self-esteem levels
mental changes taking place at this developmen- of 2809 adolescents were assessed. Results indi-
tal stage, many adolescents, particularly females, cated that self-esteem consistently predicted self-
struggle with low self-esteem; the chapter on compassion levels, whereas self-compassion
self-esteem within this handbook discusses this levels did not predict levels of self-esteem, indi-
at length. Although both self-compassion and cating that among adolescents, it may be neces-
self-esteem are ways of self-relating, self-esteem, sary to feel valued, worthy, and deserving to give
defined as a global evaluation of one’s self-worth oneself compassion. More research with adoles-
(Baumeister et al., 2003), differs from self- cent populations is needed to replicate these
compassion in that it is acquired and maintained findings.
by comparing oneself with others. For example, The different roles of self-compassion and
social media provides a readily accessible way self-esteem as linked to adolescents’ psychologi-
for adolescents to compare themselves to others cal well-being are evidenced in a study by
through number of “likes”, “shares,” and filtered Marshall et al. (2015). In this longitudinal study
or curated images posted on social media plat- of 2448 high school students in Australia, self-
forms. Unfortunately, this comparison often has a compassion had a buffering effect, protecting
negative impact on one’s self-esteem; in fact, against the negative effects of low self-esteem.
45% of adolescents aged 15–21 indicated that For grade 9 students who were high in self-
engaging in social media makes them feel judged, compassion, having low self-esteem did not have
and 38% report that it makes them feel bad about an effect on their mental health; in grade 10,
themselves (American Psychological these students had no significant change in their
Association, 2018). Yet even if the comparison mental health. However, grade 9 students who
does not have a negative outcome or even results were both low in self-compassion and self-esteem
in a boost in one’s self-esteem, the consequence had worse mental health when they were assessed
of comparing oneself with others leads to an in grade 10. Thus, having high self-compassion
emotional separation from others at a time in life appeared to protect against the negative repercus-
when what is most needed is connection with sions of having low self-esteem (Flett et al., 2003;
others and a sense of belonging. For example, Hewitt & Flett, 1991; Marshall et al., 2015).
whether one considers oneself above average in a
particular trait or below average (i.e., high self-
esteem or low self-esteem), an outcome is that Self-Compassion as a Buffer Against
one sees oneself as apart from others, rather than Stress and Trauma
feeling accepted and included, or as an integral
part of a community. Further, establishing high Managing stressful circumstances in a healthy
self-esteem is dependent upon performance and way is an essential skill that adolescents must
achievement, and inevitably one will not always learn to transition to becoming adults who lead
perform at their best or even fail, and thus one’s fulfilling and satisfying lives. Being able to cope
self-esteem is unstable. In contrast, self- with stressful circumstances productively and
compassion offers a way of self-relating that is successfully is therefore critical to healthy ado-
stable over time. Through self-compassion, one lescent development. Among adolescents, self-
compassion has been shown to be associated with forest fire occurred in northern Israel in December
increased adaptive coping following stressful 2010, forcing the evacuation of an educational
events. For example, one study found that under- residential youth village in which high school
graduates (mean age = 18 years) in Japan who students lived, 50% of whom had come from
were higher in self-compassion reported 1 month homes where they experienced chronic stressors
later that they felt more in control of a recent such as poverty, violence, and substance abuse
stressful event and felt that it was less threatening and 20% of whom were orphans. Notably, within
to them compared to those who were lower in 1 month of the fire, 88% of adolescents reported
self-compassion (Chishima et al., 2018). that they feared for their lives when the fire was
Furthermore, self-compassion was negatively taking place. Among these youth who were
related to avoidance coping; those adolescents already considered at-risk, both longitudinal and
who were higher in self-compassion were less multilevel mediational analyses demonstrated
likely to engage in maladaptive coping strategies that having greater self-compassion predicted
such as denying, disengaging, or distracting less post-traumatic stress, panic symptoms,
themselves from a problem (Chishima et al., depressive symptoms, and suicidality 3 and
2018). 6 months later (Zeller et al., 2015).
Self-compassion may also play a buffering The potential buffering effect of self-
role in protecting adolescents from negative out- compassion described here is also supported by
comes resulting from traumatic early life experi- evidence from physiological responses to stress
ences and chronic stress. For example, among in an experimental protocol. The Trier Social
adolescents who had experienced abuse and Stress test is a well-established research protocol
neglect as children and were part of the Canadian that has been used extensively to elicit a physio-
child welfare court system, those who reported logical stress response that can then be measured
greater self-compassion were less likely to expe- in a lab setting. Adolescents were exposed to the
rience psychological distress, problem alcohol Trier Social Stress test in which they were asked
use, or report a suicide attempt than those with to give a speech and perform math computations
greater self-compassion, even when accounting in front of two neutral-faced lab-coated adults.
for early life maltreatment (Tanaka et al., 2011). Adolescents who self-reported greater self-
Among another population of adolescents experi- compassion had less of a change in their systolic
encing chronic stress, Prentice et al. (2021) inves- blood pressure during the lab stressor than those
tigated adolescents and young adults who with lower self-compassion (Bluth et al., 2016b),
struggle with chronic physical health problems indicating that self-compassionate adolescents
requiring ongoing medical care. In this study, may get less activated in stressful situations than
self-compassion was positively associated with adolescents who are less self-compassionate.
emotional well-being and negatively associated However, more research using various physiolog-
with mental distress. Difficulties in emotion reg- ical measures of evaluating stress is needed to
ulation mediated the relationship between self- substantiate this finding.
compassion and distress; this suggests that In addition to buffering the effects of external
interventions addressing emotion regulation dif- stressors (Flett et al., 2003; Hewitt & Flett, 1991;
ficulties and promoting self-compassion may be Marshall et al., 2015), self-compassion also
particularly helpful for teens facing the chal- appears to protect against the negative impacts of
lenges of chronic medical illness (Prentice et al., internal characteristics that increase vulnerability
2021). to adverse outcomes, such as maladaptive perfec-
Being more self-compassionate appears to be tionism. Maladaptive perfectionism is defined by
beneficial in managing not only long-term having high personal standards that involve high
chronic stressful events, such as childhood abuse/ self-criticism, being overly worried about mak-
neglect and health problems, but also acute ing mistakes, and fear of being negatively evalu-
stressful events. The weeklong Mount Carmel ated by others. Many adolescents struggle with
maladaptive perfectionism in various domains of high self-compassion were less likely to nega-
their lives, including physical appearance, aca- tively evaluate their appearance when comparing
demics, and their interactions and relationships their image to someone who they considered
with peers. This type of perfectionism has been more attractive (Ntoumanis et al., 2020).
linked to depression (Flett et al., 2003; Hewitt & Similarly, Rodgers et al. (2017) found that
Flett, 1991) and is considered transdiagnostic in self-compassion moderated the relationship
that it affects many aspects of health, including between perceived overweight status, appearance
anxiety and eating disorders (Egan et al., 2011). comparison, and appearance esteem in their study
For example, maladaptive perfectionism related of 232 adolescents, aged 13 to 18 years.
to academic achievement among adolescents has Appearance comparison, which is the process of
been linked to anxiety and depression (Einstein comparing one’s physical appearance to others
et al., 2000) and negative affect after taking a test and engaging in mostly unfavorable comparisons,
(Flett et al., 2009). Ferrari et al. (2018) demon- has been identified as a critical mechanism in the
strated that by treating self-critical thoughts as maintenance of body image concerns and medi-
passing events and as an opportunity to treat one- ates the relationship between weight status and
self with kindness, one is able to interrupt and body dissatisfaction. Perceived overweight status
subvert the pathway to depression. In this study, in adolescents is associated with body dissatisfac-
541 adolescents in a high school setting com- tion and poor self-esteem. The two self-
pleted questionnaires comprising measures of compassion components of common humanity
perfectionism, depressive symptoms, and self- and mindfulness moderated the association
compassion. As expected, the results showed a between perceived overweight status and appear-
positive correlation between maladaptive perfec- ance comparison among boys, but not among
tionism and depression and a significant moder- girls. In other words, for those boys who had
ating or buffering effect of self-compassion on higher levels of mindfulness and common human-
the relationship between maladaptive perfection- ity, the link between perceiving themselves as
ism and depression, thus weakening this relation- overweight had less of an effect on negatively
ship (Ferrari et al., 2018). In other words, when evaluating their appearance (Rodgers et al., 2017).
self-compassion was high in adolescents, the link Self-compassion has also been shown to be a
between maladaptive perfectionism and depres- moderator in the association between non-
sion was not as strong, and adolescents who were suicidal self-injury (NSSI) and depressive symp-
more self-compassionate were less likely to toms in adolescence (Xavier et al., 2016). NSSI,
become depressed. described as self-injury that is not associated
Many adolescents and young adults struggle with suicidal intent, is prevalent in adolescents,
with maladaptive perfectionism concerning body particularly females. In fact, one study reported
image, the subjective assessment or judgment on that one in four females and one in ten males
one’s physical appearance. Ntoumanis et al. reported engaging in NSSI over the previous
(2020) studied the association of upward appear- 12 months (Monto et al., 2018). Six hundred
ance comparison (comparing oneself to another forty-three adolescents aged 12–18 years com-
who is perceived as more attractive) on appear- pleted questionnaires containing measures of
ance evaluation (the sense of satisfaction with emotional health, risk-taking and self-harm, self-
one’s own body image) in 396 Greek adolescents. compassion, and daily peer hassles (i.e., conflicts
This study investigated appearance-specific self- with friends regarding beliefs, opinions, and
compassion, i.e., self-compassion that is specific choices). The results showed that those who
to negative appearance-related thoughts, rather reported higher depression scores and daily peer
than global self-compassion. For these adoles- hassle scores were more likely to self-injure.
cents, appearance self-compassion moderated, or Importantly, self-compassion had a significant
buffered, the effects of upward comparison on modifying or buffering effect on the relationship
appearance evaluation; those adolescents with between depression and NSSI; higher levels of
self-compassion were associated with lower lev- adolescents (Neff & McGehee, 2010). Bluth and
els of NSSI, independent of the adolescents’ Blanton (2015) examined differences in self-
depression levels (Xavier et al., 2016). compassion at different adolescent developmen-
As suicide is the second leading cause of death tal stages and found that level of self-compassion
among adolescents aged 15–19 in the United did not differ between males and females in mid-
States and the fourth leading cause of death in dle school but differed significantly between
China, finding ways to obviate suicide attempts is males and females in high school, where girls
of critical concern. In one study, self-compassion scored lower in self-compassion than their male
moderated the association between suicidal ide- counterparts, as well as lower in self-compassion
ation and suicidal attempts in a cohort of 520 than middle school females. Further, the inverse
Chinese adolescents (Sun et al., 2020). Those relationship between self-compassion and nega-
adolescents with higher self-compassion (mea- tive affect was significantly greater among older
sured by high scores when combining the three adolescents compared to that of younger adoles-
positive components of self-compassion and low cents (Bluth & Blanton, 2015).
scores when combining the negative components Much has been posited about why adolescent
of self-compassion) who had thoughts of suicide females experience greater depressive symptoms
were less likely to attempt suicide over a and negative affect than males (Nolen-Hoeksema
12-month interval, compared to those with low & Girgus, 1994), and likely similar explanations
self-compassion (Sun et al., 2020). exist for lower self-compassion. First, there may
Sex differences in the moderating role of self- be biological explanations; puberty brings
compassion have also been found. Results of a increases of estrogen and testosterone, and these
cross-sectional study of 1057 adolescents (65% changes, and particularly the amount of fluctua-
female, mean age 14.5 years) supported the tion in these changes, have been linked to depres-
inverse relationship between self-compassion sion (Andersen et al., 2022; Copeland et al.,
and perceived stress, depression, and anxiety and 2019). Social changes take place at this time as
found that self-compassion moderated the asso- well; gender intensification theory suggests that
ciation between perceived stress and anxiety for in early adolescence, boys and girls take on more
males only (Lathren et al., 2019) but moderated “traditional” gender roles for a time, which work
the association between perceived stress and in boys’ favor; boys tend to dominate and direct
depression equally between sexes. These findings conversations, for example, resulting in a loss of
are consistent with an earlier study showing that agency for girls (Del Giudice, 2015).
self-compassion was a buffer against later onset Self-compassion levels have also been mea-
of anxiety or depression following a traumatic sured among sexual/gender minority adolescents
event (Zeller et al., 2015). (i.e., LGBTQIA+) and were found to have lower
level of self-compassion than their sexual/gender
majority peers, with a medium effect size. Vigna
Gender and Age as Moderators et al. (2017) postulated that this is an effect of the
of Self-Compassion internalization of discrimination and stigma that
many SGM experience daily. Indeed, minority
Similar to findings from a meta-analysis with stress theory explains that SGM adolescents suf-
adults that reported that women had lower levels fer from substantial proximal and distal stressors,
of self-compassion overall compared to men such as discrimination in school, rejection from
(Yarnell et al., 2015), most evidence in adoles- family, and discomfort with their identity result-
cent studies have also found levels of self- ing in higher rates of depression, anxiety, and sui-
compassion are greater in males (Bluth & cidality compared to their non-SGM peers
Blanton, 2015; Bluth et al., 2016b; Castilho et al., (Goldbach & Gibbs, 2017).
2017; Pullmer et al., 2019a). However, one study In another study of 238 Canadian high school
found no difference between male and female students, results indicated significantly higher
self-compassion in males than in females self-esteem and self-compassion, when com-

(Pullmer et al., 2019b); this longitudinal study pared to younger adolescents (aged 9–10 years).
investigated relationships between baseline Although not measured in this study, previous
self-compassion and the mediating function of literature attributes this to the fact that older
psychological distress on eating behaviors and female adolescents have lower self-compassion,
body satisfaction at two time points, 14 to higher negative affect, and less life satisfaction
18 weeks apart. While findings demonstrated that than their younger female adolescent counter-
self-compassion was positively associated with parts (Bluth & Blanton, 2015). Further, older
body satisfaction, and negatively associated with adolescents have also shown greater increases in
eating pathology for both males and females at self-compassion scores following an intervention
both time points, changes in psychological dis- when compared to younger adolescents (Bluth &
tress mediated the relationships between self- Eisenlohr-Moul, 2017); this may be because hav-
compassion and the outcomes of body satisfaction ing lower self-compassion levels at baseline
and eating pathology for females but not males. affords a greater opportunity to raise level of self-
The authors suggested that it may be that there compassion across an intervention. Interestingly,
are other pathways in which self- compassion the meta-analysis of studies on self-compassion
influences body satisfaction and eating pathology that examined gender differences found that
in males, such as concerns about muscle mass, although men reported higher self-compassion
for example (Pullmer et al., 2019b). levels than women, this association diminished
There is some evidence that the response to with increasing age, perhaps due to increased
self-compassion interventions also differs by development of the common humanity aspect of
gender. Bluth and Eisenlohr-Moul (2017) self-compassion in older individuals (Yarnell
reported a trend for a greater increase in self- et al., 2015); that is, with age, people are more
compassion in females than males following an able to see that experiencing emotions, particu-
8-week self-compassion program. This is similar larly emotions that are challenging, is part of the
to findings from a study of a 6-week mindfulness experience of being human.
program in which there was preliminary evidence
that females were more engaged than males; for
example, only 60% of boys used mindfulness Self-Compassion as a Mediator:
stress-reduction techniques during the post- The Role of Self-Compassion
intervention stress test, compared to 100% of the in Predicting Outcomes
girls (Bluth et al., 2017). As developmental matu-
rity occurs at different ages for males and females, Self-compassion has been shown to be a mecha-
differences may be related to males’ relative lack nism which explains the relationship between
of maturity and emotional states compared to various risk or protective factors that adolescents
females of the same age (Steinberg & Morris, are exposed to and their psychological outcomes.
2001). Also, as adolescent males often adopt tra- For example, Neff and McGehee (2010) reported
ditional male hegemonic norms, they may be that self-compassion partially mediated the rela-
reluctant to engage in compassion programs that tionship between early life influences, including
they perceive as being “weak” or “soft” (Kirby & maternal support and family functioning and
Kirby, 2017); rather, programs that emphasize adolescent well-being, defined by depression,
the cultivation of courage or strength may be anxiety, and connectedness. Adolescents’ reports
more appealing. of maternal support and better family functioning
Self-compassion levels can also vary accord- led to greater self-compassion, which was then
ing to the age of the adolescent. Stolow et al. associated with less depression and anxiety and
(2016) reported that older adolescents (aged greater sense of connectedness. This suggests
12–16 years) showed higher levels of self- that healthy family functioning provides support
criticism and depressive symptoms, and lower for establishing and maintaining self-compassion
in the individual, which then leads to better men- (as compared to indirect victimization) had worse
tal health during adolescence. psychological maladjustment than others, and
In another study, self-compassion mediated self-compassion partially mediated the relation-
the relationship between shameful memories and ship between victimization and psychological
traumatic experiences that had been experienced maladjustment. In other words, those adolescents
earlier in life and depressive symptoms occurring who had experienced more victimization and
in adolescence. Shameful memories arise from direct victimization had lower levels of self-
past experiences in which one is the target of compassion, which was then associated with
exclusion, rejection, or criticism; the recollection higher levels of psychological maladjustment
of these experiences later in life can produce and more internalizing and externalizing prob-
intense emotional responses, including feelings lems (Játiva & Cerezo, 2014).
of shame, self-criticism, and isolation (Castilho Wu et al. (2019) found that self-compassion
et al., 2017). Adolescents are particularly vulner- mediated the relationship between peer accep-
able to shame memories because they are engaged tance and non-suicidal self-injury (NSSI) in 816
in the development of self-identity and social Chinese adolescents. Increased peer acceptance
connectedness, and memories of past experiences led to increased self-compassion, which then was
have a strong effect on the maturation of a posi- associated with decreased depressive symptoms
tive self-identity (Castilho et al., 2017). Among and decreased NSSI. This mediation model was
1100 adolescents in Portugal, Castilho et al. moderated by behavioral impulsivity; for those
(2017) found that self-compassion mediated the adolescents with higher levels of impulsivity,
relationship between adolescents’ shame memo- increased self-compassion was linked with
ries and depressive symptoms, such that shame decreased NSSI, while for adolescents with lower
memories were linked with lower self- levels of impulsivity, there was no significant
compassion, which in turn was associated with relationship between self-compassion and NSSI
greater depressive symptoms. Higher levels of (Wu et al., 2019). The implications of this study
self-compassion were associated with higher are that for adolescents who are impulsive, such
emotional self-regulation and self-soothing, as those with attention deficit hyperactivity disor-
which may have contributed to the adolescents’ der (ADHD) who may struggle with being
ability to use more effective strategies to deal accepted by their peers, cultivating self-
with difficult emotions. One crucial strategy for compassion may be particularly important for
the healthy functioning of adolescents is the for- decreasing depressive symptoms and NSSI.
mation of supportive social bonds; this study In a study with 1872 US adolescents, Vigna
concluded that self-compassion may facilitate a et al. (2017) examined the relationship between
sense of interpersonal connectedness and of com- bias-based bullying and victimization related to
mon human experience, which may help adoles- sexual/gender minority (SGM) status. Bias-based
cents build social bonds and lessen shame and bullying is the targeted, stigmatized harassment
self-criticism, which is then linked with lower of those who are perceived as marginalized or
depression (Castilho et al., 2017). “other” in some way by their peers. SGM youth
Similarly, 109 adolescents with poor school reported higher levels of exposure to adversity,
performance who had experienced being victim- risk-taking behaviors, bias-based bullying, peer
ized (i.e., victimization as a child by a parent or victimization, and depression and anxiety, and
siblings; having experienced assault, robbery, or lower levels of self-compassion, compared to
kidnapping; sexual victimization; indirect vic- their SGM majority peers, and self-compassion
timization such as observing others being victim- attenuated the relationship between bias-based
ized; Internet victimization) were assessed (Játiva bullying/peer victimization and both anxiety and
& Cerezo, 2014). Those who had experienced depression. The degree to which self-compassion
poly-victimization (i.e., several types of victim- mediated the association of bias-based bullying
ization) and directly experienced victimization and anxiety and depression varied according to
the adolescents’ level of exposure to bias-based In addition to explicitly introducing and

bullying; those with higher levels of bias-based teaching self-compassion practices in the
bullying reported less of a mediating effect of MSC-T program, self-compassion is also taught
self-compassion on this association (Vigna et al., implicitly in mindfulness programs and retreat
2017). These results suggest that for those with settings. In these programs, self-compassion is
relatively lower levels of bias-based bullying, embedded within the context of teaching mind-
greater self-compassion could potentially facili- fulness. For example, in the adolescent mindful-
tate the pathway to reducing the adverse effects ness programs such as Learning to BREATHE
of bias-based bullying and internalization of (Broderick, 2021) and iBme (www.ibme.com),
stigma and thereby improve the mental health concepts of self-compassion are taught implic-
outcomes for SGM youth. itly within the program, and self-compassion
practices are included, although the focus of the
program is learning mindfulness skills. Galla
Interventions: Cultivating Self- (2016, 2017) measured change in self-compas-
Compassion in Adolescents sion across two studies in two subsequent years
in a mindfulness retreat program for adolescents
Recognizing the beneficial correlates of self- and reported that within-person change in self-
compassion in adolescents, and the positive out- compassion was the “driver” behind more of the
comes of the Mindful Self-Compassion (MSC) outcomes than within-person change in mind-
program developed by Neff and Germer (2013), fulness. Self-compassion predicted decreases in
an adaptation of MSC was created for adoles- perceived stress, rumination, depressive symp-
cents, called Mindful Self-Compassion for Teens toms, and negative affect and increases in posi-
(formerly known as Making Friends with tive affect and life satisfaction, for example
Yourself) (MSC-T). MSC-T is currently an eight- (Galla, 2016).
session group program involving weekly sessions
of 1.5-hour duration that teaches skills of self-
compassion. Implementation of MSC-T has Limitations and Future Directions
demonstrated decreases in depression, anxiety,
negative affect, and stress and increases in self- As research on adolescents and self-compassion
compassion pre- to post-intervention (Bluth is just over a decade old, there are many gaps in
et al., 2021; Bluth & Eisenlohr-Moul, 2017; the literature that need to be addressed. First,
Bluth et al., 2016a; Galla, 2016). Like MSC, most studies are cross-sectional which precludes
MSC-T has a foundation of mindfulness and determining a causal link between self-
focuses on teaching skills of self-compassion; in compassion and mental health outcomes.
particular, participants in both MSC and MSC-T Although Krieger et al. (2016) provided support
are taught to recognize that most of us tend to be that self-compassion was antecedent to depres-
much harder on ourselves than we are on others sion in a cross-lagged panel analysis with an
and that harsh self-criticism often is detrimental adult sample, longitudinal studies are needed
to our mental health. For example, in the MSC-T among adolescent populations to support direc-
program, adolescents learn to recognize when tion of effects. For example, it may be that among
their inner critic arises and are taught to then adolescents, those with less depressive symptoms
actively take steps to practice being kinder and are more able to be self-compassionate, rather
more compassionate to themselves. Perhaps most than self-compassion predicting depressive
importantly, adolescents discover that they are symptoms, or it may be that these relationships
not alone in their struggles and that other adoles- are bidirectional. Additionally, longitudinal stud-
cents encounter many of the similar emotional ies with at least three time points are needed to
pitfalls as do they. Often, this is very eye-opening determine mediation pathways, as cross-sectional
to adolescents. mediation studies have distinct limitations, and
should be used only as a preliminary way to con- online with minor modifications has been shown
ceptualize mediation (MacKinnon, 2008). to be feasible (Bluth et al., 2021), it may be that
Also, there is a lack of standardization of out- online implementation of self-compassion inter-
come assessments across studies, including stan- ventions is the most effective way to reach ado-
dardized measures assessing emotional lescents, particularly those in remote areas or
well-being and mental health. As one example, in those who, due to illness or other reasons, are
their meta-analysis, Pullmer and Chung et al. unable to attend a program in-person (Finlay-
(2019a) reported that studies utilize numerous Jones et al., 2020). Further, it would be valuable
measures of depressive symptoms. Using stan- to engage the adolescents as community advisors
dard measures would allow for comparison on how to best tailor the intervention to meet the
across studies and make synthesizing the results specific needs of their subpopulation, as well as
of these studies more accurate. Recent debates in how to best reach these adolescents and recruit
the literature over the factor structure of the self- them into the program. For example, in a review
compassion scale (e.g., Muris et al., 2019; Neff of self-compassion as an active component in the
et al., 2018) have added variability to the way prevention of anxiety and depression in adoles-
self-compassion is defined and measured. cents and young adults, Egan et al. (2022) inter-
Hopefully, the publication of the youth self- viewed 20 young people, to ascertain their
compassion scale (Neff et al., 2021) will help to understanding of self-compassion and how to
standardize self-compassion assessment in youth. best offer self-compassion programming to ado-
In addition, there is lack of standardization of lescents and young adults. Findings were illumi-
definitions across different age categories (e.g., nating; for example, certain terms, such as
young teens versus older teens, middle school “intervention” and even “self-compassion” and
versus high school), and using agreed-upon defi- “self-love,” were turnoffs for some, whereas for
nitions of these different stages of development one participant, appealing to cultivating wisdom
would make it more possible to compare across and courage was more attractive and would get
studies. Similarly, acknowledging multiple gen- more “buy-in.” Many voiced that they had similar
ders and establishing criteria for multiple genders fears of compassion as that of adults; that is, they
within research studies (i.e., providing various were afraid of losing motivation to accomplish
gender choices) would better align with current their goals and expressed that self-compassion
conceptualizations of gender. sounded “weak” or “lazy.” Clearly, it would be
There is also a dearth of interventional studies, important to clarify these misconceptions when
and the field will benefit from implementing teaching self-compassion to adolescents.
manualized interventions, such as MSC-T, and Additionally, many contributed that designing
assessing outcomes in various populations and programs that addressed the diversity which
subpopulations of youth. MSC-T can also be tai- exists among young people is essential, as the
lored to meet the needs of different populations; “one-size-fits-all” model does not necessarily
for example, Bluth et al. (2021) adapted MSC-T work. Ideally, these interventional studies need to
for transgender adolescents with promising find- be randomized and controlled, preferably with an
ings, and Boggiss et al. (2020) adapted MSC-T to active control group but, at minimum, with a
a brief format for adolescents with Type 1 diabe- waitlist control or a treatment-as-usual control
tes and disordered eating. Recognizing the differ- group. Follow-up assessments (e.g., at 3 months,
ences in self-compassion with regard to gender 6 months, and 1 year) are needed to determine
and age is critical in developing adolescent self- whether outcomes are maintained over time.
compassion interventions, as it is prudent to tai- Lastly, intervention studies need to be replicated
lor interventions to the unique developmental and by different researchers in different settings to
emotional needs of the participants. support generalizability.
Further, as adolescents are generally adapt- Further, ascertaining the intervention compo-
able to online learning, and implementing MSC-T nents that are the most effective in achieving out-
comes is needed. Various guided meditations, immigrants. The differences between different
exercises, didactic instruction, and discussion adolescent genders merit investigation, as it is
comprise the interventions. Determining the crit- possible that different interventional approaches
ical components that are vital in achieving posi- and formats may be more effective for different
tive outcomes would be advantageous in further genders. For example, when teaching adolescents
tailoring the interventions. Also, it may be that who have experienced trauma, it is important to
certain components are more efficacious in a par- take measures to ensure their emotional safety,
ticular culture or among a particular subpopula- providing them with options such as keeping
tion of adolescents, and other components may their eyes opened or closed or even disengaging
be beneficial in other settings. Chio et al. (2021) with the exercise completely. For some subpopu-
found differential effects of self-compassion lations, such as those who have experienced
components in dialectical and non-dialectical physical or sexual abuse, those with eating disor-
cultures among adults; there may be similar ders, or those who identify as transgender, it may
effects for youth populations as well. Thus far, no be important to not include the compassionate
research to our knowledge has investigated for body scan, as this could be unnecessarily
whom and under what conditions which compo- triggering.
nents of the interventions are most effective. Various implementation settings merit study
In addition, it is important to evaluate the as well, including schools, hospitals, juvenile
fidelity of the intervention and whether it is being detention systems, foster care programs, and
delivered in the way it was intended. Fidelity afterschool programs. Most notably, as most ado-
checks should be included to ensure that all com- lescents worldwide attend public or private
ponents of the intervention are being taught. schools, implementing MSC-T or other self-
Also, the amount of training and experience that compassion programs in schools is an important
the instructors have should be noted, as well as direction to increase the availability and accessi-
their own practice history with mindfulness and bility of such programs. An adaptation of MSC-T
self-compassion. Being able to embody mindful- for school implementation has been created but
ness and self-compassion, as well as thorough has not yet been tested empirically in school set-
training in teaching contemplative practices in tings. The ability to reach all students, not only
groups, is highly recommended and included as those whose parents or caregivers have the
one of the six domains in the Mindfulness-Based resources or opportunity to enroll them in self-
Interventions: Teaching Assessment Criteria, a compassion programs, may have far-reaching
tool created to systematically evaluate the integ- implications for the overall mental health of ado-
rity of mindfulness-based interventions (Crane lescents and, more distally, their long-term aca-
et al., 2013; Griffith et al., 2021). Additionally, demic and behavioral functioning.
experience working with adolescents in an edu- Finally, self-compassion and its associations
cational or therapeutic capacity should be a with mental health may vary at different points in
requirement, as teaching adolescents has specific the life cycle and at different developmental
challenges unique to their developmental stage. stages of childhood and adolescence. Ideally,
Future research should use larger and more research studies would elucidate the windows of
diverse sample populations to determine whether sensitivity in youth development at which the
findings can be generalized to the general popu- beneficial effects of self-compassion interven-
lation. Self-compassion can be studied in adoles- tions would be most efficacious. For example, it
cent subpopulations, particularly in marginalized may be that implementing a program to cultivate
or intersecting groups, including BIPOC, self-compassion in late childhood for females
sexual/gender minorities, adolescents experienc- may help to evade the mental health plummet that
ing homelessness or undocumented status, those is so common among adolescent females. It may
with a history of childhood abuse, those strug- be that other genders need a different approach at
gling with chronic health conditions, and recent a different stage of development.
In conclusion, adolescents today struggle with Positive Psychology, 10(3), 219–230. https://doi.org/1
0.1080/17439760.2014.936967
an array of mental health challenges that have Bluth, K., & Eisenlohr-Moul, T. A. (2017). Response
implications for lifelong maladaptive trajecto- to a mindful self-compassion intervention in teens:
ries. Self-compassion has been shown to be asso- A within-person association of mindfulness, self-
ciated with positive mental health factors, and compassion, and emotional well-being outcomes.
Journal of Adolescence, 57, 108–118. https://doi.
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have been instrumental in providing coping Bluth, K., Gaylord, S. A., Campo, R. A., Mullarkey,
mechanisms to shift the way in which adoles- M. C., & Hobbs, L. (2016a). Making friends with
cents respond to these stressors. Implementing yourself: A mixed methods pilot study of a mind-
ful self- compassion program for adolescents.
self-compassion interventions has tremendous Mindfulness, 7(2), 479–492. https://doi.org/10.1007/
potential for adolescents, and future research is s12671-015-0476-6
needed to replicate and confirm the current Bluth, K., Roberson, P. N. E., Gaylord, S. A., Faurot, K. R.,
findings. Grewen, K. M., Arzon, S., & Girdler, S. S. (2016b).
Does self-compassion protect adolescents from stress?
Journal of Child and Family Studies, 25(4), 1098–
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Self-Compassion and Positive
Aging 7
Lydia Brown
Introduction tional, physical, and social well-being, and

engaging meaningfully in life, despite challenges
As people age, they experience a wide range of that may arise such as the emergence of health
changes that can both positively and negatively issues (Gergen & Gergen, 2001).
influence mental and physical health. Social role Self-compassion, with its emphasis on
transitions are plentiful in later life. Adjustment acknowledging and responding kindly to one’s
to an empty nest when children leave home, own experience of suffering (Neff, 2003), might
retirement, and grandparenthood are examples of help explain why some people are better able to
transitions that can be simultaneously rewarding optimize well-being and thus experience positive
and yet stressful. While later life is a time of great aging. Self-compassion might enable older adults
happiness and fulfillment for many people to embrace later life transitions with balanced
(Carstensen et al., 2003), there is also consider- awareness, kindness, and an underlying sense of
able heterogeneity in people’s ability to adjust to common humanity, rather than feeling isolated,
the transitions of later life (Steverink et al., 2001). overidentified with the negatives of aging, and
Some people are better able to maximize the joys self-critical of their experience of growing older
of aging while adapting well to inevitable (Brown et al., 2018a). As visualized in Fig. 7.1,
changes, a process known as positive aging (Hill, this chapter outlines the literature linking self-
2011). Others, however, find the transitions of compassion to four pillars of positive aging: (1)
aging more challenging, and their well-being is mental well-being, (2) physical well-being, (3)
compromised as a result (Carpentieri et al., engagement in activity, and (4) social connected-
2017). Positive aging is best viewed as a process ness (Gergen & Gergen, 2001). Within this dis-
rather than an outcome (Kunuroglu & Yuzbasi, cussion, I explore processes that might explain
2021; Freund & Baltes, 1998; Gergen & Gergen, how self-compassion facilitates positive aging,
2001). Positive aging entails optimizing emo- via cultivation of a healthy attitude toward aging,
acceptance of change, behavioral flexibility, and
flexible goal pursuit. First, I explore why self-
L. Brown (*) compassion may be a natural resilience factor, as
Melbourne School of Psychological Sciences, well as a helpful alternative to self-esteem to cul-
University of Melbourne, Parkville, VIC, Australia
tivate a healthy self-image in later life.
Academic and Research Collaborative in Health, La
Trobe University, Bundoora, VIC, Australia
Healthscope Hospitals, Melbourne, VIC, Australia

https://doi.org/10.1007/978-3-031-22348-8_7
110 L. Brown
Fig. 7.1 A modified version of Gergan and Gergan’s life ical well-being, social connectedness, and engagement in
span diamond model of positive aging. This modified activity. Processes that help explain how self-compassion
model presents self-compassion as a central ingredient of facilitates positive aging are in italics
the four pillars of positive aging: mental well-being, phys-
Echoing a cultural context that is predomi-

ultivating a Healthy Self-Image
C nantly negative about aging, an individual’s self-
in Later Life esteem typically follows a sharp downward
trajectory in older adulthood. Self-esteem is
The experience of aging undeniably affects an defined as one’s overall sense of self-worth or
individual’s perception of the self (Hazel, 1991). attitude toward the self (Robins & Trzesniewski,
Key social institutions, including the media and 2005). As seen in Fig. 7.3, representing meta-
workplaces, proliferate negative views of aging analytic self-esteem data, self-esteem typically
as a time of loss and decline (Australian Human starts off high in childhood then plummets –
Rights Commission, 2013, 2016). For instance, especially for girls – during adolescence, before
the Australian Human Rights Commission gradually rising again throughout early and mid-
surveyed over 2000 older adults about their views dle adulthood. Self-esteem then takes a second
on media representations of aging, and responses sharp dive at approximately age 65, and it contin-
were overwhelmingly negative (Fig. 7.2). ues to fall for both men and women during later
Participants believed that the media portrayed life, before reaching all-time lows in the eighth
older adults as being frail, vulnerable, and bur- decade (Robins & Trzesniewski, 2005). There are
densome, and furthermore these portrayals nega- substantial individual differences in late life self-
tively influenced participants’ attitude toward esteem trajectories, and those with cognitive
their own personal views of aging (Australian decline experience the most pronounced reduc-
Human Rights Commission, 2013). tions (Wagner et al., 2013). Nevertheless, this
7 Self-Compassion and Positive Aging 111
Fig. 7.2 Word cloud of older adult views of media repre- (Reprinted with permission from Australian Human
sentations of aging. The larger the word font, the more Rights Commission, 2013)
frequently the word was reported by participants.
Fig. 7.3 Self-esteem trajectories across the life span. (Reprinted with permission from Robins & Trzesniewski, 2005)
data demonstrates that later life can be a vulner- is needed to facilitate healthy self-image in later
ability factor for low self-esteem. Because life.
attempts to bolster self-esteem can be ineffective Unlike self-esteem that declines in older adult-
(Baumeister et al., 2003), an alternative approach hood, evidence demonstrates that self-
compassion increases with age (Homan, 2016;
112 L. Brown
Hwang et al., 2016; Neff & Vonk, 2009). In a ple tend to treat themselves more compassion-
study of 2187 adults aged 18–83, Neff and Vonk ately as they age. However, given that current
(2009) found that self-compassion was positively evidence indicates that self-compassion increases
correlated with age, whereas partial correlations with age, older adults may benefit from using this
revealed that self-esteem significantly decreased strength to maximize health and well-being in
as people aged (Neff & Vonk, 2009). Similarly, a later life.
Korean study of nearly 2000 younger and midlife
adults found evidence of a small but significant
positive association between age and self- Self-Compassion and Mental Well-
compassion (r = 0.18) (Hwang et al., 2016). In being in Later Life
agreement, in a multigenerational sample of
adults aged 18 to 95 (n = 296), Homan (2016) An extensive body of research demonstrates that
found evidence of a strong positive association self-compassion is correlated with high mental
between self-compassion and age (r = 0.32). well-being in younger adults (see Zessin et al.,
More recently, a large study of community- 2015 for a review), and a growing body of
dwelling adults in the United States (n = 1090) research is now finding similar – and in some
found that the relationship between self- cases stronger – associations between self-
compassion and age followed an inverse compassion and well-being in older adults.
U-shaped relationship with age, peaking at Mental well-being involves two facets: (i) the
approximately 77 years (Lee et al., 2021). While absence of distressing psychological symptoms
the reasons for this are unclear, it may be that the such as symptoms of depression, anxiety, and
physical and cognitive decline associated with stress and (ii) the presence of positive qualities
advanced old age interfere with the capacity for including happiness, curiosity, and life satisfac-
mindfulness or self-kindness or that declining tion (Huppert & Whittington, 2003). Positive
social connections and mobility increase one’s qualities can be further delineated into hedonic
sense of isolation. well-being, which involves the presence of plea-
It is unclear why self-compassion might surable emotions and life satisfaction, and eudai-
increase with age, although some researchers monic well-being, which is a sense of purpose
have proposed plausible explanations. For exam- and meaning in life (Ryan & Deci, 2001).
ple, Homan (2016) suggests that the accumula- Emerging research shows that self-compassion is
tion of life experiences may lead to people correlated with all three of these aspects of men-
becoming more self-compassionate as they age; tal well-being in later life (Brown et al., 2018a).
as people navigate the challenges of life, they
take a more gentle and flexible approach to them- Low Levels of Psychological
selves and others. Self-compassion is strongly Symptoms Mounting evidence has found that
related to reflective wisdom (Neff et al., 2007b), self-compassion is associated with fewer symp-
which is the capacity to engage in self- toms of depression and anxiety in older adults. In
examination as a means to attain self-insight, as terms of depression, a study by Smith (2015) was
well as the capacity to gain insight by looking at one of the first to investigate the association
situations from many different perspectives between depression and self-compassion in a
(Ardelt, 2011). For this reason, Neff and Vonk sample of American older adults. Smith (2015)
(2009) suggest that the growth of self-compassion recruited 102 independent older adults living in a
with age might be associated with the develop- continuing care retirement community with a
ment of wisdom (Neff & Vonk, 2009). Reflective mean age of 82 years and found evidence of a
wisdom appears to increase in later life, although strong association between levels of self-
the association is weak and varies as a function of compassion and fewer depressive symptoms,
education (Ardelt et al., 2018). Clearly, more whereby self-compassion explained over 50% of
empirical work is needed to understand why peo- the variance in depressive symptoms (Smith,
2015). In agreement, a subsequent US study by was not tested empirically (Hodgetts et al., 2020;
Homan (2016) found evidence of a strong corre- Yarnell et al., 2019). Since levels of self-
lation between depressive symptoms and self- compassion tend to be slightly lower in women
compassion in a community-based sample of relative to men (Yarnell et al., 2019), an alternate
older adults (mean age = 70 years), recruited hypothesis is that aging women are in greater
from a local public library and senior center need of self-compassion, and thus a unit increase
(Homan, 2016). A Canadian study of patients in self-compassion could be associated with a
with chronic obstructive pulmonary disease and stronger reduction in rumination and depression
healthy controls (mean age = 67 years) echoed for women who are starting from a lower self-
this finding, once again demonstrating strong compassion baseline.
links between self-compassion and depression in In addition to the cross-sectional associations
older adults (Harrison et al., 2017). This study is above, a pilot randomized controlled trial (RCT)
important, because it indicates that self- has investigated the potential of a ten-session
compassion may be protective of depression self-compassion-based training program to
among older adults with health issues, a topic improve mental well-being and adaptation to
discussed later in this chapter. stress in a sample of community-dwelling older
adults (Perez-Blasco et al., 2016). The authors
New research is starting to consider the mech- found that participation in the program was asso-
anisms that might explain how self-compassion ciated with significant reductions in anxiety rela-
is protective against depressive symptoms in tive to waitlist control, but there was no significant
older adults (Hodgetts et al., 2020; Thoma et al., change in depression. Aside from the small sam-
2021). In a community-based cross-sectional ple size (n = 45) which was not adequately pow-
study of 241 Australian adults aged 65 years and ered to detect treatment effects, another concern
older, Hodgetts et al. (2020) investigated the with this study is that the authors did not use the
potential role of thinking styles in explaining the empirically validated 8-week Mindful Self-
relationship between self-compassion and Compassion (MSC) intervention (Neff & Germer,
depression. Specifically, the research looked at 2013) and instead developed a study-specific
how ruminative responses, defined as repetitive intervention. MSC has been rigorously devel-
and passive focus on symptoms of distress, oped and now trialed in a range of settings, where
together with a focus on the possible causes and it has been found to reduce depressive symptom-
consequences of these symptoms (Nolen- atology (Finlay-Jones et al., 2018; Friis et al.,
Hoeksema et al., 2008), might account for (i.e., 2016; Neff & Germer, 2013). For ease of
mediate) the relationship between self-between-study comparisons and quality assur-
compassion and depressive symptoms. The ance purposes, there is a pressing need to research
authors found evidence to support a mediation the efficacy of the standard MSC program in
model, whereby older adults higher in self- older adult groups, with adequately powered
compassion were less prone to ruminate on their designs that are capable of detecting between-
problems, which in turn predicted fewer depres- group differences, as well as potential modera-
sive symptoms. Interestingly, this pattern of asso- tors (e.g., gender).
ciations was stronger for women than men,
indicating that self-compassion may be espe- Hedonic Well-being A small group of studies
cially protective of depressive symptoms for has explored associations between self-
older women relative to older men. In their dis- compassion and hedonic well-being, including
cussion, the authors speculate that self- measures of positive affect and satisfaction with
compassion may be more aligned to femininity life (Allen et al., 2012; Phillips & Ferguson,
and therefore may be a more socially appropriate 2012; Smith, 2015; Kunuroglu & Yuzbasi, 2021).
and thus effective strategy to reduce rumination Community-based cross-sectional studies of
for women relative to men; however, this idea older adults residing in the United States (Allen
114 L. Brown
et al., 2012) and Turkey (Kunuroglu & Yuzbasi, strengthen across the life span. Data to support
2021) have found that self-compassion is posi- this idea comes from a large community study of
tively correlated with life satisfaction. In addition 1813 Korean adults aged 22–61 years (Hwang
to a bivariate association with life satisfaction, et al., 2016). In this study, the authors found that
Kunuroglu and Yuzbasi (2021) used path analysis the relationship between self-compassion and
to test a model where self-compassion mediated well-being strengthened with age, with self-
the relationship between life satisfaction and suc- compassion being more strongly associated with
cessful aging. This model was supported, well-being for midlife compared to younger
indicating that levels of life satisfaction might adults (Hwang et al., 2016). In this study, well-
help shape self-compassion, which in turn pre- being was measured with the Concise Measure of
dicts successful aging in older adult groups. Subjective Well-Being Scale (Suh & Koo, 2011)
However, this study was cross-sectional in nature, which predominantly measures hedonic well-
and it is plausible that self-compassion may con- being. The authors draw on developmental theory
tribute to levels of life satisfaction, rather than the to help explain their results (Havighurst, 1948).
other way around. Indeed, a recent experimental From this perspective, life satisfaction is thought
study from Iran adds weight to this idea (Asadi to be derived from increasingly fixed and uncon-
Bijaeyeh et al., 2021). Asadi Bijaeyeh et al. trollable factors with age. In younger adulthood,
(2021) examined the efficacy of an 8-week self- there is typically more freedom and opportunity
compassion training program in promoting life to modify life circumstances to attain satisfaction
satisfaction and resilience among 15 female nurs- and happiness. In contrast, as they age, people
ing home residents in Iran, relative to a control typically become increasingly established in
group of 15 female residents who did not receive family units and career pathways that have high
the intervention. The authors found that self- barriers to exit. Thus, according to Hwang et al.
compassion led to improved life satisfaction and (2016), the accepting perspective afforded by
resilience post-intervention, with gains main- self-compassion may be increasingly relevant to
tained at follow-up (Asadi Bijaeyeh et al., 2021). facilitate adjustment to life circumstances that
This indicates that self-compassion-based train- cannot be changed, because “fixed factors”
ing might help seniors cultivate greater satisfac- become increasingly common with age. A caveat,
tion with life. More experimental research is however, is that this study included a sample of
needed to see if this finding replicates across cul- younger and midlife adults. In later life, many
tures and settings. older adults experience greater flexibility and
freedom relative to midlife as children gain inde-
To date, two studies have found evidence that pendence and leave home. This transition may
self-compassion is associated with positive emo- coincide with fewer financial stressors for some
tionality in later life. Smith (2015) recruited 102 older adults. Older adults often have more flexi-
adults residing in a retirement community in the bility in time, via retirement or reduced working
United States (mean age = 82 years) and found hours, enabling more time to focus on hobbies
that participants with higher self-compassion and meaningful activities. Thus, an alternate
concurrently reported higher levels of happiness hypothesis is that the relevance of self-
(Smith, 2015). An Australian study by Phillips compassion peaks at midlife and becomes less
and Ferguson (2012) examined links between relevant in later years.
self-compassion and positive affect in a younger Available evidence, however, does not support
sample of community-dwelling older adults with this idea. A US study by Greene et al. (2016) sur-
a mean age of 73 (Phillips & Ferguson, 2012). veyed 525 midlife and older adults who identified
This study also found evidence of a positive asso- as being lesbian, bisexual, transgender, intersex,
ciation between self-compassion and happiness. or queer, administering measures of self-
An interesting finding is that the association compassion and mental and physical health. The
between self-compassion and well-being might authors found that self-compassion was a stron-
ger predictor of mental health among members of 2007a). In the same way, older adults high in self-
the sample who were aged 65 years and over compassion might have the flexibility to find new
(n = 124) relative to the midlife subsect of the meaningful pursuits following role transitions
cohort. The authors also found that older adults such as retirement or adapt hobbies to accommo-
exhibited higher self-compassion than the midlife date functional changes rather than disengaging
group, replicating the finding that self- and giving up on them completely (Brandtstädter
compassion increases with age (Homan, 2016; & Renner, 1990). While the capacity to find new
Hwang et al., 2016). In their discussion, the goals is important across the life span, it is known
authors do not speculate as to why self- to be particularly central to well-being in later
compassion was a stronger predictor of mental life (Wrosch et al., 2003). As such, self-
health in older adulthood relative to midlife. One compassion might be a helpful psychological
possibility relates to the notion that self- resource to facilitate behavioral flexibility and
compassion is a developmental task that deepens new goal setting in later life.
with age due to life experiences (Homan, 2016). Ego integrity is the last of Eric Erikson’s psy-
If older adults struggle to meet this developmen- chosocial stages of life span development
tal task of building a healthy relationship with (Erikson, 1963). According to this model, the
themselves as they age, their well-being might developmental task of later life is to reach a place
suffer as a consequence. Future qualitative work of fulfillment and a sense of content for a life well
could be helpful to shed light on this intriguing lived despite loss and inevitable mortality, rather
issue by interviewing aging adults about their than falling into despair. In their model, Phillips
experiences of self-compassion and well-being, and Ferguson (2012) found that self-compassion
for example. was a positive predictor of ego integrity. This
finding has not been replicated to date, and more
Eudaimonic Well-being A small number of work is needed to investigate the role of self-
studies have investigated the association between compassion in negotiating the developmental
eudaimonic well-being and self-compassion in tasks of later life.
older age groups, with unanimous findings that In sum, a small but compelling body of
self-compassion is associated with greater eudai- research has investigated the relationship between
monia (Allen et al., 2012; Homan, 2016; Phillips self-compassion and mental well-being in later
& Ferguson, 2012; Homan, 2018; Brown et al., life. Converging research now shows that self-
2016). Phillips and Ferguson (2012) developed a compassion is associated with fewer psychologi-
path analytic model to investigate the role of self- cal symptoms and higher hedonic and eudaimonic
compassion in predicting two aspects of eudai- well-being. While self-esteem typically declines
monic well-being – meaning in life and ego across later adulthood (Robins & Trzesniewski,
integrity – in a community sample of 185 older 2005), self-compassion may be protected or even
adults. The authors found that self-compassion enhanced in later life and thus could be a natural
was nearly twice as strong a predictor of meaning resource developed through life experience that
in life compared to positive affect, an index of people can draw on to navigate challenges.
hedonic well-being.
Phillips and Ferguson (2012) argue that self- elf-Compassion May Improve
S
compassion might facilitate meaning in life Well-being via Promoting a Positive
through enabling behavioral flexibility, which is Attitude to Aging
the ability to adapt to find new meaning despite
losses and changes. In younger adults, self- In addition to direct effects, self-compassion may
compassion seems to help people respond adap- also shape adaptive attitudes to aging which in
tively rather than disengage following a loss or turn contribute to health, well-being, and func-
disappointment (Neely et al., 2009; Neff et al., tioning in the second half of life. In this way, self-
116 L. Brown
compassion may facilitate a more positive nificance of age-attitudes. However, many cul-
attitude toward aging, which in turn has adaptive tures – especially western cultures – hold ageist
ramifications for health (Brown et al., 2016). views (Fig. 7.2. Australian Human Rights
Brown et al. (2016) developed a structural equa- Commission, 2013), and this can make it difficult
tion model to investigate relationships between for older adults to feel positively about their
self-compassion, attitudes to aging, and health experience of aging. Further, empirical work has
and well-being outcomes in a sample of 517 found that direct attempts to foster a positive atti-
midlife women aged 40–60. In this study, women tude to aging can be ineffective (Levy et al.,
high in self-compassion typically reported a posi- 2014); therefore, indirect pathways to feel posi-
tive view of their personal experience of aging. tively about aging are needed. In the study by
Specifically, women higher in self-compassion Brown et al. (2016) described above, a model
viewed aging as an opportunity for psychological was supported whereby higher self-compassion
growth, including development of wisdom. They predicted a positive attitude to aging, which in
also held more adaptive attitudes about physical turn predicted both mental and physical well-
aging relative to those lower in self-compassion; being (Brown et al., 2016). From these results,
for instance, they reported valuing the impor- the authors suggest that self-compassion might
tance of exercise regardless of age. Finally, they be an effective pathway to feel more comfortable
were less likely to feel a sense of age-related psy- and accepting of the aging process, and this posi-
chosocial loss. Taken together, this shows that tive attitude in turn has important ramifications
when aging starts to become personally relevant for mental and physical health.
at midlife, self-compassion appears to help peo-
ple embrace aging with a more positive attitude,
despite the ageist views that are often communi- Self-Compassion and Physical
cated by social institutions such as the media. Well-being
In an earlier study by Allen and Leary (2013),
older adults were asked to write about age-related By age 65, the average adult lives with two or
events. The authors found those high in self- more chronic medical conditions, and these
compassion embraced a more positive emotional comorbidities increase in prevalence with
tone when writing about their lived experiences advancing age (Barnett et al., 2012). There are
of aging, adding support to the idea that self- three pathways by which self-compassion might
compassion can enable people to hold a more contribute to good physical health in later life.
adaptive view of age-related experiences. To The first and most established pathway is through
explore this idea further, future research would facilitating adjustment to illness, meaning self-
do well to investigate if self-compassion induc- compassionate people are better able to accept a
tions and interventions such as the MSC program change in health status. This may serve to lessen
(Neff & Germer, 2013) might help foster positive the psychological burden of illness. The second
attitudes to aging. pathway is through facilitating healthy behaviors
Holding a positive view of aging has impor- such as exercise and a healthy diet. Finally, but to
tant benefits for well-being (Bryant et al., 2012) date least conclusively, self-compassion has
and physical health (Levy et al., 2002). Older potential to exert a direct physiological effect on
adults with a positive view of aging tend to have health in later life, for instance, through immune
fewer psychological symptoms and greater satis- functioning and anti-inflammatory processes.
faction with life (Bryant et al., 2012). In terms of
physical health, a seminal longitudinal study of Adjustment to Illness A few studies have now
660 adults aged 50 years and over found that considered self-compassion as a moderating fac-
those with a positive view of aging lived up to tor that attenuates the impact of physical health
7.5 years longer than those with a negative view symptoms on mental health in older adults (Allen
of aging (Levy et al., 2002), indicating the sig- et al., 2012; Homan, 2016; Smith, 2015; Herriot
& Wrosch, 2021). For instance, in a community deviation below the mean age of the sample).
sample of adults aged 67–90 years, Allen et al. Moreover, longitudinal analyses revealed that
(2012) found that self-compassion significantly low self-compassion was associated with a 4-year
weakened the association between physical increase in chronic health issues for participants
symptoms and well-being. The authors found in advanced old age. In contrast, older partici-
that for any given level of physical pain, limited pants who had higher self-compassion were pro-
mobility or poor self-reported health status, older tected against a subsequent rise in chronic health
adults with greater self-compassion experienced issues over the study period. In their discussion
higher well-being compared to those with less of these results, the authors explain that self-
self-compassion, who were more psychologi- compassion may be especially important to
cally affected by their physical health health outcomes in advanced old age. Advanced
conditions. old age is a time where there are often many
uncontrollable losses which can contribute to
Data from studies by Homan (2016) and poor health outcomes (Heckhausen et al., 2019),
Smith (2015) largely accord with this idea. and the capacity to accept these losses with self-
Homan (2016) found that self-compassion ame- kindness, mindfulness, and common humanity
liorated the impact of poor self-rated health on may be paramount (Herriot & Wrosch, 2021).
depression (but not anxiety). In a sample of 102 It is plausible that self-compassion training
senior residents living in a retirement commu- might be helpful for aging adults living with
nity, Smith (2015) found no evidence of an over- health issues. For instance, Brown et al., 2019
all association between self-reported health and developed a brief, four-session self-compassion-
both depression and happiness. However, when based intervention for midlife and older adults in
self-compassion was included as a moderator, outpatient hospital treatment for a chronic medi-
those low on self-compassion evidenced a mod- cal condition. In this small feasibility study
erately strong connection between self-reported (mean age = 64 years), authors found that patients
health and depression and happiness, whereas responded well to the training program, rating the
health was independent of well-being for those sessions as being enjoyable (mean rating 6.8/7)
with higher self-compassion. This is a particu- and relevant to daily life (mean rating 6.4/7). The
larly interesting finding because it shows that participants also experienced marked reductions
older adults low on self-compassion may be at in depressive symptoms, as well as trends toward
high risk of experiencing psychological symp- increased self-compassion and positive affect
toms and reduced well-being in response to over the course of the program. A limitation of
health issues. In turn, lower well-being is known the study was that the intervention was brief; par-
to contribute to poorer physical outcomes includ- ticipants provided feedback that they would have
ing morbidity and mortality (Carney & Freedland, preferred more time to practice self-compassion
2017; Diener & Chan, 2011), completing a down- skills to consolidate their learning. While this is a
ward self-perpetuating cycle of poor physical and preliminary study, the finding demonstrates that
mental health. chronically unwell aging adults have an interest
A longitudinal study by Herriot and Wrosch in self-compassion-based training, and it may
(2021) followed health and self-compassion tra- facilitate adaptation to illness. Research to pilot
jectories of 268 older adults with a mean age of the standard 8-week MSC with older adults is
75 years at baseline to further investigate links needed to extend this preliminary research and
between self-compassion and physical health. In determine whether adaptations are required to
this study, the authors found that self-compassion tailor the program to the specific needs of older
was associated with fewer physical symptoms in adults.
advanced age (i.e., 83 years, one standard devia-
tion above the mean age of the sample) but not Health Behaviors Several studies from across
early older adulthood (i.e., 67 years, one standard the life span have now found that self-compassion
118 L. Brown
is associated with a range of healthy behaviors Direct Physiological Effects A small but grow-
including exercise, healthy diet, and engagement ing body of research has investigated the underly-
with medical treatment and high-quality sleep ing physiological correlates of trait
(Dunne et al., 2018; Sirois et al., 2015; Hu et al., self-compassion (Svendsen et al., 2016; Breines
2018; Terry et al., 2013; for reviews see Chaps. et al., 2014; Breines et al., 2015; Friis et al., 2015;
18 and 19 of this Handbook). In a series of stud- Herriot et al., 2018), as well as physiological
ies that included both younger and older adults changes caused by self-compassion inductions
(age range 18–75 years), Terry et al. (2013) found and training programs (Brown et al., 2019; Friis
that self-compassionate people typically felt less et al., 2016; Kirby et al., 2017). Herriot et al.
guilt or embarrassment about health issues and (2018) investigated relationships between self-
were more likely to seek medical assistance ear- compassion, age-related stressors (including
lier in the course of illness than those lower on functional disability, life regrets, and physical
self- compassion. A proactive approach to health health issues), and cortisol levels in a community-
may become increasingly important with age, as dwelling group of 233 adults with a mean age of
health issues accumulate. Likewise, the effects of 75 years (Herriot et al., 2018). Cortisol is a hor-
healthy behaviors typically strengthen over time, mone that is released in response to stress (Zorn
with behavioral choices earlier in life affecting et al., 2017). Findings of the study revealed that
health and well-being outcomes across the life self-compassion significantly moderated the rela-
span (Vaillant, 2008). For this reason, the role tionship between age stressors and diurnal corti-
that self-compassion might play in facilitating sol secretion, whereby self-compassion was
healthy lifestyle choices and a proactive approach increasingly associated with low cortisol secre-
to health is of central relevance to later life health tion in those reporting high regret and health-
and well-being. related stress. This finding demonstrates that
self-compassion may dampen the physiological
Healthy behavior choices made at midlife are impact of age stressors, in this case through
thought to be particularly powerful determinants weakening cortisol reactivity to stress.
of healthy aging trajectories (Willcox et al., 2006;
Kelly et al., 2016). One study by Hallion et al. Physiological benefits of self-compassion
(2018) looked at self-compassion and physical have also been observed in younger adult groups
activity participation in an online survey of 169 (see Chap. 17 for a review), and these findings
midlife adults aged 40 to 65. Contrary to the have implications for older adults. In an experi-
hypothesis, they found no evidence of a direct ment of social stress, Breines et al. (2014) asked
link between self-compassion and physical activ- 41 young adults to give an impromptu speech fol-
ity. However, the authors found evidence of an lowed by an arithmetic task in front of a live audi-
association between self-compassion and self- ence of evaluative judges (Breines et al., 2014).
regulatory strategies, which in turn are known to The authors found that self-compassionate par-
contribute to healthy behaviors such as exercise ticipants experienced less stress-induced inflam-
(e.g., McAuley et al., 2011). This indicates that mation (interleukin-6; IL-6) after the stressful
relationships between self-compassion and health encounter compared to those lower on the trait.
behaviors might be indirect. It should be noted Stress-induced inflammation can contribute to
that this was a relatively small study that may longer-term health outcomes, increasing the risk
have lacked statistical power. Clearly, additional of developing cardiovascular disease and diabe-
large, well-designed studies are needed to expand tes (Juster et al., 2010). IL-6 and IL-6 receptor
on these results by considering links between concentrations have also been found to relate to
self-compassion and health behaviors in older mental well-being in later life, including relation-
adulthood. ship quality and purpose in life (Friedman et al.,
2007). Therefore, self-compassion may amelio-
rate inflammatory responses to stress, which in
turn may have positive ramifications for health well-being is buoyed despite the inevitable chal-
and psychological well-being in later life. It lenge of being sick. Second, studies of younger
should, however, be noted that evidence linking adults demonstrate that those high in self-
self-compassion with inflammatory markers is compassion are more likely to take care of them-
preliminary, and future work is needed to expand selves by making healthy lifestyle choices and
on these early results. the effects of these choices accumulate over time
Heart rate variability (HRV) is an index of across the life span and become increasingly
autonomic nervous system functioning associ- prominent with age. Third, self-compassion may
ated with both physical and mental health across lead to direct physiological benefits such as
the life span (Brown et al., 2018b; Thayer et al., reduced inflammatory response to stress and
2010; Bhattacharyya et al., 2008). High HRV is improved HRV, but large-scale, high-quality
indicative of flexible nervous system that adapts research is needed to verify these effects.
efficiently to an ever-changing biopsychosocial
environment (Thayer et al., 2012; Appelhans &
Luecken, 2006). High resting HRV is associated Self-Compassion and Engagement
with emotion regulation (Appelhans & Luecken, in Activity
2006), and emotion-based experimental tasks
have been used to activate short-term increases in Later life can bring newfound opportunities for
HRV (Smith et al., 2011). Self-compassion is an freedom, travel, and the pursuit of hobbies and
adaptive emotional regulation skill that helps personal growth. At the same time, role transi-
soothe negative emotional states and is associ- tions such as retirement and the emergence of
ated with high HRV in college students (Svendsen health issues can pose challenges for some older
et al., 2016). Furthermore, self-compassionate adults. With this matrix of gains and losses, flex-
inductions and interventions have been reported ibility is needed to adapt to change and thus enjoy
to increase resting HRV in studies of younger the pleasures of aging without becoming over-
adults (Kirby et al., 2017). Yet little research has whelmed by the losses.
explored whether self-compassion training might Selective optimization with compensation
improve HRV in older adults. In a pilot feasibility (SOC) is a popular developmental model that
study of a self-compassion intervention for aging helps describe how people adjust to inevitable
adults with health issues, Brown et al. (2019) life transitions that occur across the life span and
reported a nonsignificant trend toward increased become increasingly common in later life (Freund
HRV following the training course, but a much & Baltes, 1998). Selection involves committing
larger study is needed to qualify these prelimi- to realistic personal goals and adjusting goals
nary results. It should be noted that a recent meta- when needed based on changing circumstances.
analysis of randomized controlled trials found no An example of this is a tennis player, who, with
evidence that mindfulness-based training pro- arthritis and advancing age, might narrow their
grams lead to improvements in resting-state HRV repertoire and select to play fewer overhead shots
(Brown et al., 2021). Self-compassion training in games to avoid pain and care for their joints.
explicitly teaches people how to soothe negative Optimization entails allocating resources to
emotional states, and so self-compassion may be achieve higher levels of functioning in selected
more closely related to HRV compared to general pursuits, for instance, the older tennis player
mindfulness training programs (Svendsen et al., might spend more time practicing their forehand
2020). shots to optimize their performance. Finally,
In sum, there are three pathways by which compensation involves finding ways to compen-
self-compassion might facilitate healthy physical sate for loss, so that life priorities can still be pur-
aging in later life. First, there is relatively strong sued, despite any physical decline. To continue
evidence that self-compassion enables people to with the tennis example, the aging player might
adjust to physical health threats, such that mental elect to play doubles and shorter games. If mobil-
120 L. Brown
ity issues continued to worsen such that playing (Allen et al., 2012). Thus, in this study, self-
tennis becomes unrealistic, the player might then compassion appeared to promote flexibility to
compensate by taking up coaching, watching compensate for age-related losses, such that
games instead of playing, or fundraising for their functioning is maintained despite the loss. For
local tennis club. In this way, they can continue to instance, a willingness to accept a walking aid
engage in the hobby despite physical decline. when it is justified could enable mobility for a
Engagement in SOC processes is a strong pre- senior to leave their house and engage with their
dictor of well-being in later life (Carpentieri local community. In contrast, those lower on self-
et al., 2017; Freund, 2008). Less research has compassion who are more bothered about accept-
considered psychological factors that might pre- ing aids could be limited by age-related losses
dict the tendency to engage with SOC processes, either through refusal to accept the aid or psycho-
versus the alternative which is either the relent- logical distress caused by using the aid without
less pursuit of unrealistic goals or disengagement acceptance. Part of the role of clinicians is to sup-
due to the inability to adapt to change. While a port older adults to see the value of accepting
novel area, data from both older and younger support when it is needed, and helping older
adult groups indicates that self-compassion might adults build self-compassion can facilitate this
facilitate adaptive behavior in the form of SOC process of acceptance and adjustment to loss.
processes. There is now some evidence from both
Firstly, studies of younger adults indicate that younger and older cohorts that self-compassion
self-compassion is associated with goal regula- might enable the flexible pursuit of goals through
tion (Neff et al., 2005; Neely et al., 2009). Neff enabling the processes of selection, optimization,
et al. (2005) found that college students who self- and compensation. Self-compassionate people
reported high levels of self-compassion were less tend to embrace mastery rather than performance
likely to embrace outcome-oriented performance goals, and mastery goals are more flexible to
goals, in which people are motivated to achieve a accommodate challenges and changes compared
goal to defend self-worth. Instead, self- to performance goals that are relatively fixed.
compassionate people were more likely to adopt Further, self-compassionate older adults are more
process-oriented mastery goals, motivated by likely to accept aids that can bolster daily life
curiosity and a desire to learn and engage for functioning to compensate for age-related losses.
learning’s sake. Research has found that mastery Future research is needed to delve more deeply
goals are more helpful than performance goals into these issues and to consider the extent to
when goal flexibility (i.e., selection, optimiza- which self-compassion might facilitate flexible
tion, and compensation) is needed. For instance, pursuit in later life.
mastery is efficacious in the context of challenges
such as interpersonal conflict (Darnon et al.,
2007) and in the context of age-related symptoms Self-Compassion and Connectedness
such as memory loss (Hastings & West, 2011). in Later Life
The capacity to hold mastery goals that are more
process-oriented may be a great benefit to facili- Social isolation and loneliness are powerful pre-
tate flexibility and meaningful engagement with dictors of poor health outcomes and risk of pre-
life in older adulthood. mature death (Holt-Lunstad et al., 2015;
A study by Allen et al. (2012) indicates that Nicholson, 2012). Health risks of isolation and
self-compassion is associated with goal flexibil- loneliness are equivalent in strength to well-
ity in later life. In this study, the authors surveyed established risk factors such as smoking and obe-
71 older adults on their eagerness to use memory, sity (Courtin & Knapp, 2017). For this reason,
hearing, and walking aids. The authors found that advancing social connection has been identified
self-compassionate participants were less both- as a key public health priority (Holt-Lunstad
ered about accepting these forms of support et al., 2017). Unfortunately, those aged 75+ are
the age group most at risk of experiencing loneli- ciated with making the most out of relationships
ness (Australian Institute of Health and Welfare, that you do have. Since self-compassion is asso-
2019). In turn, lack of connection with others is ciated with relationship quality, it is plausible
linked with high rates of suicide that are observed that self-compassionate older adults might be
in later life (Van Orden & Conwell, 2011). Given able to derive more psychological benefit from
the enormous costs of late life isolation, it is casual social interactions, for instance, a chat
important to consider the extent to which self- with the mailman or local storeowners, relative to
compassion might have a role to play in facilitat- those who are less self-compassionate – an inter-
ing social connectedness and helping address this esting hypothesis for future research.
major public health crisis. Given that a core com- A meta-analysis of interventions designed to
ponent of self-compassion is “common human- prevent social isolation and loneliness in older
ity” (i.e., the capacity to recognize that one’s adults found evidence that group-based programs
difficulties are part of the common human experi- are more effective than one-to-one programs pro-
ence), it may be expected that people with higher viding personalized support (Cattan et al., 2005).
levels of self-compassion feel more connected to Moreover, group programs that incorporated
others, particularly during times of difficulty. educational or training input were the most effec-
Few studies have investigated relationships tive of all in reducing isolation. In their discus-
between self-compassion and connectedness in sion, the authors recommend including training
later life, but early work has showed promising in intrapersonal resources within group pro-
correlational effects (Allen et al., 2012; Homan, grams, such as teaching on self-esteem. Since
2016). Homan (2016) investigated links between self-esteem is typically fragile in the face of dif-
trait self-compassion and positive relationship ficulties and is not easily taught (Neff, 2011),
quality in a sample of 121 older adults and found offering group training on self-compassion could
evidence of a strong relationship between the be a more effective pathway to social connection
constructs (r = 0.56). Using a different measure, for older adults. Modifications of the MSC pro-
Allen et al. (2012) found that self-compassionate gram to include content that is specifically rele-
older adults were less likely to report that health vant to older adults could be helpful (Bryant,
issues interfered with their social functioning. 2017). In this way, the process of participation in
While these were cross-sectional studies that the group would offer a direct route to the experi-
limit inferences of causality, this emerging evi- ence of social connectedness. Simultaneously,
dence indicates that self-compassion is associ- course content on self-compassionate aging
ated with positive social functioning in later life. might facilitate healthy aging among
More recently, a longitudinal study of 1090 participants.
community-dwelling adults (baseline mean age
61.5 and 66 years for women and men, respec-
tively) found that self-compassion was positively road Processes Explaining Why
B
associated with mental well-being and inversely Self-Compassion Promotes Positive
associated with loneliness across the life span Aging
(Lee et al., 2021).
Studies with younger adults add support to As illustrated in Fig. 7.1, self-compassion facili-
this idea. Self-compassion is associated with tates positive aging via broad, interrelated pro-
high-quality romantic relationships and a felt cesses: attitudes to aging, acceptance of change,
sense of community and relationship harmony behavioral flexibility, and flexible goal pursuit. In
(Neff & Beretvas, 2013; Akın & Akın, 2015; turn, these processes enable the four pillars of
Yang, 2016). While these measures of relation- positive aging which include mental well-being,
ship quality cannot counterbalance the absence physical well-being, engagement in activity, and
of relationship that is prevalent in later life, it social connectedness. In a society that holds
demonstrates that self-compassion is a skill asso- explicit and implicit biases against aging and
122 L. Brown
older adults, embracing a positive view of aging (Gergen & Gergen, 2001). First, self-compassion
can be challenging, perhaps especially for women is associated with mental well-being in later life,
who are exposed to negative media representa- including reduced risk of psychological symp-
tions of aging women (Lemish & Muhlbauer, toms and a greater likelihood of both hedonic and
2012). Research has found that self-compassion eudaimonic well-being. Self-compassion may
enables individuals to hold more positive views also hold benefits for physical health in later life,
of aging, which in turn has beneficial sequelae a second key pillar of positive aging, by facilitat-
for positive aging, especially in the domains of ing adjustment to health issues, promoting
mental and physical health (Brown et al., 2016). healthy behaviors, and potentially direct physio-
Self-compassion also facilitates adjustment to logical pathways such as immune functioning
change. An example of this is converging evi- and HRV. Self-compassion is also associated
dence linking self-compassion to good adjust- with engagement in activity and social connect-
ment to illness in the second half of life (Allen edness, the last two pillars of positive aging
et al., 2012; Homan, 2016; Smith, 2015; Herriot (Gergen & Gergen, 2001). Self-compassion
& Wrosch, 2021). Self-compassionate older enables meaningful activity and is associated
adults are more likely to maintain high levels of with high-quality relationships (Homan, 2016),
well-being, despite illness and physical symp- which can protect against loneliness and isolation
toms that are increasingly common in later life. in later life.
Finally, self-compassion enables behavioral flex- While research is still needed to uncover
ibility as well as flexible goal pursuit via selec- mechanisms that explain how self-compassion
tion, optimization, and compensation processes facilitates positive aging, there appears to be
(Freund & Baltes, 1998). One example of this is broad processes that are relevant. Self-
that self-compassionate older adults appear to be compassion works by helping people embrace a
less bothered about accepting aids (e.g., for walk- positive attitude to aging and adjust to changes
ing and hearing). This type of behavioral flexibil- that are plentiful in later life, behavioral flexibil-
ity enables continued engagement in life. ity, and flexible goal pursuit. These broad pro-
cesses relate to all four pillars of positive aging.
More empirical work is needed to unpack these
Conclusion and Future Directions ideas.
The field of self-compassionate aging is still
Self-compassion is an adaptive psychological in its infancy. The field needs to move beyond
resource that facilitates adjustment to challenges cross-sectional research to develop and test the
across the life span, and it may be especially use- efficacy of rigorous self-compassion-based train-
ful in later life when physical, psychological, and ing programs that are modified to suit the needs
social changes are plentiful. The field of self- of older adults (Bryant, 2017). We also need to
compassionate aging is relatively new. The first see more experimental research, to consider if
scientific paper on the topic was published in brief self-compassion inductions might be an
2012 (Allen et al., 2012). The past decade has effective way to prime aging adults to be more
seen a rapid rise in publications, and most study self-compassionate toward their experience of
designs have been cross-sectional, investigating aging. In the context of an aging society, there is
associations between trait self-compassion and an urgent need to find cost-effective ways to sup-
health and well-being outcomes in older adult port aging adults cope with the unprecedented
groups (Brown et al., 2018a). changes and losses of later life (Gurwitz &
From the literature published to date, there is Pearson, 2019). Self-compassion is a promising
evidence that self-compassion is associated with psychological resource that may help people
four pillars of positive aging including (1) mental respond to these challenges of aging, and more
well-being, (2) physical well-being, (3) engage- research is needed to expand this field of research.
ment in activity, and (4) social well-being
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A meta-analysis. Applied Psychology: Health and
Self-Compassion Across Cultures
8
Kohki Arimitsu
Introduction other hand, emotional experiences and their func-

tions are influenced by culture, as the values and
Compassion is a response to others’ suffering social influences that are shared by people living
that involves attunement, empathy, and motiva- in a certain region influence—among other
tion to relieve that suffering and has been vari- things—how people relate to themselves and
ously defined as an emotion, a virtue or value, each other.
and a motivation (Goetz et al., 2010; Strauss Neff (2003a) developed the Self-Compassion
et al., 2016). Self-compassion refers to directing Scale (SCS), a measure comprising three sub-
these same qualities toward oneself and is char- scales that measure compassionate self-
acterized by a balanced acceptance of emotions responding (CS) (self-kindness, common
in times of failure or difficulty, recognizing that humanity, and mindfulness) and three that mea-
the experience is shared by others, and channel- sure uncompassionate self-responding (UCS)
ing kind feelings toward oneself (Neff, 2003b). (self-criticism, isolation, and overidentification).
From an evolutionary perspective, compassion Since their development, several translations of
may be conceived as an emotion or motivation the SCS, its short form (Raes et al., 2011), and
that serves an adaptive function across cultures youth form have been validated, including trans-
(Goetz et al., 2010). Studies have revealed that lations in Arabic (Alabdulaziz et al., 2020),
behavioral and physiological responses associ- Chinese, Farsi (Nazari et al., 2022), French
ated with both giving and receiving compassion (Kotsou and Leys, 2016), German (Hupfeld &
are common among people from various regions Ruffieux, 2011), Greek (Mantzios et al., 2013),
(Gilbert, 2015; Goetz et al., 2010). For example, Indonesian (Darmawan et al., 2020), Italian
a gentle touch on the cheek or shoulder of a per- (Petrocchi et al., 2014; Veneziani et al., 2017),
son in need is a common way of conveying kind- Japanese (Arimitsu, 2014), Korean (김경의
ness among people in many countries. Similarly, et al., 2008), Malay (Khatib et al., 2021),
evidence documenting neurophysiological pro- Sinhalese (deZoysa et al., 2021), Slovak
files of self-compassion suggests that there are (Halamová et al., 2018), Slovenian (Uršič et al.,
biological systems that underpin this phenome- 2019), Spanish (Garcia-Campayo et al., 2014),
non across cultures (Kim et al., 2020). On the Taiwanese (Chen & Chen, 2019), and Turkish
(Deniz et al., 2008, 2022).
An extensive body of research indicates that
K. Arimitsu (*)
Kwansei Gakuin University, Nishinomiya, Japan self-compassion is a modifiable trait and state
e-mail: [email protected] variable that is reliably associated with adaptive

https://doi.org/10.1007/978-3-031-22348-8_8
130 K. Arimitsu
physical, psychological, and relational health Factory Analysis (CFA) and Exploratory
outcomes (Ewert et al., 2021; MacBeth & Structural Equation Modeling (ESEM). They
Gumley, 2012; Zessin et al., 2015). However, as tested five different models, including a single-
with most psychological research, most of these bifactor model, with one general self-compassion
studies have been conducted in the United States. factor and six group factors, and a two-bifactor
This therefore raises the question of whether the model. The two-bifactor model had two corre-
construct of self-compassion is understood the lated general factors, representing compassionate
same way across different cultures, whether the self-responding (CS) and uncompassionate self-
factor structure of the SCS is culturally influ- responding (UCS) each with three group factors.
enced, and whether mean scores on the SCS vary Fit statistics using ESEM were excellent for a
according to respondents’ cultural background. six-factor correlated model and both bifactor
Studies have found cross-cultural differences in models, although factor loadings indicated that
the factor structure of the SCS (Neff et al., 2019; the two general factors were not well specified.
Tóth-Király & Neff, 2020), suggesting that the Accordingly, the authors recommended the use
construct may be experienced or perceived differ- of the SCS to measure six subscale scores or a
ently across cultures (Montero-Marin et al., total score, but not the CS and UCS factors.
2018). This chapter examines whether cultural Support for the six-factor and bifactor models has
factors may impact not only the mean values and been found across countries including Argentina
factor structure of the SCS but also the relation- (Cababie & Etchezahar, 2022), France (Kotsou &
ship between self-compassion and various well- Leys, 2016), Italy (Petrocchi et al., 2014), and
being outcomes. Specifically, this chapter reviews ethnic groups, including African Americans
cross-cultural studies to determine whether self- (Zhang et al., 2019).
compassion could be affected by the cultural
view of the self.
Measurement Invariance of the SCS
actor Structure of the SCS Across

F Insight into the generalizability of the SCS across
Cultures cultures has been provided by Tóth-Király and
Neff (2020), who used bifactor Exploratory
In her original paper describing the factor struc- Structural Equation Modeling (ESEM) to exam-
ture of the SCS, Neff (2003a, b) found support ine measurement invariance of the SCS across
for a higher-order one-factor model, which places groups based on language, population type (stu-
one general “self-compassion” factor above the dent, community, clinical, mixed), gender, and
six subscales. This provided a basis for calculat- age. Measurement invariance refers to whether
ing a total self-compassion score (this is done by the same construct is being measured across
reverse scoring all self-judgment, isolation, and groups. Tóth-Király and Neff (2020) tested six
overidentification items and taking a grand mean dimensions of measurement invariance, using a
of all six subscale means). In a follow-up with total of 18 samples collected from 15 countries,
four distinct samples, Neff et al. (2017) subse- representing 12 language groups. They found
quently found that while the use of a total scale support for strong invariance across these differ-
score was justified, this was better explained by a ent language groups, demonstrating that people
bifactor model, in which each item loads on to from different linguistic backgrounds, such as
both a general factor (i.e., self-compassion) as English, Spanish, German, and Greek, conceptu-
well as a “group” factor (i.e., one of the six sub- alize self-compassion in a similar way. This also
scales). Neff et al. (2019) then conducted a study suggests that the SCS can be expected to function
of the SCS using 20 samples from 16 countries similarly across linguistic groups, i.e., that asso-
and 14 languages using both Confirmatory ciations between self-compassion and outcomes
8 Self-Compassion Across Cultures 131
such as depression and well-being will be similar. Király and Neff (2020) examined mean differ-
It should be noted, however, that the sample did ences in self-compassion across different
not include Chinese and Japanese individuals. linguistic groups within different populations
Other studies have explored whether relation- (students, community members, and clinical
ships between self-compassion and health out- samples). Among students, Koreans were found
comes may vary according to ethnicity or culture. to have the highest self-compassion scores, fol-
Some evidence for cross-cultural differences in lowed by Iranians, with lower scores found
the strengths of the association between self- among the Canadian, American, and Norwegian
compassion and health outcomes has been found. groups. As for community members, Spanish,
For example, Arimitsu et al. (2019) demonstrated Italian, Hungarian, and Brazilian samples scored
that self-compassion was more likely to enhance high, while Australian, American, and German
hedonic well-being in individualistic cultures samples scored lower and Greeks and British had
than in collectivistic cultures and that compas- the lowest scores. In contrast, other studies have
sion for others was associated with enhanced found no statistically significant differences in
eudaemonic well-being in collectivistic cultures. total self-compassion scores across countries.
In their study of college students, Boyraz et al. For example, there was no difference between
(2020) reported that ethnicity moderated the link students in China and the United States (Birkett,
between self-criticism and perceived health, with 2013) or between HIV patients in Canada, China,
negative associations observed between self- Namibia, Puerto Rico, and the United States
criticism and perceived health among Hispanic/ (Kemppainen et al., 2013). However, the afore-
Latinx and European American participants, but mentioned samples comprised a small number of
not among Asian American participants. students and HIV patients, which may have
Interestingly, they also found that after adjusting resulted in sampling bias, reflecting an influence
for self-criticism, self-compassion was positively other than culture.
associated with perceived health among Asian
Americans and European Americans but not
Hispanic/Latinx participants; further, this rela- Cultivation of Self-Compassion
tionship was stronger for Asian Americans. Across Cultures
However, in a meta-analysis of 168 studies across
27 unique cultures—the largest synthesis of self- Another dimension of understanding self-
compassion studies to date—Chio et al. (2021) compassion across cultures relates to whether
found that there were no cross-cultural differ- and how it can be cultivated with different cul-
ences in the strength of the relationships between tural or ethnic groups. Self-compassion interven-
self-compassion and well-being or psychological tion studies have been conducted in several
distress. countries, including China (Huang et al., 2021;
Guo et al., 2020), Slovakia (Halamova et al.,
2020), Japan (Arimitsu, 2016), and Iran
Mean Differences in SCS Across (Rezapour-Mirsaleh et al., 2021). While many of
Cultures these studies use novel intervention protocols,
studies of standardized self-compassion training
In an early study, Neff et al. (2008) compared protocols, such as the Mindful Self-Compassion
mean scores on the SCS among participants in (MSC) program, provide the opportunity to com-
Thailand, Taiwan, and the United States. They pare outcomes across cultures. Pilot studies in
found significant differences in self-compassion China of both online (Yeung et al., 2021) and
scores: Thai participants had the highest scores, face-to-face versions of MSC (Finlay-Jones
Taiwanese participants had the lowest scores, and et al., 2017) found comparable results to trial out-
Americans were somewhere in between. comes reported in Western cultures (e.g., Neff &
Additionally, as part of their 2020 study, Tóth- Germer, 2013). Furthermore, a meta-analysis of
132 K. Arimitsu
studies aimed at improving mental health by alistic cultures—those which focus on the indi-
increasing self-compassion has revealed moder- vidual rights and needs of each person—are more
ate effects on depression, anxiety, and well-being likely to endorse an independent self-construal,
(Kirby et al., 2017). It includes findings not only in which oneself is perceived as relatively sepa-
from the United States and Western countries but rate from others. Typically, such self-construal is
also from East Asia, including Japan and China. considered characteristic of Western countries.
These studies very clearly show that self- This is contrasted with collectivistic cultures,
compassion is amenable to cultivation across cul- which emphasize the needs of the community,
tures and that effective cultivation is associated and in which the interdependent view of the self
with a range of health and social benefits. prevails. Interdependent self-construal empha-
sizes the inseparability of self and others and are
considered characteristic of Asian countries.
ultural Differences and Their
C There is some evidence that those in collectivistic
Influence on Self-Compassion cultures might be more likely to endorse the
“common humanity” facet of self-compassion
In sum, research to date suggests that while in (Akin and Eroglu, 2013). This has implications
many cases the factor structure of the SCS is sim- for self-compassion, in part because in Western
ilar across cultures, and measurement invariance cultures, one of the primary misgivings about
has been demonstrated, this is not a universal self-compassion is that it will undermine motiva-
finding. Further various studies have shown that tion (Robinson et al., 2016). In contrast, self-
there are cultural differences in the SCS means, criticism, on the other hand, is often considered
although self-compassion interventions appear necessary to maintain motivation and personal
feasible and acceptable across cultures and are standards, despite self-criticism increasing vul-
associated with similar benefits in Eastern and nerability to mental health problems (Schanche,
Western countries. To gain further insight into 2013). In Eastern countries, self-criticism may
these findings and consider why self-compassion also be viewed positively, but for different rea-
may or may not vary across cultures, several sons, namely, for its role in helping to promote
dimensions of cultural influence must be social harmony and maintain positive relation-
explored. For example, a robust body of work has ships (Yamaguchi et al., 2014). Interestingly,
explored the ways in which Eastern and Western research has suggested that stronger endorse-
cultures differ along dimensions of affective ments of either independent or collectivist con-
expression, self-construal, and beliefs about the struals are associated with greater self-criticism,
world, which are in turn influenced by several depending on the dominant culture (Yamaguchi
factors, including social norms, values, and reli- et al., 2014). Yamaguchi et al. (2014) found that
gious beliefs. In the following section, these US participants who reported higher levels of
dimensions are discussed and research exploring independent self-construal reported more self-
how they intersect with self-compassion is criticism, while in Japan, those who reported
explored. more interdependent self-construal were also
more likely to criticize themselves.
There is some suggestion in the literature that
Self-Construal and Dialecticism the different functions of self-criticism across
Eastern and Western countries may have different
Self-construal theory posits that cultural differ- implications for mental health. For example,
ences in affect, cognitions, and behavior are there is evidence demonstrating that in collectiv-
influenced by the degree to which a person con- ist contexts, interdependent self-construal
siders themselves fundamentally connected to or reduces the detrimental impact of self-criticism
separate from others (Markus & Kitayama, on mental health problems (Aruta et al., 2021).
1991). According to this view, those in individu- Aruta et al. (2021) proposed that when self-
criticism occurs in the context of interdependence, Applying the dialectical thinking to self-
the benefits gained by fulfilling social norms and compassion, East Asian cultures may tend to
preserving relationships counter any negative have ambivalent emotional experiences, resulting
impacts of self-criticism, thereby promoting bet- in experiencing equal amounts of self-kindness
ter mental health outcomes. In more independent and self-criticism simultaneously, albeit at more
countries, it might be assumed that criticizing moderate levels than Western cultures. This
oneself in order to maintain motivation to achieve response pattern could be quite different from
personal goals does not serve this same affiliative Western non-dialectical cultures. If the pattern is
purpose; moreover, self-criticism for competitive evident, it would also be necessary to consider
motives may increase separation from others and that the factor structure of self-compassion and
increase vulnerability to depression (Gilbert & its relationship with well-being may differ
Woodyatt, 2017). However, the adaptive function depending on the differences in dialectical think-
of self-criticism in Eastern cultures may depend ing among cultures. Chio et al.’s (2021) meta-
on the degree to which an individual feels aligned analysis of data from 27 cultures examined
with cultural values (Aruta et al., 2021). Further, whether dialectical thinking might impact the
when self-criticism is harsh, and when it co- correlation between CS and UCS components of
occurs with feelings of isolation and overidentifi- the SCS. The results suggested that across cul-
cation, it is likely to be detrimental for mental tures, there were moderate associations between
health, regardless of one’s cultural background. CS and UCS, but dialectical culture moderated
Additionally, recent findings from Boyraz et al. the correlation. In other words, correlations
(2020) suggest that the impact of culture and eth- between conflicting constructs, such as self-
nicity on the relationships between self- kindness and self-criticism, were found to be
compassion, self-criticism, and health outcomes lower in cultures that endorsed more dialectical
are more complex and cannot be explained by thinking. However, as the SCS generalizes across
single measures of cultural value or beliefs. different events, the extent to which it can pro-
vide insight into whether CS and UCS occur
Dialectical Thinking Dialectical thinking refers simultaneously is limited. Accordingly, it is
to a technique of accepting and integrating two important to test this hypothesis using the state
seemingly contradictory and opposing things to rather than trait Self-Compassion Scale.
create a better idea. The tendency toward dialec- A cross-cultural study examined the effects of
tical thinking and feeling varies across cultures the CS and UCS on well-being and psychological
and may influence the experience of compassion distress among students in Hong Kong and the
(Chio et al., 2021). People in dialectical cultures United States (Fung et al., 2021). The results
tend to experience positive and negative emo- revealed that both were associated with well-
tions simultaneously because they accept the being and psychological distress only among stu-
ambivalence of things (Schimmack et al., 2002). dents in Hong Kong. For American students,
For example, Japanese people are reported to UCS were related to well-being, depression, and
have a dialectical emotional style in which they anxiety, while CS were not related to depression
experience both positive and negative emotions and anxiety. This result is consistent with research
with moderate frequency compared to Americans on American students and adults (Brenner et al.,
(Miyamoto & Ryff, 2011). Moreover, people 2018). Fung et al. (2021) discussed that these cul-
with a moderate dialectical emotional style were tural differences were found because of the ten-
found to experience fewer physical symptoms in dency for individuals from collectivist cultures
Japan than in the United States (Miyamoto & toward dialectical thinking. They proposed that a
Ryff, 2011). These results suggest that a balanced greater ability and experience to possess seem-
experience of emotions, rather than experiencing ingly contradictory statements and emotions at
more positive and fewer negative emotions, may the same time led to both UCS and CS uniquely
lead to better well-being among East Asians. affecting well-being as well as depression and
134 K. Arimitsu
anxiety. They also argued that self-compassion The cultural value or emphasis placed on
might mitigate the impact of negative traits, such affective and motivational states such as compas-
as self-criticism, on mental health issues because sion likely influences their linguistic and behav-
of the correlation between CS and UCS. Self- ioral expression in that culture. For example, if a
compassion is, however, characterized by an culture emphasizes compassion, it should be rela-
increase in CS and a decrease in UCS, such as tively easier for helping behaviors to take root in
being kind to oneself instead of being self- that culture (Koopmann-Holm & Tsai, 2017).
critical. Again, this line of inquiry requires the Furthermore, the vocabulary related to compas-
use of the state Self-Compassion Scale (Neff sion should be more extensive and more distinct
et al., 2021) to determine profiles of state CS and from other words related to emotion. Shaver et al.
UCS across cultures and investigate their rela- (1992) found differences in the English, Italian,
tionships with health outcomes. Further, it should and Chinese emotion lexicon for compassion
be noted that even in cultures like Japan, who (Shaver et al., 1992), suggesting that the way in
tend to report higher levels of dialectical think- which compassion is understood and expressed
ing, experimental studies have found that CS and may differ depending on cultural background.
UCS of the SCS changed in tandem as a unitary Qualitative research to understand the lexicon
construct following self-compassion intervention associated with self-compassion across cultures
(Arimitsu, 2016). is an important direction for future research.
There are two types of psychological well-
being—hedonic and eudaemonic—which have
Affective Expression been shown to vary in degree and relationship to
compassion across cultures. High levels of life
Another way that culture may influence self- satisfaction and positive emotions and the
compassion is via the socialization of emotion. absence of negative emotions are referred to as
For example, each culture has a variety of valued hedonic well-being, which is experienced when
daily-life emotions (Mesquita, 2003), ideal emo- one has achieved pleasure and avoided pain.
tions (Tsai, 2007), and behaviors. In a study com- Arimitsu et al. (2019) conducted a comparative
paring ideal emotions between the United States study of the relationship between compassion for
and China (Tsai, 2007), it was found that people self and others and hedonic and eudaemonic
in the United States tended to idealize high- well-being and psychopathology between the
arousal, positive emotional states (e.g., excite- United States, which has an independent view of
ment, enthusiasm) while people in China tended the self, and Japan, with an interdependent view
to idealize low-arousal, positive emotional states of the self. They hypothesized that self-
(e.g., calmness, serenity). These differences in compassion, which motivates people to move
self-views indicate that in collectivistic cultures, forward despite failures and difficulties, would
other-focused emotions such as friendliness and maintain and improve hedonic well-being, such
guilt are likely to be more salient. Conversely, in as positive emotions and life satisfaction, in inde-
individualistic cultures, affective responses that pendent cultures more than in interdependent
emphasize separateness from others—such as cultures. The study revealed that self-compassion
pride and anger—may be more salient (Kitayama was a factor in improving positive affect and life
et al., 2006). This suggests that adaptive emo- satisfaction in both countries, but the explained
tions themselves differ due to differences in cul- variance for positive affect was higher in the
tural views of the self and relationship with United States than in Japan.
others. Accordingly, the expression of self- On the other hand, in interdependent cultures,
compassion, and its intensity and relationship it is adaptive to be able to meet the wishes and
with well-being, might differ between indepen- expectations of those around oneself to the great-
dent and interdependent cultures. est extent possible, and it is necessary to acquire
the flexibility to change one’s thoughts and focused, independent culture, self-compassion
actions appropriately depending on others. would be more robustly associated with lower
Therefore, eudemonic well-being is more likely SAD symptoms than in an interdependent cul-
to be enhanced when people have a high level of ture, while in an interdependent, other-focused
compassion for others. Among the measures of culture, compassion for others would be more
eudemonic well-being, interpersonal happiness is likely to be associated with lower TKS symptoms
one that may be enhanced by compassion for oth- than in an independent culture. The results
ers in interdependent cultures. Hitokoto and revealed no evidence of the predicted culture
Uchida (2015) developed a scale that measures moderation effects. Self-compassion was associ-
interdependent happiness, which serves as a ated with lower SAD symptoms, while compas-
comprehensive assessment of whether one has sion for others was associated with lower TKS
harmonious relationships with others, makes oth- symptoms across cultures, but there was no effect
ers happy, is on par with others, and is in a peace- of cultural self-construals on the relationship
ful emotional state. The study found that in Japan, between self-compassion and psychiatric symp-
being in harmony with others, rather than one’s toms. It should be noted, however, that the study
own superiority over others, leads to life satisfac- included only two different cultural groups—
tion and positive emotions. The moderation effect Japan and the United States—and had limited
of culture on interdependent happiness was indicators for well-being and psychopathological
found, with higher compassion associated with symptoms.
higher interdependent happiness only in Japan,
an interdependent culture.
Culture and self-construals may also impact Values and Social Norms
the relationship between compassion for others
and negative emotions related to others (Arimitsu Hofstede et al.’s (2001, 2010) Cultural
et al., 2019). Previous cross-cultural studies Dimensions Theory proposes six dimensions of
showed that social anxiety disorder (SAD) is cultural values that are thought to influence
characterized by self-focused attention that behavior. In addition to individualism-
increases not only the belief that one is behaving collectivism, these dimensions are masculinity-
in a socially inappropriate manner but also nega- femininity (i.e., the extent to which one is focused
tive thoughts and feelings about oneself. on tasks and competitive achievements versus
However, Taijin-Kyofu-Sho (TKS) features the people and relationships), power distance (the
other-focused cognition of fearing that one’s degree to which unequal power distribution in a
inappropriate behavior will make others uncom- society is accepted by the less powerful), long-
fortable. Patients with TKS fear offending others term orientation (the extent to which individuals
by emitting offensive odors, blushing, staring prepare for the future), uncertainty avoidance
inappropriately, and presenting an improper (the degree of comfort that society members have
facial expression or physical deformity (Hofmann with ambiguity), and indulgence-restraint (the
& Hinton, 2014). TKS symptoms tend to be more extent to which individuals endorse hedonism
prevalent in interdependent cultures than in inde- and impulsive behavior). Montero-Marin et al.
pendent cultures because the former tends to be (2018) examined the relationship between the six
more attentive to the feelings of others dimensions of Hofstede’s cultural values and CS
(Norasakkunkit et al., 2012). Since people with and UCS of the SCS in 11 countries and found
SAD and TKS focus their attention on the self that the higher the cultural value of long-term ori-
and others, Arimitsu et al. (2019) proposed that entation, the higher the CS scores. This may be
their relationship with compassion for self and because both self-compassion and long-term ori-
others may differ, and the relationship might also entation reflect a higher level of self-regulation
differ depending on the cultural view of self. In (Biber & Ellis, 2019). Similarly, indulgence—the
other words, it was predicted that in a self- opposite of self-control—was also associated
136 K. Arimitsu
with lower CS scores. Furthermore, the higher help strangers than they are in countries without
the cultural value of individualism, the higher the such traditions of simpatia (Levine et al., 2001).
UCS scores. Furthermore, in the Korean and The results of a field experiment in 23 major cit-
Japanese samples, where long-term orientation, ies around the world revealed large cross-cultural
uncertainty avoidance, and self-control were differences in helping behaviors toward strang-
high, the correlation between CS and UCS of the ers, ranging from 93% in Rio de Janeiro to 40%
SCS was low, the factor loadings of CS items in Kuala Lumpur. A potential direction for future
were high, and the factor loadings of the UCS work is to determine whether simpatia’s charac-
items were low. teristics of warmth and positive relationship
A cross-cultural study examined self- building would have a positive impact on self-
compassion with work engagement and mental compassion and whether this varies across
health problems among Dutch and Japanese cultures.
workers (Kotera et al., 2020). The results revealed
that mental health problems were significantly
inversely associated with self-compassion among Limitations and Future Prospects
Japanese workers and with work engagement
among Dutch workers. With reference to As the current chapter demonstrates, cultural dif-
Hofstede’s cultural value dimensions, Japan has a ferences have been examined in the mean and
higher tendency toward power inequality, mascu- factor structure of SCS, and in the relationship
linity, and uncertainty avoidance than does the between SCS, well-being, and psychopathology.
Netherlands, while the Netherlands has a higher One of the limitations of this research is the lack
tendency toward individualism and indulgence of experimental studies. Although several studies
than does Japan. Although the comparison have shown that self-compassion could reduce
between these two countries is minimal, it sug- experimentally induced distress, few have inves-
gests that self-compassion has no effect on men- tigated this phenomenon cross-culturally using
tal health problems among Dutch people. Other the same protocol in equivalent samples. Large-
studies, however, revealed contrary findings of scale studies and collaborative efforts across
work engagement predicting the onset of depres- countries can support standardization of trial pro-
sion in Japan (Imamura et al., 2016) and self- tocols to generate more robust insights into the
compassion being associated with lower process and outcomes of self-compassion train-
depression in the Netherlands (Kreemers et al., ing across cultures.
2020). Further studies are needed to determine In the literature reviewed in this chapter, there
whether these cultural differences are consis- is suggestion that the effects of self-criticism and
tently observed not only in such cross-sectional self-compassion on emotions and motivation
studies but also experimental ones. may vary across collectivist and individualistic
countries. An experiment might clarify whether
individualism increases the effect of CS on moti-
Other Factors vation and well-being because of the desire for
self-actualization and individual uniqueness or
Most of the cultural differences reviewed in this whether collectivism weakens the effect of CS
chapter were related to individualism-collectivism because of their belief of self-improvement effect
and cultural self-view. There are, however, other of self-criticism. It may also be interesting to test
factors and psychological indicators that may whether the effects of self-compassion training
impact self-compassion. One such cultural factor are impacted by “priming” participants with a
is simpatia or the tendency to avoid conflict and stimulus that reinforces the role of self-
outright negativity in favor of warm, positive compassion within their cultural value system
social interactions. This is most prevalent in Latin (e.g., priming participants from individualist
countries, in which individuals are more likely to cultures by telling them that self-compassion will
increase their motivation for personal goals or spread globally. It will be necessary to gather
telling participants from collectivist countries extensive practical knowledge to apply the vari-
that self-compassion will increase group har- ous findings across cultures and to clarify what
mony and interpersonal relationships). kind of innovations are needed in self-compassion
Future intervention studies and qualitative interventions.
work could also focus on whether resistance to The second limitation is that most cross-
self-compassion is influenced by culture and the cultural comparisons are based on the self-
implications of this for intervention engagement. construal dimensions of
For example, depending on the religious back- collectivism-individualism. Further, cross-
ground of the participants, it may be offensive to cultural studies tend to make comparisons
emphasize that self-compassion and its medita- between cultures at the extremes of only one
tion techniques are derived from Buddhism. dimension, without accounting for the impact of
Since compassion is an important part of the doc- other dimensions. Given that cultural dimensions
trines of not only Buddhism but also Christianity, are multifaceted and complex, larger samples are
Hinduism, and many other religions, it may not required to enable multivariate analyses. Such
be necessary to inform participants about studies could test whether the influence of self-
Buddhist doctrines. Moreover, participants from compassion on emotions and motivation across
Buddhist countries who are well versed with cultures depends on situational factors, such as
Buddhism may feel uncomfortable practicing whether success or failure is experienced in an
something slightly different from what they are in-group or in interactions with an out-group.
familiar with in their own culture. For example, The third limitation is the translated version of
one of the practices of Zen Buddhism in Japan is the SCS; although the one bifactor plus six-factor
zazen, which is different from mindfulness medi- model of the SCS has a good fit across cultures, it
tation in both doctrine and method. In contrast to inevitably has exceptions. The results of a meta-
some “mental training” meditation approaches, analysis (Chio et al., 2021) revealed that cultural
Zazen focuses on “simply” sitting with aware- differences in the correlations between CS and
ness of body and mind, without the explicit goal UCS of the SCS are influenced by dialectical
of improving mental health or concentration. For thinking tendency, which allows for the coexis-
participants who are familiar with such tradi- tence of each aspect in dialectical cultures. To
tional religious practices, being told that a medi- test this hypothesis, researchers should measure
tation method or program has been scientifically the dialectical tendency across cultures and test
proven to be effective may seem awkward. Such the fit of the model.
instances of knowledge getting in the way of The fourth limitation is the lack of studies that
practice are likely to occur in all countries, cul- use behavioral indicators. Although this is related
tures, and religions as the concepts of mindful- to the lack of experimental studies, it is better to
ness and compassion and their meditation examine how behavior in certain situations dif-
methods spread. fers among cultures to avoid verbal bias. For
In order to account for the cultural background example, a cultural difference in the form of more
of the participants, it should be common practice sharing behaviors among Asian children has been
to match the cultural background of the facilitator reported (e.g., Stewart & McBride-Chang, 2000).
as well as the language used or to adapt the While individualistic cultures seek self-
method to the culture. Mindfulness-based inter- actualization and individual uniqueness, in col-
ventions applied to Hispanic populations have lectivistic cultures, parents train their children
demonstrated that cultural adaptation can be used from an early age to view shared behavior as part
to improve engagement and implementation of family approval and identity and to be seen as
without compromising the quality of the research “givers” by others. For self-compassionate
(Castellanos et al., 2020). Programs to improve behaviors, Gilbert et al. (2017) developed a scale
self-compassion are currently becoming wide- consisting of items such as “Pay attention to what
138 K. Arimitsu
might be helpful to you” and “Create a state of More experimental studies using the state SCS
mind that is supportive, helpful, and encouraging should be conducted across more cultures in the
to you.” If individualistic cultures are more prone future.
to self-actualization and self-enhancement, then
the propensity for these behaviors may also be
higher in these cultures compared to collectivis- References
tic cultures.
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Self-Compassion Among Sexual
and Gender Minorities: 9
The Importance of Self-Kindness
in a Frequently Unkind World
Abra Vigna and Penelope Strauss
Caring for myself is not self-indulgence, it is self-preservation, and that is an act of political
warfare.
Audre Lorde
Introduction gests that almost one in two young trans people

has attempted suicide (Bradlow et al., 2017;
The ability to predict the distribution of health, Strauss et al., 2020a). These disproportionate
hope, morbidity, and mortality based upon social rates of mental health struggles correlate with
identity is a clear marker of an unjust society. In higher lifetime rates of harassment, discrimina-
most Western nations, people who identify as tion, and victimization experiences that are spe-
something other than heterosexual or cisgender cific to individuals perceived as having a
are often considered abnormal and predictably marginalized identity (Katz-Wise & Hyde, 2012).
experience a disproportionate burden of ill health. Up to 94% of SGM youth report having experi-
For example, although most sexual- and gender- enced some form of sexual- orientation-
based
minority (SGM) individuals demonstrate robust victimization (Mustanski et al., 2011).
mental and physical health (Saewyc, 2011), The most well-supported theory explaining
meta-analyses of population-level data show that this phenomenon is a variation of stigma theory
suicide attempts are nearly 2.5 times higher in called the minority-stress model (Meyer, 2003a,
lesbian, gay, and bisexual (LGB) adults (King b). The minority-stress model posits that in addi-
et al., 2008) and 3 times higher in LGB youth tion to managing the chronic stress of diminished
(Marshal et al., 2011) compared to their hetero- access to resources and opportunities, minorities
sexual peers. Rates among gender minorities are subject to acute stressors in the form of rejec-
appear to be on par, or higher than sexual minori- tion, violence, and harassment that at times result
ties (Reisner et al., 2015b). Global research sug- in the internalization of stigma. Together, these
forces result in reliably high rates of mortality
A. Vigna (*) and morbidity relative to those experienced by
UW Population Health Institute, University of nonminority individuals. In this chapter, we
Wisconsin-Madison, Madison, WI, USA examine the data indicating that self-compassion
(SC) buffers the impact of these stressors and
P. Strauss interrupts internalization of stigma, thereby func-
Telethon Kids Institute, Nedlands, WA, Australia

https://doi.org/10.1007/978-3-031-22348-8_9
144 A. Vigna and P. Strauss
tioning as a protective factor for minoritized their sexuality. In this chapter, we respectfully
identity groups. Our focus is on the emerging use the term SGM to encompass the diversity of
data regarding sexual and gender minorities and identities of individuals who are not exclusively
includes a summary of the evidence regarding heterosexual or not fully gender conforming or
distinctions between singly and multiply margin- identify as something other than cisgender. We
alized groups, such as between SGM youth who recognize, however, that SGM is not universally
identify as white and between SGM youth who used.
also identify as racial minorities. Gender identity and sexuality are independent
facets of one’s identity (Igartua et al., 2009;
Rieger & Savin-Williams, 2012). Sexual identity,
Rose by Any Other Name: LGBA,
A sexual arousal, and sexual behavior display con-
TNG, TGD, or Sexual- and Gender- siderable independence from one another and, for
Minority Populations some people, are independently fluid over the life
course (Coker et al., 2010; Mock & Eibach, 2012;
The terms people use to indicate their sexuality Rosario et al., 2011). As a result, an individual’s
and gender identities are ever evolving. Common current proclaimed sexual identity is not suffi-
self-ascribed terms indicating membership in cient information to determine their sexual his-
these populations include lesbian, gay, bisexual, tory, the content of their fantasies, their gender
queer, questioning, asexual (LGBQA), and presentation, or their gender identity. People who
trans/transgender, nonbinary, and gender expan- engage in same-sex sexual activity may not self-
sive/nonconforming (TNG). Subcommunities identify with a sexual-minority identity (i.e., not
and age cohorts often affirm their own distinct heterosexual), and not all gender-nonconforming
terminology reflective of racial, regional, and individuals identify as TNG (or any of that term’s
temporal specificity (Cohler & Hammack, 2007). synonyms) (Mustanski et al., 2014). This may be
Additionally, it has become increasingly com- particularly true for members of age cohorts dur-
mon for younger individuals to resist identifying ing whose adolescence nonconformity was heav-
with any label or category (Olive, 2012). ily policed and for individuals presently in
Preferred terms used to indicate SGM popula- adolescence and thus in a developmental period
tions differ between countries, cultures, and of identity exploration.
individuals. Due to the emergent nature of identity and the
In academia, the term sexual and gender shifting vogue of identity descriptors, it is diffi-
minority (SGM) applies to all individuals who do cult to estimate the proportion of the population
not fulfill hegemonic expectations of either gen- that identifies or would qualify as
der or sexuality. Gender-minority individuals, SGM. Additionally, the pressure of cisheteronor-
thus, are persons who do not identify with the mativity and the threat of the consequences of
gender assigned them at birth (e.g., TNG indi- deviation from it delay many individuals from
viduals) and/or do not conduct their lives or affirming their nonheterosexual or gender-
express themselves in what are considered nonconforming inclinations to themselves or on a
gender-conforming ways relative to their context survey. Cistheteronormativity refers to the expec-
(e.g., gender-expansive or gender-nonconforming tation that it is “normal” for each person to affirm
individuals) (Toomey et al., 2010). Separately, the gender legally assigned to them at birth (i.e.,
individuals may be defined as sexual minorities if are cisgender) and to desire only heterosexual
they do not experience exclusively heterosexual relationships (Gordon & Meyer, 2008; Schilt &
sexual or romantic attractions, do not favor exclu- Westbrook, 2009). It also refers to the dominant
sively heterosexual partnering, or do not identify expectation that genitalia are classifiable as
as heterosexual; such individuals may use terms indicative of one of two gender categories (i.e.,
such as gay, lesbian, bisexual, pansexual, girl or boy) and that those categories align with
demisexual, and asexual, among others, to define certain interests. An example is the expectation
9 Self-Compassion Among Sexual and Gender Minorities: The Importance of Self-Kindness… 145
that all who are born with vulvas identify as girls/ nate indigenous populations during colonization
women and both prefer and are better at caretak- processes (Tyler, 2018).
ing activities such as cooking and providing emo- In addition to rationalizing unjust social prac-
tional support or childcare/eldercare. tices such as disproportionate police contact,
Cisheteronormativity also insists that it is unnat- incarceration, or denial of the full rights of citi-
ural for people to desire sexual and romantic zenship (e.g., legal marriage or adoption), stigma
activities with others who have similar genitalia messages and practices are intended to instill
(e.g., girls have vulvas and should like boys who shame in those who violate cisheteronormative
have penises and vice versa). While cisheteronor- expectations. Content analyses of stigma mes-
mative identities remain dominant, an increasing sages directed at SGM populations suggest that
number of people outwardly identify as diverse the same mythological linkages between legally
in their sexuality and/or gender and at increas- assigned sex/presumed gender at birth and con-
ingly younger ages. Current estimates for the formity to gender norms and sexuality are used to
proportion of adults who are trans or gender instill shame in SGM people (Ioerger et al., 2015;
diverse are between 0.5% and 1.2% (Flores et al., Kimmel, 2004; Nadal et al., 2011; Worthen,
2017; Winter et al., 2016), and for high-school- 2016; Schilt & Westbrook, 2009). When people
aged people, current available estimates range believe these myths and experience shame for
from 2.3% to 2.7% (Rider et al., 2018; Fisher who they are, the resulting psychological distress
et al., 2019). Since gender identity and sexuality can be considerable. As will be described in
are typically not included in population-based greater detail below, an abundance of evidence
data collection methods (such as censuses), it is indicates that stigma drives population-level
difficult to know how these numbers differ from health inequities by increasing the number and
the true numbers of SGM individuals in the gen- intensity of stressors people face, decreasing
eral population. Consequently, existing estimates access to the personal and institutional resources
of the proportion of SGM individuals in the pop- needed to cope with them, and eroding physical
ulation are likely underestimates. and emotional well-being via the internalization
of stigma (Hatzenbuehler et al., 2013; Toomey
et al., 2010; White et al., 2015).
tigma and Other Punishments
S
for Violating Social Norms
mpirical Investigations of Stigma:
E
Stigma is the phenomenon of ascribing less value The Minority-Stress Model
to some people in a place (Link & Phelan, 2001).
Stigma identifies out-group members in order to Meyer (1995, 2003a, b) and others (Brooks,
create an in-group to idealize, privilege, and pro- 1981; Hendricks & Testa, 2012) have delineated
tect. Stigma ideologies, such as cisheteronorma- three key assumptions of the minority-stress
tivity and white supremacy, create cultural model. The first is that minority stressors are dis-
mythologies regarding what is considered natural tinct from and additive to the stressors that all
or civilized. Such myths in turn justify interper- individuals within the same culture tend to expe-
sonal and structural discrimination against, status rience. For example, in addition to dealing with a
loss for, and stereotyping of persons or groups global pandemic or the loss of a loved one,
with certain characteristics (Hatzenbuehler et al., minorities are less likely to receive adequate
2013; Martin, 1990; Sidanius & Pratto, 2012). medical care when seeking help and more likely
Stigma ideologies of otherness have a long his- to lose their jobs during a social lockdown than
tory in societies with steep social gradients. For are majority individuals. The second assumption
centuries, utilizing stigma stories or propaganda is that a state of minority stress is chronic due to
has been a key tactic for empires to justify poli- relatively stable structures of marginalization.
cies and practices to harass, exclude, and elimi- Thirdly, the minority-stress model assumes that
minority stress is a consequence of existing in a which stigma impacts health and well-being.
discriminatory context and not endemic to the This includes the nonconscious autonomic stress
individual. Minority stressors are assumed to response, as well as the conscious decisions peo-
impact the well-being of an individual via the fol- ple make to keep themselves safe. For example,
lowing three mechanisms: observable discrimi- one common bodily response to discrimination
nation, an individual’s response to discrimination, that erodes one’s health and well-being is to
and internalization of stigma. remain alert for future threat. Hypervigilance is a
chronic state of autonomic arousal that prioritizes
Mechanism #1: Observable energy for fight or flight and delays rest, diges-
Discrimination The first mechanism is the con- tion, and healing processes. Hypervigilance is
text of discrimination. This includes interper- often accompanied by decisions to hide one’s
sonal and/or institutional-level discrimination, identity to avoid potential rejection or discrimi-
violence, and threats to physical and/or material nation. Since many minorities either conceal
safety or security. Examples of institutional-level their identity or have been denied opportunities
discrimination range from policies banning med- to access health care, a common available option
ical doctors from providing gender-affirming for dampening hyperarousal is self-medication
medical care to individuals who are transgender, via alcohol or unprescribed drugs (Beemyn &
to school policies that ban SGM-inclusive sexual Rankin, 2011; Brubaker et al., 2009; Rood et al,
education curricula or prohibit transgender ath- 2016; Jerome & Halkitis, 2009). The prevalence
letes from participating on teams aligned with of this pattern of responding is reflected in higher
their affirmed gender, to disproportionate school rates of substance use and abuse among SGM
pushout of SGM youth (Mitchum & Moodie- individuals than among their cisgender, hetero-
Mills, 2014). SGM individuals also encounter sexual peers (Nadal, 2013; Reisner et al., 2015a).
employment, housing, and health-care discrimi-
nation at greater rates than their non-SGM peers
(Bachmann & Gooch, 2018; Grant et al., 2011; Mechanism #3: Internalization of Stigma The
Strauss et al., 2020a; Strauss et al., 2020b). For third pathway by which stigma impacts health
example, a very limited subset of the medical and well-being is through believing the stigma
workforce provides gender-affirming medical messages are true. Understood as the internaliza-
interventions, which are strongly associated with tion of homophobia, transphobia, or stigma, the
decreased psychological distress and suicidality process is typically unconscious and contributes
in SGM populations from youth through adult- to the fear or belief that one deserves one’s mis-
hood (Dolan et al., 2020; Mahfouda et al., 2017, treatment for one’s deviations from so-called
2018; Wernick et al., 2019). normality (Newcomb & Mustanski, 2010;
Puckett et al., 2015). This mechanism is consid-
Interpersonal discrimination is observed more ered the most damaging, as it is the process by
often among SGM youth than among their non- which one becomes one’s own bully and remains
SGM peers. Common examples include familial chronically burdened by managing the stress of
rejection or abuse, bias-based harassment by shame (Russell, 2007). Shame increases one’s
peers and teachers, and exposure to a greater inclination for self-isolation as well by reducing
number of adverse childhood experiences the likelihood that one will seek external sup-
(Andersen & Blosnich, 2013; Grant et al., 2011; ports, even among individuals who have affirmed
Grossman & D’Augelli, 2006; Kosciw et al., a minoritized identity. For example, a common
2008; McLaughlin et al., 2012; Zaza et al., 2016). self-policing sentiment that perpetuates isolation
among SGM populations is the fear that one is
Mechanism #2: Expectation and not “queer enough” to seek LGBTIQ-specific
Concealment Individual reactions and mental health services. Internalized homophobia
responses are the second mechanism through has been one of the strongest predictors of post-
traumatic stress symptoms among SGM popula- ing their emotions (Hatzenbuehler et al., 2009) or
tions (Dragowski et al., 2011). ruminating and thereby overidentifying with
their stigma experiences are more likely to report
In simple terms, the minority-stress model psychopathology (Szymanski et al., 2014;
suggests that stigma experiences cause the health Yadavaia & Hayes, 2012). So too are those who
disparities seen in minorities (i.e., SGM status → have increased expectations of rejection (Denton
stigma stressors → health inequities). Stigmatized et al., 2014), fear of being a burden to others
people in societies have their need for belonging (Baams et al., 2015), or difficulty detaching from
unmet in many circumstances; are more likely to negative thoughts (Hatzenbuehler et al., 2009).
be treated with violence by persons, organiza-
tions, and the government; have limited recourse
when they are mistreated; and are routinely elf-Compassion May Support
S
denied access to resources for meeting various Resilience to Minority Stress for SGM
needs, such as employment, upward mobility, Populations
shelter, and training. The long-term results of
increased stressors and reduced resources include Resilience is the manifestation of adaptive func-
physical and mental health challenges and post- tioning that supports one’s innate tendency to
traumatic stress symptomatology (Mustanski make sense of hardship and integrate it into how
et al., 2016). one functions. Described as “ordinary magic”
because of its near universality, resilience can be
Getting into the Weeds of Mechanism #3: The seen in the ability to move forward from an
Psychological Mediation Framework Since adversity rather than regress to the level of func-
the internalization of stigma is pernicious, tioning experienced before that adversity
Hatzenbuehler (2009) formulated the psycholog- (Masten, 2001). A close cousin of the study of
ical mediation framework to tease apart compo- stress and coping, resilience science focuses on
nent variables that contribute to the process of uncovering the constellation of individual, social,
internalization and thus identify potential inter- and ecological factors that contribute to defying
vention points. The psychological mediation the increased odds of mortality and morbidity
framework delineates a path analysis by which that accompany a history of facing adversity
mechanism one travels through mechanisms two (Masten, 2001). In resilience science, factors that
and three—either simultaneously or sequen- reduce the number, or lessen the severity, of the
tially—of the minority-stress model to arrive at a potential negative impacts of adversity are
psychopathology. This framework identifies the described as protective (Fergus & Zimmerman,
sub-mechanisms of internalization, including 2005; Luthar, 2006).
emotional (dys)regulation processes such as Although the minority-stress model primarily
hypervigilance or rumination (i.e., mechanism explains the route to psychopathology, it also
one), maladaptive social coping processes such provides a framework for explaining how an indi-
as physical or psychological self-isolation or vidual’s emotional, cognitive, and social coping
concealment (i.e., mechanism two), and the tenor strategies can be protective, and thus result in
of the cognitive meaning-making that accompa- resilience (Meyer, 2015; see Fig. 9.2). For exam-
nies awareness of stigma (see Fig. 9.1). In theory, ple, bringing present-moment awareness to the
stigma “gets under the skin” via increased levels distress that arises from experiencing discrimina-
of emotional dysregulation, self-isolation or con- tion or stigma and treating oneself with kindness
cealment, and negative self-stories, resulting in and comfort rather than self-judgment could be
psychopathology (Hatzenbuehler, 2009). an adaptive emotional coping approach.
Similarly, seeking out a supportive community to
Tests of this theory are thus far supportive. help carry the burden of distress, rather than self-
Individuals who respond to stigma by suppress- isolating and shouldering it alone, could act as a
Fig. 9.1 Adaptation of the psychological mediation framework. (Hatzenbuehler, 2009)
Fig. 9.2 Resilience-focused adaptation of the psychological mediation framework. (Hatzenbuehler, 2009)
buffer against adverse experiences. Finally, mak- being. In contrast by choosing to see one’s expe-
ing sense of the stress as an experience of com- riences as reflective of a common struggle and a
mon humanity could be a route for adaptive normative human response to stigma, one can
cognitive processes. For example, the prevailing feel supported by a sense of connection to all
myth of meritocracy suggests that all pain and suffering and potentially the shared goal of col-
suffering is a reflection of your value as a human lective liberation.
As a trait-level quality of responding to the with more kindness and less judgment, with a
self with warmth, acceptance, a sense of collec- sense of connection via common humanity rather
tive struggle, and a nonjudgmental presence, than withdrawing and self-isolating, and with
compassionate self-responding would theoreti- mindful awareness rather than an overidentifica-
cally facilitate resilience in the face of minority tion with one’s pain. Significant empirical evi-
stress. We will use the remaining portion of this dence regarding how the autonomic nervous
chapter to explore evidence that supports the the- system functions supports the premise that over-
ory that self-compassion facilitates resilience in all SC is a balance of these six components (see
the face of stigma among SGM individuals, con- Neff et al., 2018, and Neff et al., 2019, for detail).
cluding with recommendations for future
research. Self-Compassion Is Associated with Reduced
Psychopathology and Increased Well-
Compassionate Self-Responding Is an being Data consistently suggest that people who
Adaptive Emotional and Cognitive Coping maintain a more compassionate stance toward
Response Responding to oneself with compas- themselves are less likely to report symptoms of
sion entails presence, warmth, and understanding depression or anxiety; this finding has emerged
and engenders a sense of a “loving, connected repeatedly and with large effect sizes (MacBeth
presence” (McGehee et al., 2017; p. 280). Neff’s & Gumley, 2012; Zessin et al., 2015). People
(2003a) theory of self-compassion (SC) outlines who are more likely to respond to their own suf-
three main components (i.e., common humanity, fering with compassion are also less likely to
kindness, and mindful attunement) that can be experience public self-consciousness, engage in
assessed according to whether they are more or social comparison or ruminative thought, hold a
less aligned with compassionate self-responding. contingent or unstable sense of self-worth, or
In contrast, stigma focuses on personal defect, engage in thought suppression as a self-regulation
exclusion, and avoidance. Unlike self-esteem, strategy (Krieger et al., 2013; Leary et al., 2007;
which hinges upon a positive view of a uniquely Neff, 2003a, b; Neff & Vonk, 2009; Neff et al.,
special self in comparison with others and is thus 2007; Raes, 2011). Experimental investigations
vulnerable to stigma messages (which are borne have shown that people with greater dispositional
of social comparison), SC theory posits that a self-compassion more accurately appraise their
healthy self-attitude arises from de-emphasizing own performance, and test subjects who are
a separate self (Neff, 2003a, b). induced to feel self-compassion experience fewer
negative emotions and accept greater personal
Compassionate self-responding entails offer- responsibility for past failures than do subjects
ing kindness to the suffering self, seeing suffer- induced to have higher self-esteem (Leary et al.,
ing as a source of connection with all of humanity, 2007).
and remaining attuned to the feelings and
thoughts that arise from suffering and then dissi-
pate. Uncompassionate self-responding entails Inductions of Self-Compassion Appear to
judging the self harshly because of an experience Reduce the Sense of Isolation and Thus
of suffering or its cause, interpreting the experi- Reduced Social Resources One hypothesis
ence or its cause as evidence of one’s unique fal- regarding how self-compassion enables adaptive
libility, and fixating on, or identifying with, the emotion regulation is that it causes one to feel
experience of suffering on a personal (i.e., ego) supported in distress. Specifically, self-
level, such as in the case of rumination or the per- compassion inductions appear to trigger a calm-
sonal fable (Alberts et al., 2007). The 26-item ing hormonal cascade (Swain et al., 2012). Such
Self-Compassion Scale developed by Neff is a calming hormonal cascade is also observed
used to calculate a total score of a systems-level when an individual is in the presence of a close
balance of a trait tendency to respond to the self companion during pain-induction experiments
(Brown et al., 2003). According to several experi- ships. Longitudinal research on adolescents who
mental designs, activating SC reduces the dura- experienced legally documented abuse or neglect
tion and magnitude of inflammatory responses suggests that individuals with higher rates of dis-
during social-evaluative stress inductions positional SC are less likely to report common
(Breines et al., 2014, 2015; Bluth et al., 2016a, maltreatment-related impairments, such as psy-
b). Similarly, researchers have found evidence chological distress, substance abuse, and serious
that SC is associated with a decreased threat suicide attempts (Tanaka et al., 2011). Other
response and an increased reliance upon reassur- research has found that among adolescents with a
ing and kind thoughts during social-evaluative history of childhood maltreatment variance in
stress-induction procedures (Arch et al., 2014). compassionate self-responding accounts for
Finally, data from SC training interventions dem- more of the variance in emotion dysregulation
onstrate that increased SC is directly associated than do a history of childhood maltreatment, cur-
with reductions in symptoms of depression and rent rates of psychological distress, and problem
anxiety across adolescence and adulthood (Bluth substance use combined (Vettese et al., 2011).
& Eisenlohr-Moul, 2017; Diedrich et al., 2016; Taken together, these data suggest compassionate
Galla, 2016; Neff & Germer, 2013; Shapira & self-responding may protect us from the deleteri-
Mongrain, 2010). ous effects of stressors in much the same way that
the internalization of secure attachment serves as
a protective factor in the face of acute adversity.
Self-Compassion May Also Confer Resilience
in the Face of Adversity, Such as Minority
Stress As Leary et al. (2007) noted, “self- Self-Compassion in SGM Populations
compassionate people more readily accept
[socially] undesirable aspects of their character Although the study of SC in SGM populations is
and behavior without obsessing about them, still emerging, preliminary correlational data
becoming defensive, or behaving badly than do support the theory that compassionate—and
people low in self-compassion” (p. 901). With uncompassionate—self-responding may partially
the inclination to de-identify with thoughts and to
mediate the presence of well-being disparities in
rest in a sense of common humanity, SC may these populations. For example, SC was found to
help SGM individuals to view stigma messages mediate the relationship between early memories
as mere messages and not statements of truth of warmth and safeness, and happiness in adult-
about themselves. This may create the space to hood among LGB adults (Greene & Britton,
see that stigma messages have an explicit pur- 2015). SC also consistently demonstrates a sig-
pose: to maintain and protect inequitable access nificant inverse relationship with peer victimiza-
to resources as defined by a social hierarchy. Thetion and suicidality and a positive relationship
process of acknowledging one’s suffering non- with subjective well-being among LGBQ adoles-
judgmentally and refusing to create an ongoing cents (Hatchel et al., 2019) and gay men (Beard
negative story about oneself has obvious applica- et al., 2017). And, as with non-SGM populations,
tions for disrupting the internalization of stigmait appears that self-kindness (versus self-
messages. In one of the few investigations of the judgment) and self-isolation (versus common
subscales of the full 26-item Self-Compassion humanity) account for much of the variance in
Scale, researchers found that reduced rates of subjective well-being (Beard et al., 2017).
self-judgment and self-isolation account for most In the first published investigation of SC rates
of the variance in predicting lower rates of among SGM adolescents, Vigna et al. (2018a)
depression and anxiety symptomatology (Van found that SGM youth in a school-based sample
Dam et al., 2011). report lower levels of SC than their sexual- and
gender-majority counterparts, with a medium
SC appears to be protective against the long- effect size. Furthermore, mediation analysis sug-
term negative impacts of abusive family relation- gested that SC may account for more of the vari-
ance in depression, suicidality, and anxiety than stigma, and SC, Fredrick et al. (2020) found that
do adverse childhood experiences, bias-based public stigma impacts quality of life indirectly
bullying, and non-bias-based bullying combined. first via self-stigma, which then impacts SC
Also, high SC rates appear to have a negative among SGM adults. However, since the study
relationship with psychological distress (Vigna was correlational, the mediational relationship
et al., 2018a, b). remains somewhat speculative.
Self-Compassion, Discrimination, and Self- Self-Compassion and Gender

Stigma In accordance with the psychological Nonconformity Violating dominant expecta-
mediation framework of the minority-stress tions of gender assigned at birth is at the heart of
model, structural equation modeling of data from stigma messaging among SGM populations
a national sample of LGB adults suggests that (Gordon & Meyer, 2008). Accordingly, much
experiences of discrimination “get under the research has found an inverse relationship
skin” via increased expectations of rejection, between gender nonconformity and mental
anger, and rumination and reduced SC (Liao health, independent of sexual orientation,
et al., 2015). One study found that higher rates of although the strength of the relationship may dif-
SC, particularly a sense of common humanity, fer based upon which gender was legally assigned
were associated with positive LGB identity at birth (Alanko et al., 2009; Rieger & Savin-
development during the process of coming out Williams, 2012; Lippa, 2008; Skidmore et al.,
(i.e., internally and externally affirming one’s 2006; Toomey et al., 2010). One study of gender-
stigmatized identity), as reflected upon by LGB nonconforming adults in Singapore found that
adults (Crews, 2012). Another study, involving SC may moderate the relationship between gen-
in-depth qualitative analyses of 16 emerging ado- der nonconformity and subjective well-being via
lescents and described in the same dissertation the degree of self-judgment, overidentification,
found that moving from uncompassionate self- and self-isolation a person is plagued by.
responding to compassionate self-responding However, in this investigation, SC did not moder-
was correlated with a movement from resistance ate the relationship between gender nonconfor-
and fear to self-acceptance and well-being. For mity and depression (Keng & Liew, 2017).
many subjects of this study, the key pivot point Notably, the statistical model employed lacked a
was the recognition of an experience of solidar- measure of adversity, relying instead upon a mea-
ity, or common humanity, with others also mar- sure of gender nonconformity, and although gen-
ginalized by stigma leading to a sense of der nonconformity is frequently associated with
belonging (Crews, 2012). This same pattern has significant harassment, this is not always the
emerged elsewhere (DiFulvio, 2011). case. Nevertheless, this study demonstrated that
SC attenuates the negative association between
In one of the few studies involving compari- gender nonconformity and subjective well-being
sons among sub-identities of an SGM sample, and thus is relevant to SGM populations and the
greater SC when encountering stigma was asso- question of SC’s utility in attenuating the impact
ciated with less proneness to disordered eating in of stigma on well-being.
gay men and TNG individuals (Bell et al., 2019).
Additionally, path analyses demonstrated that the
effects of moderators of internalized stigma on Self-Compassion and Parental Rejection The
subjective well-being SC significantly moderated impact of parental acceptance or rejection of a
the effect on subjective well-being, whereas young SGM person is profound (Katz-Wise
mindfulness alone did not, among SGM men liv- et al., 2016; Khaleque & Rohner, 2002). In one of
ing with HIV in Hong Kong (Yang & Mak, 2017). the first investigations of the health impacts of
Finally, in the only study on the relationship degree of family rejection on SGM youth, Ryan
between self-stigma, or the internalization of et al. (2009) found that young LGB adults who
reported higher levels of family rejection were ongoing thwarting of the need for belonging,
8.4 times more likely to report having attempted either exacerbates the impact of parental rejec-
suicide, and 5.9 times more likely to report high tion when low or compensates for parental rejec-
levels of depression, compared with peers from tion when high (Matos et al., 2017).
families that reported no or low levels of family
rejection. Similarly, higher levels of family rejec-
tion were associated with 3.4 times increased Self-Compassion and the Intersection
likelihood of using illegal drugs and 3.4 times of Multiple Marginalized Identities
increased likelihood of reporting engaging in
unprotected sexual intercourse (Ryan et al., The minority-stress model is predicated on the
2009). Accordingly, investigations of factors thatnotion that social hierarchies define the opportu-
might moderate the negative impact of parental nities, challenges, and resources available to a
rejection are common. For example, several person according to that person’s identity.
researchers have modeled the role of compas- However, there is no single SGM experience, nor
sionate or uncompassionate self-responding in is there a single experience of being a member of
mediating the relationship between parental any stigmatized group (Cyrus, 2017; Mueller
rejection or support and psychological distress. et al., 2015). SGM individuals have racial identi-
Results of these investigations suggest that SC ties, citizenship statuses, native languages, and
fully mediates the relationship between parental unique relationships with colonization practices
support, parental acceptance at the time of com- and globalization patterns, all of which contrib-
ing out, and present-day levels of internalized ute to a diversity of experiences of minority stress
homophobia and subjective well-being among and access to the resources needed to keep stress
LGB adults (Beard, et al., 2017; Gertler, 2014; levels manageable (Holley et al., 2012; White
Toplu-Demirtaş et al., 2018). Hughto et al., 2015). At its root, intersectionality
theory requires that we consider how our various
Emerging research supports the premise that identities combine, or interact, to produce experi-
whether one tends to respond to oneself with ences reflective of the pressures placed on our
compassion is particularly important in explain- various socially assigned identities, such as those
ing the relationship between one’s stigma-related defined according to sexual and gender minority
parental rejection and depression. For example, or majority and racial minority or majority
one cross-sectional study found that SC mediated (Crenshaw, 1991). For example, a Black queer
the relationship between shame memories and woman’s total experience of oppression is not
current functioning for gay men, but not for het- reducible to an experience of racism or cishetero-
erosexual men. However, the ability to remain sexism or sexism; rather, the intersection of these
mindfully aware of distress and behave in accor- pressures in her life makes for a unique experi-
dance with one’s values (i.e., psychologically ence. Among other things, intersectionality calls
flexible) mediated the relationship between us to recognize that a white queer woman’s expe-
shame memories and current depressive symp- rience of oppression is distinct from a Black
toms among all participants of the study. One queer woman’s experience.
important distinction between the two groups Intersectionality theory thus cautions research-
was that the shame memories of the gay men ers to resist the urge to apply one-size-fits-all
were related to their fathers, whereas the shame repairs to issues of injustice, such as health ineq-
memories of the heterosexual men were about uities (Bowleg, 2012; Moradi et al., 2010).
nonparental adults. The authors of the study thus Moreover, as resilience science notes, the more
speculate that SC is more relevant for sexual- external the adversity one contends with in the
minority men who are already managing ongoing form of structural discrimination and violence,
stressors of global belonging as stigmatized peo- the less effective intraindividual resilience fac-
ple. The authors speculate that SC, under this tors will be in protecting against the deleterious
impacts of stigma-laden contexts (Masten, 2001). finding suggests that experiencing discrimination
This conclusion is particularly germane to inquiry in the form of interpersonal bias-based bullying
into SC as a resilience factor for SGM individu- has a stronger relationship with compassionate
als. One would expect that the greater the struc- self-responding for white SGM youth than it
tural discrimination SGM individuals face, the does for BIPOC SGM (Vigna et al., 2018b).
less effective an individual-level resilience factor Similarly, in conditional process analyses of the
such as SC would be at buffering the impacts of effect of intersectional identity on depressive
stigma on well-being. symptoms as moderated by SC, white SGM stu-
Investigation into the conditions in which SC dents report the highest rates of depressive symp-
serves as a resilience factor among SGM is emer- tomatology at average and below-average rates of
gent. The one investigation the authors of this SC of all identity groups (Vigna et al., 2020).
chapter could find suggests that although BIPOC The higher rates of depression symptomatol-
(Black, Indigenous, and People of Color) who ogy, anxiety symptomatology, and suicidality
are SGM may report two to three times the fre- among white SGM students compared with
quency of exposure to structural discrimination BIPOC SGM students mirror the rates of depres-
as that experienced by white SGM students, sion and anxiety among white versus Black
white SGM students report the highest rates of adults in the United States (Keyes, 2007, 2009;
mental health concerns. In this study, levels of McGuire & Miranda, 2008). Indeed, a strong pat-
structural discrimination were determined tern of internalization challenges across racial-
according to factors of economic hardship, hav- ization experiences is well documented. For the
ing an incarcerated parent, not trusting the police, past century, white people have consistently had
and the assignment of specialized education the highest rate of suicide of all the racial groups
plans and/or experiencing exclusionary disci- in the United States, despite benefiting from the
pline. Despite reporting higher rates of structural greatest structural privileges (National Center for
discrimination, BIPOC students reported the Health Statistics, 2016). It is possible that racial-
highest rates of SC, while white SGM students ized socialization into the myth of meritocracy
reported the lowest, with a small-to-moderate discourages white SGM students from seeing
effect size (Vigna et al., 2018b, 2020). their stigma as artificially designed to maintain
Additionally, within racial groupings, compari- inequitable power distributions (Bañales et al.,
sons of SC scores across sexual and gender cate- 2020). Instead of finding solidarity in the experi-
gories always favored the less marginalized ence of being oppressed, white SGM may be
group, with sexual- and gender-majority students more inclined to believe that there is something
having more compassion for the self than their wrong with who they are and thus they deserve
racially matched SGM counterparts, to a moder- exclusion and shame. Coupled with the finding
ate and large effect for BIPOC students. In con- that BIPOC students reported the highest rates of
trast with the authors’ hypothesis, the largest SC, this hypothesis suggests that racialization
difference in SC scores was found between sex- experiences that support the depersonalization of
ual- and gender-majority and white SGM, to a stigma are relevant for consideration in studies of
large effect size (Vigna et al., 2018b). the relationship between SC and mental health.
Given the wide variability in experiences of Existing literature provides preliminary sup-
marginalization, it is possible that protective fac- port for the hypothesis that racialization experi-
tors such as SC function differently at the inter- ences related to the development of critical
section of racialization, and gender- and awareness of social power structures and systems
sexuality-socialization, experiences. Conditional may impact well-being via depersonalization.
process analyses of the effect of identity on SC, For example, research comparing internalization
as moderated by rates of victimization from bias- rates and mental health between white and
based bullying, revealed a significant interaction BIPOC SGM adults suggests that BIPOC SGM
effect for white SGM youth, but not for SoC. This adults are less inclined to internalize SGM-
focused stigma and subsequently experience the stigma as a tool of oppression, a focus on solidar-
same patterns in psychological distress. In other ity with all of humanity may have the effect of
words, BIPOC SGM may be less inclined to resourcing ongoing engagement in the emotion-
ascribe their stigma experiences to moral failings ally challenging cross-group efforts for collective
or individual flaws associated with being SGM liberation from oppressive structures.
(Moradi et al., 2010). Additionally, longitudinal Eliminating external sources of stigma is the
research has found that system-justifying beliefs, most efficient and effective way to eliminate the
such as that “the system is fair for everyone,” impacts of internalized stigma (Puckett et al.,
were associated with stronger declines in well- 2016; Russell, 2007). Many of the intergroup
being among early-adolescent BIPOC (Godfrey efforts to do so focus on improving community
et al., 2019). If SC can support the depersonaliza- resilience, on improving the conditions of com-
tion of stigma messages and experiences for all munities to support and sustain individual well-
SGM people, it may support the shift toward a being (Hatzenbuehler & Pachankis, 2016; Hall &
collective experience rooted in the quest for lib- Zautra, 2010). Aspects of community resilience
eration that is related to psychological well-being have been found to promote well-being despite
among SGM folks and racial minorities social stigma across levels of social ecology.
(DiFulvio, 2011; Godfrey et al., 2019). Evidence-based conditions of community resil-
ience specific to SGM stigma include parental
acceptance (Ryan et al., 2010; van Beusekom,
Self-Compassion Is Not the Sole et al., 2015), gay-straight alliances in public
Answer to Dealing with Stigma schools (Hatzenbuehler, 2011; Poteat et al., 2012;
Toomey et al., 2012), inclusive school policies
Stigma, and the minority stress that results from (Hatzenbuehler, 2011; Hatzenbuehler et al.,
it, creates real internal and external challenges. 2011), community connectedness (Kertzner
As a root cause of population health inequities, et al., 2009), visible SGM communities
stigma drives and justifies the creation and per- (Hatzenbuehler, 2011; Hatzenbuehler et al.,
petuation of conditions that exclude, exploit, or 2012), and legislation that affirms identities and
violate minorities based on one or many of their reinstates the rights of citizenship or provides
identities. Although one cannot compassion one- protections for LGBTQ individuals
self out of incarceration or poverty, data do sug- (Hatzenbuehler et al., 2009a, b, 2010).
gest that SC is a promising tool for reframing Notably, macro-level legislation that reduces
one’s understanding of one’s material conditions social stigma by affirming equality for SGM peo-
and potentially supporting a shift toward collec- ple has demonstrated promotive impacts on psy-
tive action aimed at eliminating stigma chological well-being for both SGM and non-SGM
structures. individuals (Hatzenbuehler et al., 2009a, b, 2010).
The research summarized in this chapter sup- It is important to emphasize that in all communi-
ports the hypothesis that SC as a style of self- ties, SGM identities are marginalized, so the above
responding that is promotive and protective of conditions of resilience are truly supportive of
psychological functioning during difficulty may everyone’s resilience only if they reflect and
help preserve individual functioning and promote impact the diversity of SGM experiences. This
engagement with similarly stigmatized others. includes having visible, culturally diverse SGM
Given that SC has a dampening effect on the communities and GSAs (gay-straight, or gender-
autonomic stress response and encourages the sexuality, alliances), adopting inclusive school
individual to affirm kindness for the self, SC may policies that teach the truth of a country’s history
be a robust intervention for staving off the burn- (i.e., critical race theory), and legislation that ben-
out that often removes activists from structural- efits all SGM people and not just those with the
change work (Breslow et al., 2015). Additionally, money to hire lawyers to enforce or access protec-
if paired with a system-level understanding of tions or benefits, and so on.
Limitations Future Directions
Overall, there have been few investigations of SC In addition to pursuing longitudinal and experi-
as a resilience factor in SGM populations, despite mental designs, future research on SC among
the likeliness of suitability in these populations. SGM populations should include an intersec-
What literature does exist is cross-sectional and tional approach that prioritizes inquiry into prac-
relies upon self-reporting and is thus subject to tical applications for reducing health inequities.
common-method bias and the impossibility of Although there is limited research documenting
inferring causality (Podsakoff et al., 2003). the burden of health inequities falling upon trans-
Additionally, reliance upon school-based or gender and gender-nonconforming BIPOC peo-
population- based surveys to examine patterns ple—particularly those who present as feminine
among SGM individuals is problematic as there of center—what exists is alarming. As such,
is evidence to suggest that, at least among adoles- efforts that broaden our collective understanding
cents, some SGM individuals are unwilling to of how to address and reduce these inequities via
“out” themselves for a survey, and thus are multilevel interventions should be prioritized.
counted as either heterosexual or cisgender when Racialization appears to be particularly ger-
they may not be, thereby obscuring the true rela- mane to investigations into SC as a practice for
tionships between SGM identity and various disrupting the internalization of stigma. For exam-
health outcomes (Macapagal et al., 2017). ple, ample evidence suggests that white racializa-
While we can make some assumptions from tion conditions lower dispositional SC by
the experimental and longitudinal research not heightening a sense of individualization via com-
explicitly including SGM individuals, data sug- petition and a fear of others (Kwate & Meyer,
gest that SC functioning is amplified among stig- 2010; Jost et al., 2004; Okun, n.d.; Sidanius &
matized populations. Further, although few Pratto, 2012). Conversely, racialization experi-
studies with the power to detect differences ences within BIPOC communities may preserve
among subgroups of the SGM category have dispositional SC by explicitly countering the hege-
been published, evidence suggests that signifi- monic meritocratic narrative that obscures the
cant health differences exist among distinct iden- organizing influence of whiteness by affirming the
tities of SGM. For example, individuals who influence of oppressive structures in our lives
select bisexual or write in their sexual orientation (Neighbors et al., 1996). Limited data suggest that
on a list of forced-choice options consistently the process of reframing the cause of stigma from
report higher anxiety rates than those who select the self to society can help reaffirm one’s identity
heterosexual, or gay or lesbian (Wadesworth & and preserve psychological health (Frost, 2011;
Hayes-Skelton, 2015). Other studies have found Godfrey et al., 2017; DiFulvio, 2011). Since extant
that young people who select the bisexual identi- literature indicates that dominant narratives con-
fier report higher rates of suicidality and depres- structing racial categories play a significant role in
sive symptomatology than young people who predicting mortality and morbidity, future
select gay or lesbian identifiers, while young researchers would do well to account for the influ-
women who select lesbian or bisexual report ence of racial conditioning on SC, as omitting it
higher rates than their male gay and bisexual has likely contributed to the variance’s remaining
counterparts (Gilbey et al., 2019). This distinc- unaccounted for in the research.
tion implies that there are differences in the expe- Logical next steps for quantitative investiga-
rience of stigma, minority stress, resilience, and/ tions include enacting purposive sampling
or adverse events (e.g., discrimination) among strategies to recruit sample groups large enough to
SGM subgroups. detect real differences among identities more pre-
cise than white, BIPOC, SGM, and non-SGM, as a period during which emotion-regulation strate-
true intersectional approach recommends. gies are solidified (Steinberg et al., 2006).
Additionally, future statistical models would ben- Second, realizations regarding one’s sexuality or
efit from datasets that include variables on multi- gender identity during this time can become
ple levels of the social ecological model to more stressful and lead to the solidification of habitual
accurately test the multilevel influences of inter- responses of managing stigma (Eliason, 1996).
sectionality on health outcomes (Seng et al., 2012). Third, SGM adolescents are not concentrated in
However, there is also much to be gained from many geographic areas or may have difficulty
qualitative inquiries into the topic of intraindivid- physically accessing SGM-affirming services or
ual resilience factors such as SC. For example, we support groups where such interventions would
know little of how individuals make sense of what normally be offered. Fourth, it may be unsafe for
helps them to flourish within stigmatizing con- SGM adolescents to seek out SGM-specific ser-
texts. Given that SC appears to play a facilitative vices or interventions as many live in homes or
role, asking people about the role that SC plays in communities where their physical safety may be
their flourishing despite adversity would provide compromised if they were to affirm these aspects
important data on construct validity. of their identity. Finally, contemporary adoles-
Beyond that, there is a dearth of literature on cent cohorts are accustomed to engaging with
SC interventions among SGM individuals. one another via virtual spaces (McDermott et al.,
Further examination of SC therapies with SGM 2013, 2016).
individuals is needed and currently underway Moreover, it is imperative that all mental
(Finlay-Jones et al., 2021). Although this chapter health practitioners working with SGM popula-
refers generally to people who are SGM, the tions understand the potential impacts of stigma
emerging literature on intersectional identities and self-stigma on the individual. Some practitio-
and SC indicates that socialization experiences ners even argue that a central tenet of psychologi-
regarding identities are important to consider in cal care for SGM populations should be the
the research on SC interventions for SGM indi- reduction of stigma and internalized stigma,
viduals. For example, given the reliable differ- starting with an individualized approach to cli-
ences in dispositional self-compassion across ents’ conceptualization of stigma (Puckett &
gender binaries, gender socialization seems par- Levitt, 2015). Incorporating SC interventions
ticularly relevant for adapting SC trainings for into generalized mental health practice could be
SGM populations. A recent investigation into the useful in helping SGM and questioning individu-
relationship between gender roles, gender iden- als to acquire immediate support, as SGM indi-
tity, and SC showed that the impact of self- viduals may face difficulty in accessing limited
identified gender on SC was consistently smaller SGM-specific services in a timely manner.
than the impact of masculine gender-role orienta- In summary, preliminary findings and the the-
tion, suggesting that socialization plays a strong oretical underpinnings discussed here demon-
role. Notably, those subjects high in both femi- strate the potential utility of SC among SGM
ninity and masculinity (or instrumental and populations; however, further research is needed
expressive qualities) tended to have the highest to determine whether a) SC functions as expected
levels of SC (Yarnell et al., 2019). These findings according to those whom it may theoretically
suggest that SC interventions may be most suc- benefit, (b) aspects of SC training need to be tai-
cessful if their content and format are adapted to lored to specific subgroups, (c) the effectiveness
acknowledge and address toxic gender, sexuality, of SC is similar across age groups, and (d) spe-
and racial identity messages and experiences. cific SC training formats are more suitable than
For several reasons, adolescence is a promis- others (e.g., online versus face-to-face formats).
ing time to introduce SC and online offerings are Finally, research with activists engaged in collec-
a promising medium for connecting with SGM tive liberation in general, and in intersectional
youth. First, adolescence is the developmental spaces specifically, is needed to test the hypothe-
sis that SC supports long-term engagement in A within-person association of mindfulness, self-

compassion, and emotional Well-being outcomes.
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Self-Compassion as a Resource
of Resilience 10
J. Austin, C. H. C. Drossaert, and E. T. Bohlmeijer
From Risk to Resilience Richardson, 2002; Zautra et al., 2010). In this

chapter we will explore self-compassion as a
For a long time, the field of clinical and devel- resource of resilience. First, we will discuss
opmental psychology has been grounded in a how resilience is defined and how it can be
disease model of stress and coping and focused related to both mental distress and mental well-
almost exclusively on pathology, mental illness, being. We will then investigate how self-
social problems, and risk factors (Zautra & compassion contributes to resilience using
Reich, 2012). Clinical psychology has been pre- examples of experiencing war and cancer.
dominantly concerned with maladaptive func-
tioning and hardly with the promotion of
adaptive functioning (Bohlmeijer & Westerhof, What Is Resilience?
2021). Well-known risk factors such as unem-
ployment and social isolation were expected to There are varying definitions of resilience. Some
result in diminished functioning and health, emphasize individual traits that contribute to
assuming a linear relation between exposure to recovery from adversity, such as optimism,
risk factors and resulting poor health outcomes. agency, and the ability to make meaning of expe-
The underlying premise was that people tend to riences. Others focus more on social and environ-
get lost in despair at times of adversity. However, mental processes that facilitate individual
rates of severe distress and posttraumatic stress resilience, such as supportive family influences
symptoms following traumatic experiences have and community cohesion (Ungar, 2012; Zautra
been found lower than anticipated (Zautra & et al., 2010). Resilience may in fact be seen as a
Reich, 2012), and a wealth of research demon- metatheory, encompassing many fields of inquiry
strated positive and adaptive changes following (e.g., social, cognitive, and evolutionary) (Joseph
adversity that were unaccounted for by known & Linley, 2006; Richardson, 2002). The consen-
risk factors (e.g., Garmezy, 1991; Luthar et al., sus seems to be that resilience is best defined as
1993; Rutter, 1993; Werner & Johnson, 2002). It an adaptive response to adversity (Richardson,
is now firmly established that resilience is a 2002; Zautra et al., 2010). A common approach is
common and ordinary response to experiencing to infer resilience based on the individual varia-
adversity (Christopher, 2004; Masten, 2001; tions in outcomes of people who experienced
adversity (Ungar, 2012). According to Zautra
J. Austin (*) · C. H. C. Drossaert · E. T. Bohlmeijer et al. (2010), these outcomes can be categorized
Department of Psychology, Health & Technology, into recovery, sustainability, and growth. First,
University of Twente, Enschede, The Netherlands recovery pertains to the return to baseline func-

https://doi.org/10.1007/978-3-031-22348-8_10
166 J. Austin et al.
tioning, or the “bouncing back” emotionally after esilience in the Context of Mental
R
adversity. This does not necessarily imply recov- Health
ery to previous parameters, since resiliency refers
to maintaining any healthy, relatively stable equi- Similar to the risk and resilience literature, there
librium of psychological and physical function- has been a tendency to automatically equate men-
ing, including a newly established one (Bonanno, tal health with an absence of mental illness or
2004). It has even been posited that recovery to symptoms of psychopathology. However, mental
pre-trauma functioning leaves the individual vul- health has two dimensions: mental illness and
nerable to future traumatization, since their world mental well-being (Westerhof & Keyes, 2010).
view has not been accommodated to encompass The World Health Organization (WHO) defines
the disruptive experience (Joseph & Linley, mental well-being as: “A state of well-being in
2006). Thus, sometimes recovery is about which the individual realizes [their] own abili-
“bouncing forward” (Walsh, 2020). Second, ties, can cope with the normal stresses of life, can
while meeting the challenges of the stressors at work productively and fruitfully and is able to
hand, resilience is fostered by sustainability of make a contribution to [their] community” (2005,
approach motivations toward personal values and p. 12). In concordance with this definition, men-
goals (Zautra et al., 2010). Being able to maintain tal well-being can be divided into three compo-
sources of positive emotions and engagement nents. The first component is emotional or
with meaningful goal-directed activities contrib- subjective well-being and comprises satisfaction
utes to a sense of well-being and can be seen as a with life and the presence of positive affect
fundamental aspect of resilience (Tugade et al., (Diener et al., 1999). The second component is
2004). Third, in addition to recovering from psychological well-being and comprises aspects
adversity and sustaining purposeful living, a dis- of positive, individual functioning such as auton-
ruptive event encompasses a potential for (adver- omy, self-acceptance, and having meaningful
sarial or posttraumatic) growth. The disruption of goals and positive relationships (Ryff, 1989). The
normalcy and the individual’s worldview during third component is social well-being and can be
times of adversity asks for a reintegration and defined as optimal social functioning in terms of
meaning-making of life events (Joseph & Linley, social engagement and societal functioning
2006; Richardson, 2002; Tedeschi & Calhoun, (Keyes, 1998). In this way, mental well-being
2003; Zautra et al., 2010). When experiences are comprises the presence of both emotional well-
accommodated in a positive direction, growth being as an indicator of feeling well along with
may occur in self-views (e.g., greater acceptance psychological and social well-being as indicators
of vulnerabilities), life orientation (e.g., renegoti- of living well. When emotional, psychological,
ating priorities), and social relationships (e.g., and social well-being are all high, this is defined
increased closeness with others) (Joseph & as flourishing (Keyes, 2002). Sustainable mental
Linley, 2006). Adversarial growth (or posttrau- health can be realized when both the reduction of
matic growth, benefit finding) has been linked to maladaptive and the promotion of adaptive cog-
increased well-being and reduced distress nitions, emotions, and behavior are focused on in
(Helgeson et al., 2006) and increased social con- interventions (Bohlmeijer & Westerhof, 2021;
nection and support (Petrie et al., 1999; Rzeszutek Wood & Tarrier, 2010).
& Gruszczyńska, 2018). While it is now estab- In the context of clinical psychology, the pos-
lished that resilience, consisting of recovery, sus- sibility of increased positive functioning as an
tainability, and growth processes, is a normal and outcome of treatment of mental illness or distress
beneficial response to adversity, the extent to has long been overlooked (Rottenberg et al.,
which resilience is accounted for in the broader 2018). Yet clients particularly value personal
mental health context (e.g., models, assessments, growth as an outcome of treatment (Zimmerman
and interventions of mental health) is less clear. et al., 2006). For example, in a systematic review
of qualitative studies on clients’ perspectives of
10 Self-Compassion as a Resource of Resilience 167
recovery among persons recovered from eating of and develop positive responses such as posi-
disorders, it was found that clinical indices for tive emotions, gratitude, strengths, virtues, posi-
recovery were considered less important than tive relationships, renewed meaning, and values
aspects of recovery related to psychological well- (Peterson & Seligman, 2003; Tedeschi &
being (De Vos et al., 2017). Also, it has been Calhoun, 1995; Zautra et al., 2010). Successful
demonstrated that the presence of mental well- regulation of these, often longer-term, positive
being cannot be taken for granted when mental responses may primarily result in personal
illness is absent. Mental illness and mental well- growth and higher levels of mental well-being.
being function as two related yet distinct phe- However, although recovery from mental distress
nomena: one continuum represents the presence may often pertain to short-term processes and
or absence of mental well-being, the other the sustainability and growth of mental well-being
presence or absence of mental illness. This two- may often pertain to long-term processes, this
related-factor model of mental well-being and ill- distinction is of course not absolute. Awareness
ness has demonstrated superiority over one-factor of positive events and emotions may promote
models in large representative surveys of adaptation in the short term (e.g., experiencing
American, English, and Dutch adults (Keyes, gratitude), and negative emotions such as sadness
2005; Lamers et al., 2011; Schotanus-Dijkstra and anger may be experienced in the long term
et al., 2016; Weich et al., 2011; Westerhof & and warrant continued coping. Below we will
Keyes, 2010) and also recently in clinical sam- argue that self-compassion can be related to both
ples (Franken et al., 2018). The two-continua distress-reducing and well-being-promoting
model explains why some people with mental ill- dimensions of resilience and mental health.
ness may still be able to flourish (De Vos et al.,
2017; Westerhof & Keyes, 2010) and clients may
reliably change on either distress or mental well- Self-Compassion as an Adaptation
being (Trompetter et al., 2017). and Resilience Resource
Self-compassion refers to a warm, wise, and kind

Resilience and the Two-Continua attitude in times of difficulty and the ability to be
Model of Mental Health sensitive to personal suffering (Neff et al., 2007).
Self-compassion can be described as an adaptive
The two-continua model of mental health is also way of relating to the self when experiencing per-
relevant to the conceptualization and research of sonal inadequacies or adversity in life (Gilbert,
resilience. One dimension of resilience is related 2010; Neff & McGehee, 2010). Many definitions
to coping with stress-related difficult emotions of (self-)compassion exist, all stating that com-
and cognitions (Livneh, 2001) (i.e., recovery). passion consists of an awareness of suffering,
Regulating these, often short-term, responses being moved by the suffering, and acting or being
with adaptive coping and emotion regulation motivated to act to alleviate suffering (Strauss
strategies is important for restoring previous lev- et al., 2016). Variations in the definitions pertain
els of functioning or bouncing back or forward to to additional elements of the ability to tolerate
an earlier or new equilibrium. Successful coping uncomfortable feelings in response to perceived
with negative emotions and cognitions may pri- suffering and a recognition of commonality with
marily influence distress and symptoms of men- other suffering beings, as well as a focus on com-
tal illness. However, there is also a growing body passion for/from others or for oneself (Strauss
of literature focusing on a second dimension of et al., 2016). For example, Gilbert (2014)
resilience, i.e., the adaptive role of positive pro- describes three flows of compassion: having
cesses in the aftermath of negative life-events compassion for the self, having compassion for
(i.e., sustainability and growth). In reaction to others, and (being open to and capable of) receiv-
adversity, people may become increasingly aware ing compassion from others. Focusing on
compassion toward the self, Neff (2003) pro- ing at one end (self-judgment, isolation, over-
posed three elements that make up self- identification) and compassionate self-responding
compassion: (1) mindfulness or holding one’s at the other end (kindness, common humanity,
present-moment experience in balanced perspec- and mindfulness), one of the reasons self-com-
tive rather than getting lost in surrounding narra- passion may reduce distress is because it facili-
tives; (2) self-kindness, or treating oneself with tates less judgment, isolation and
care and understanding rather than with harsh over-identification.
self-judgment; and (3) common humanity, or the For example, one way in which self-
acknowledgment that imperfection is a shared compassion may serve as a resource of recovery
aspect among all humans rather than a sign of and resilience in general is through regulating
personal failure. Together, these elements form a overwhelming emotions with mindfulness.
self-
compassionate frame of mind. Self- Through mindfulness, experiences are held in
compassion is positively related to resilience in balanced awareness without resisting, avoiding,
various general and clinical populations or exaggerating them (Germer & Neff, 2019).
(Alizadeh et al., 2018; Bluth et al., 2018; Hayter Mindfulness facilitates awareness and clarity
& Dorstyn, 2014; Nery-Hurwit et al., 2018) and regarding emotional experiences, which are help-
can promote resilience in a number of ways. We ful for active coping (Eckland & Berenbaum,
will now explore self-compassion as an adapta- 2020). People high in self-compassion are more
tion resource in the context of recovery (mental able to maintain openness and equanimity in the
distress) and sustainability and growth (mental face of stressors, thereby modifying the context
well-being) processes of resilience, as illustrated in which these negative experiences occur
in Fig. 10.1. (Trompetter et al., 2017). In addition, people high
in self-compassion seem to exhibit less maladap-
tive emotion regulation strategies such as experi-
Recovery from Mental Distress ential avoidance (Allen & Leary, 2010; Eichholz
with Self-Compassion et al., 2020; Finlay-Jones et al., 2015; Raes,
2010; Scoglio et al., 2018; Trompetter et al.,
Given that self-compassion is often measured on 2017). This nonreactive, nonjudgmental stance
a spectrum with uncompassionate self-respond- toward the stressors at hand is linked to higher
Fig. 10.1 Model of self-compassion (including mindfulness (solid arrow) but may also involve boosting well-
ness, self-kindness, and common humanity aspects) as a being (dashed arrow). Sustainability and growth
resource of resilience in the context of mental illness and predominantly involve increasing mental well-being
well-being. An adverse event is depicted as a precedent to (solid arrow) but may also pertain to reducing mental ill-
resilience. This model does not include other (non- ness (dashed arrow). Self-compassion aids both the
resilient) responses to adversity that may occur. Recovery distress-reducing and well-being-promoting dimensions
predominantly involves reduction of mental distress/ill- of resilience.
resilience in clinical and nonclinical populations ment, anger, or contempt. In contrast,

(Chien-Chung et al., 2020; Freligh & Debb, self-kindness can activate self-soothing emotions
2019; Montero-Marin et al., 2015; Roemer et al., (Gilbert, 2014). Indeed, individuals with PTSD
2015; Zarotti et al., 2020). Gilbert (2014) with higher levels of shame engage more in self-
describes three main emotion regulation systems: critical and less in self-reassuring ways of think-
one focused on abilities to notice and respond to ing (Harman & Lee, 2010). Self-kindness may
threat appropriately (threat system), one focused also take the form of self-care behaviors to facili-
on seeking out and acquiring resources (drive tate recovery, for example, by taking rest, self-
system), and one focused on caring and resting soothe, lower productivity, guard boundaries,
(soothing system). The soothing system repre- adhere to medical/psychological treatment, and
sents an evolved mammalian caregiving system, conduct healthy lifestyle behaviors. Evidently,
allowing mammals, in contrast to other lifeforms, self-kindness not only pertains to being kind and
to protect, nurture, and soothe their immaturely self-soothing (i.e., “yin self-compassion”) but
born young. Through mindfulness, the soothing may just as well involve firm action such as set-
system is accessed, allowing for a non-striving, ting boundaries or undergoing difficult treat-
accepting, and being-in-the-moment experience ments (i.e., “yang self-compassion”) (Neff &
rather than a state based on activation (e.g., pro- Germer, 2018). The objective is to alleviate suf-
tecting or achieving) (Gilbert, 2014). When fering, and whether that involves soothing or firm
recovering from adverse life events, mindfulness action likely differs from situation to situation
thus supports the individual to not get lost in sur- and from person to person.
rounding narratives and stay rooted in present- Finally, self-compassion may foster experi-
moment experiences. ences of common humanity, belonging, and
In addition to being present, self-kindness can social support (Alizadeh et al., 2018; Neff, 2003;
be evoked in order to comfort and care for our- Wilson et al., 2020). Through the awareness that
selves in the midst of emotional turmoil, thereby suffering is part of life and experiencing suffering
alleviating distress (Germer & Neff, 2019). This is not a personal failing, experiences can be de-
is related to the notion that (self-)compassion shamed, and feelings of self-blame are dimin-
involves the motivation to alleviate suffering and ished (Gilbert, 2014; Neff, 2003). This means
that by practicing self-compassion, we are treat- that common humanity evokes an understanding
ing ourselves with the same kindness and under- that we haven’t necessarily done something
standing that we would treat another during times wrong and that emotional challenges are simply
of adversity (Gilbert, 2014). While mindfulness part of the human experience. In contrast, in
alone is about the experience and being mode, response to adverse events, people often tend to
self-compassion is about the experiencer and feel as if everyone else has it easier and that the
doing mode. In other words, mindfulness is personal suffering is abnormal rather than a part
focused on our relationship with our experiences of being human (Germer & Neff, 2019). Self-
(how we perceive and respond to external and compassion is related to greater feelings of being
internal stimuli), while self-compassion focuses supported (Alizadeh et al., 2018; Wilson et al.,
on how we relate to ourselves (e.g., as a person 2020) and thus may be helpful in counteracting
having a difficult experience). In the context of these feelings of isolation.
recovery, self-kindness may take the form of nur-
turing, reassuring, or self-supportive thoughts or
behaviors, rather than self-critical thinking or ustainability and Growth of Mental
S
destructive behaviors (Neff, 2003). Being critical Well-being with Self-Compassion
toward one’s own role in causing, exacerbating,
or dealing with an adverse event can be seen as an Beyond initial recovery, confrontation with
internal threat to our self-concept, thereby acti- adversity can ignite a process of revaluation of
vating threat-based emotions such as disappoint- values and goals in life. Self-compassion could
foster sustainability of approach motivations and et al., 2015; Zeligman et al., 2017). Loneliness in
growth, thereby contributing to mental well- turn hinders the opportunity to experience growth
being. Commonly, discrepancies between a pre- (Lee et al., 2019; Zeligman et al., 2017). In con-
vious world view (e.g., a just and fair world) and trast, self-compassion promotes resilience by
the threat to this worldview instigated by the facilitating decreased loneliness (Akın, 2014).
adversity (e.g., this suffering is unfair) are Indeed, research shows that self-compas-
attempted to be bridged in a process of meaning- sion is related to higher resilience and mental
making (Park & Ai, 2006). Self-compassion can well-being in the context of various types of
facilitate the process of meaning-making, for adversity, such as low well-being (Sommers-
example, by evaluating the adversity in a bal- Spijkerman et al., 2018), work- and study-
anced way (Yela et al., 2020). Research shows related stress and anxiety (Kemper et al., 2015;
that past the initial shock or survival mode fol- Lefebvre et al., 2020; Tang, 2019), chronic ill-
lowing adverse events, rumination and overiden- ness (Baker et al., 2019; Hayter & Dorstyn,
tification with the adverse event often persist 2014; Nery-Hurwit et al., 2018), interpersonal
(García et al., 2015; Im & Follette, 2016; Kim violence (Scoglio et al., 2018), divorce
et al., 2017; Szabo et al., 2017). Through mind- (Masumeh et al., 2019), and other types of
fulness, adverse experiences can continue to be trauma such as natural disaster and traffic acci-
held in balanced awareness (Tubbs et al., 2019; dents (Shebuski et al., 2020). More recently, a
Vujanovic et al., 2009), allowing flexibility to burgeoning body of research has explored the
process experiences and to create space for mak- protective role of self-compassion in buffering
ing sustainable and growth-promoting choices. In against stressors arising as a result of the
conjunction, self-kindness helps to facilitate pro- COVID-19 pandemic (Lau et al., 2020). For
active action, which could promote well-being in example, studies have demonstrated that self-
the long term (Akın, 2014). These fierce aspects compassion is associated with less pandemic-
of self-compassion, such as encouraging growth related stress and greater resilience in
and drawing boundaries, facilitate getting back to populations who have experienced extreme
a meaningful life after dealing with adversity disruption and occupational challenges, includ-
(Germer & Neff, 2019). In the context of Gilbert’s ing health professionals (Kotera et al., 2021),
three emotion regulation systems, this implies a teachers (Chen, 2022), and parents (Davis
reactivation of the drive system, involving the et al., 2021).
motivation to engage in valued activities once Despite many decades of research on adver-
again. This engagement may take the form of sity, very little is known about differences
committed action steps (e.g., developing asser- between various kinds of adversity and how
tiveness skills, refraining from addictive behav- they may affect resilience. However, distinc-
iors, targeted exposure to fears) that serve tions have been made between chronic adversity
personal values such as taking good care of one- or single-incident trauma (Bonanno & Diminich,
self and others (Tirch et al., 2014). While inte- 2013) and internal or external sources of threat
grating the adverse experiences into a new (Sumalla et al., 2009). To explore the ways in
narrative, awareness of common humanity which self-compassion may contribute to resil-
enables seeing adversity as part of being human, ience in depth, we will use two different types of
rather than a unique and isolating personal failure adversity as case studies: going through war
or a case of bad luck (Neff, 2003). This may (i.e., an external threat) and receiving a cancer
allow for a growth-promoting narrative, with diagnosis (i.e., an internal threat). These con-
more flexibility in moving onward in life. Past trasting types of hardship will aid the explora-
adversity and trauma pose a risk for experiencing tion of self-compassion as a resource of
loneliness (Hensley et al., 2012; Hyland et al., resilience across adversity types.
2019; Kearney et al., 2018; Zahava Solomon
Self-Compassion and Resilience (e.g., that others are fundamentally benevolent)

in the Context of War Veterans may be challenged (Creamer & Forbes, 2004).
Wartime experiences during combat and other
The Adversity of Going Through War missions pose the risk of the so-called moral
injury, in which one’s deeply held personal
“Difference exaggerated, invented, or politicized beliefs are transgressed or violated. Cognitive
in the extreme can explode into large-scale armed dissonance then results from the discrepancy
conflict between groups that find others so ‘other’ between personal beliefs about one’s goodness
that they must be killed” (Sylvester, 2011, p. 1), and the goodness of the world and the disruptive
in other words, war. Exposure to the atrocities of wartime experiences (Litz et al., 2009). Moral
war may involve committing, witnessing, or fail- injury is in turn associated with increased distress
ing to prevent acts of violence; experiencing and suicidality (Forkus et al., 2019; Kelley et al.,
betrayal, loss, and sexual misconduct; and 2019).
observing grotesque mutilations, injury, and Problems in social and occupational function-
death (Forkus et al., 2019; Lueger-Schuster et al., ing, such as unemployment, marital issues, and
2012; Snyder, 2014). War affects individuals in homelessness, are prevalent among veterans
myriad ways, as combatant, victim of abuse, fam- (Held & Owens, 2015; Prigerson et al., 2001).
ily member, service or health professional, and Furthermore, the devastating effects of war are
many more (Sylvester, 2011). For this chapter, not limited to veterans themselves. Their parents,
we will focus on veterans of war and the psycho- children, partners, and health professionals may
logical consequences of surviving a war after be affected by secondary trauma (Bramsen et al.,
serving in the military. Other research addresses 2002; Gibbons et al., 2012; Gliske et al., 2019;
mental illness and well-being in military recruits Johnson et al., 2014; Melvin et al., 2012;
and prisoners of war (e.g., Mantzios, 2014; Vasterling et al., 2015). Although the adversity of
Solomon et al., 2009). war is clear, the above also implies that if 23% of
Veterans are at increased risk for posttrau- veterans experience PTSD, that means that 77%
matic stress symptoms and posttraumatic stress of veterans do not experience this level of contin-
disorder (PTSD). PTSD is a mental health disor- ued distress. In a longitudinal study that moni-
der resulting from exposure to trauma, character- tored symptoms of PTSD, depression, and
ized by intrusive reexperiencing of the event, anxiety over the course of 2 years, 68% of veter-
avoidance, negative cognitions, and emotional ans were characterized as resilient (Isaacs et al.,
arousal, among other symptoms (Diagnostic and 2017). What helps these veterans to be resilient
Statistical Manual of Mental Disorders – Fifth after wartime, and in particular, what role does
Edition: DSM-5, 2013). The occurrence of PTSD self-compassion play in this?
among veterans has been estimated at around
23% (Bryan et al., 2013; Fulton et al., 2015), and
a greater proportion may experience posttrau- romoting Resilience in Veterans
P
matic stress symptoms (Melvin et al., 2012; with Self-Compassion
Schreuder et al., 2000). Depression (Gadermann
et al., 2012), suicidal ideation (Craig et al., 2015), Research shows that self-compassion is related to
deliberate self-harm (Bryan & Bryan, 2014), ele- decreased PTSD symptomology in veterans
vated levels of anger (Renshaw & Kiddie, 2012; (Dahm et al., 2015; Forkus et al., 2019; Hiraoka
Wilk et al., 2015), and drug and alcohol abuse et al., 2015; Meyer et al., 2019; Rabon et al.,
(Burnett-Zeigler et al., 2011; Jeffery et al., 2013; 2019) and that self-compassion interventions can
Seal et al., 2011) are common among veterans. help reduce PTSD symptomology (Lang et al.,
Fundamental views about the self (e.g., that one 2019; Steen et al., 2021). Since avoidance is a
has control over their experiences), the world key part of PTSD, the mindfulness component of
(e.g., that it is a safe place), and other people self-compassion may be helpful to tolerate, be
with, or engage with difficult experiences (Kelley an important resource, as emotional stability
et al., 2019). Indeed, mindfulness interventions facilitates growth in veterans (Heppner et al.,
have been found acceptable (Bravo et al., 2019) 2015; Tsai & Pietrzak, 2017). Behaviors stem-
and effective (Bremner et al., 2017; King et al., ming from kinder styles of self-relating may con-
2013; Polusny et al., 2015) in reducing PTSD tribute to personal goals and purpose, and purpose
symptomology for veterans. The mindfulness in life is in turn related to growth in veterans
component of self-compassion allows for a non- (Isaacs et al., 2017; Tsai & Pietrzak, 2017).
evaluative and accepting stance toward difficult Noteworthy, in the context of Gilbert’s drive sys-
experiences. This approach-oriented attitude tem (which focuses on acquiring (coping)
could also support veterans to refrain from using resources), striving to overcome worthlessness
substances as an avoidant coping strategy (Forkus through maladaptive overachieving or addictive
et al., 2019). behaviors may occur, as is common in veterans.
In the case of moral injury, viewing oneself as At the same time, the drive system is an impor-
a bad person and engaging in self-punishing cog- tant source of vitality, positive emotions, and
nitions or behaviors are typical (Litz et al., 2009). motivation (Irons & Lad, 2017). While traditional
Viewing or participating in morally transgressive masculinity norms in military culture are related
events challenges not only one’s moral compass to worse mental health outcomes overall, the
but also perceptions of the self as a capable and masculinity aspect of “success dedication” is
just individual (Forkus et al., 2019). In contrast, linked to greater quality of life and mindfulness
some facets of self-compassion moderate the link in veterans (Ramon et al., 2019). This dedication
between moral injury and adverse outcomes to success inherent to military culture could be a
(e.g., suicide ideation), suggesting that the impact potential catalyst for facilitating compassionate
of moral injury can be attenuated by self- goals and self-care behaviors, as this drive for
compassion (Kelley et al., 2019). Self-kindness success may be a source of vitality to be used for
may be particularly helpful to be more under- other goals as well. Furthermore, perceived social
standing toward oneself, counteracting harsh support (Staugaard et al., 2015; Tsai & Pietrzak,
self-criticism and stimulating self-care (Gilbert 2017) as well as altruism (Isaacs et al., 2017; Tsai
et al., 2006; Neff, 2003). This may further facili- et al., 2016) predicts growth in veterans. Self-
tate breaking the cycle of negative cognitions in compassion could facilitate this growth via com-
trauma-related guilt (Held & Owens, 2015) and mon humanity through increased social
depression (Forkus et al., 2019). Similarly, com- connection (Germer & Neff, 2019).
mon humanity may help to integrate transgressive Evidence for self-compassion interventions to
experiences into a sense of self, in which the vet- facilitate resilience in veterans is still limited.
eran is simply an imperfect human being who Interventions specifically aimed at training self-
had to make difficult decisions in a tough situa- compassion seem promising (Serpa et al., 2021;
tion (Forkus et al., 2019). This could facilitate a Alliger-Horn et al., 2016; Grodin et al., 2019;
sense of belonging as well as connecting with Lee, 2009), while other types of interventions
others, especially after going through an isolating may increase self-compassion indirectly (e.g.,
experience of war and then having to reintegrate Bergen-Cico et al., 2018). Compassion-based
into society. interventions typically include psychoeducation
In addition to recovery, this reintegration about emotions and various exercises to cultivate
requires finding new goals and calibrating mean- compassionate skills and attitudes, which may be
ing in post-war life, in order to facilitate mental adapted to the needs of veterans (Grodin et al.,
well-being. Posttraumatic growth may involve 2019). Lee (2009) describes how the cultivation
positive perceptions of new possibilities, rela- of compassionate resilience can be helpful for
tions to others, personal strengths, and a new veterans with PTSD. Compassionate resilience,
appreciation of life (Cann et al., 2010). Increased as trained with compassion-based interventions
emotional stability through mindfulness may be such as compassion-focused therapy, enables the
development of self-soothing capabilities and challenges social roles both within close relation-
feelings of safeness in the face of confronting ships (e.g., from partner to caregiver or care
memories (Lee, 2009). This may take the form of recipient) and within the societal and employ-
developing an image of a compassionate self who ment context (e.g., from employee to being
cares for and self-soothes a traumatized part of exempted from work). Some cancer patients
the self (Alliger-Horn et al., 2016). Using this report feelings of loneliness, for example,
imagery to learn compassionate self-talk can because despite abundant social support, the ill-
break the cycle of self-criticism that is maintain- ness is something they only go through by them-
ing feelings of threat. Furthermore, being able to selves. They may also experience feelings of
access feelings of self-compassion facilitates the uselessness because of not being able to contrib-
development of new perspectives on the meaning ute to others (Austin et al., 2021). Despite all this,
of the traumatic event, which may be actively it is estimated that around 65% of people with
addressed with compassionate rescripting. This cancer do not experience prolonged distress
can be useful to work though trauma stories and (Herschbach et al., 2020; Wang et al., 2016;
develop more helpful inter- and intrapersonal Zabora et al., 2001). What helps these patients to
relationships (Lee, 2009). be resilient after receiving a cancer diagnosis,
and what role does self-compassion play in this?
Self-Compassion and Resilience

in the Context of Cancer romoting Resilience in People
P
with Cancer with Self-Compassion
he Adversity of Going Through
T
Cancer Resilience in the context of cancer pertains to
adaptation to a cancer diagnosis and may involve
What does it entail to have cancer? Many cancer attributes such as meaning-making, positive
patients describe receiving a diagnosis of cancer emotions, social support, and cognitive flexibility
as an event that turns their entire life upside down (Seiler & Jenewein, 2019). Recovery from cancer
and demolishes all sense of certainty (Austin may involve different challenges than other
et al., 2021). Cancer, a term that describes a (acute) types of trauma, given that the source of
group of diseases in which abnormal and uncon- the threat is internal, the stressors are widespread,
trollable cell growth occurs (WHO, 2020), the threat is ongoing in the future, and there is
involves profound physical, functional, psycho- greater perceived control over the threat (Sumalla
logical, and social changes. It is estimated that, et al., 2009). Accordingly, individuals with can-
worldwide, more than 18 million people each cer may experience a greater sense of personal
year are diagnosed with cancer, and the physical, failure if disease progression worsens. Seiler and
emotional, and financial burden of cancer contin- Jenewein (2019) posit that resilience in the con-
ues to grow globally (WHO, 2020; International text of cancer occurs both directly, via individual
Agency for Research on Cancer, 2019). coping abilities and personality traits, and indi-
Regarding the physical burdens of a cancer diag- rectly, via redefinition of the individual’s self,
nosis, patients face side effects of their treatment post-diagnosis. This is akin to recovery (direct)
(e.g., nausea due to chemotherapy), fatigue, pain, and sustainability and growth (indirect) pro-
and functional limitations (e.g., decreased mobil- cesses. As previously discussed, self-compassion
ity). They are at an increased risk for depression addresses both of these pathways. Self-
and anxiety (Trindade et al., 2018; Zabora et al., compassion appears a relevant adaptation
2001), and many cancer patients struggle with resource in the context of cancer, since higher
distress, negative body image, and self-blame self-compassion in cancer patients has been asso-
(Callebaut et al., 2017; Przezdziecki et al., 2013; ciated with lower depression (Pinto-Gouveia
Zabora et al., 2001). In addition, cancer often et al., 2014; Todorov et al., 2019; Zhu et al.,
2019), anxiety (Todorov et al., 2019; Zhu et al., shortly after receiving a cancer diagnosis.
2019), and distress (Pinto-Gouveia et al., 2014; However, another qualitative interview study
Todorov et al., 2019), lower body-image distress with people with breast cancer found similar
(Todorov et al., 2019), and higher treatment aspects in the context of (sustainability and)
adherence (Sirois & Hirsch, 2019) and is directly growth, describing experiences of renewed atti-
related to higher resilience (Alizadeh et al., tudes toward the self, relationships, and life in
2018). general (Barthakur et al., 2016).
To learn more about self-compassion as part Similar to veterans, compassion-based inter-
of an adaptation process in response to a cancer ventions are increasingly available for people
diagnosis, we conducted an interview study with with cancer (Austin et al., 2020). While these
26 cancer patients about their experiences of self- interventions are promising, attending self-
compassion (Austin et al., 2021). Patients were compassion training face-to-face is not always
asked to familiarize themselves with the concept feasible for people with cancer (and, perhaps,
of self-compassion by trying out various self- other populations who experienced adversity).
compassion exercises for 2 weeks, after which The often already high load of medical appoint-
patients were asked about their ideas, experiments of cancer patients constitutes a substantial
ences, and examples regarding self-compassion burden of care. Lathren et al. (2018) offered a
in the context of their diagnosis. Various self- Mindful Self-Compassion training entirely via
compassionate actions and cognitions were videoconferencing, thereby addressing a popula-
described, originating from participants’ per- tion of young adult cancer survivors at a distance.
sonal experiences. Related to mindfulness, par- Mobile technology offers benefits in terms of
ticipants described allowing emotions to arise, as addressing issues of accessibility and availability
well as releasing them as they come up. This also (Gemert-Pijnen et al., 2018; Kelders & Howard,
included taking a balanced perspective, instead 2018) in general and in times of crisis and may
of getting lost in negative thoughts. Many differ- offer additional benefits regarding integration of
ent forms of self-kindness were described. In the newly learned skills into daily life (Jones et al.,
context of self-kind rather than self-critical think- 2015; Williams et al., 2007) and interactive and
ing, participants described acknowledging that personalization features. In our current work, we
you are going through a hard time; realizing that are co-designing and evaluating a self-compassion
things aren’t your fault; encouraging yourself; mobile intervention for people with newly diag-
acceptance of the condition, negative emotions, nosed cancer with cancer patients and oncology
and functional limitations; and paying attention nurses (Austin et al., 2022). We expect that par-
to positive things in life. ticipation in mobile interventions such as this one
Further, participants described self-kind will help cancer patients relate to themselves and
behaviors, such as guarding social and physical their cancer experience with compassion and that
boundaries, undertaking pleasurable activities, this in turn will facilitate their resilience in the
asking for and accepting help, and taking respon- face of the diagnosis. This work is an important
sibility for their health. While participants did not step in the direction of offering feasible low-
explicitly describe their experience in terms of threshold self-compassion and resilience inter-
common humanity (e.g., realizing that adverse ventions for people with limited capacity due to
experiences and failings are human and part of experienced adversity.
life), they described feeling connected to other
patients, close family, and friends. Patients
acknowledged the importance of self-compassion Conclusion
in the challenging time after receiving a cancer
diagnosis. These experiences mostly pertain to In this chapter we have discussed resilience as
the recovery aspect of resilience, since partici- the ability to adapt to adversity and difficult life
pants were interviewed about their experiences circumstances, particularly in the context of
surviving military service and surviving cancer. people diagnosed with cancer: A multimethod quali-
tative study. Frontiers in Psychology, 12. https://doi.
There is growing evidence that self-compassion org/10.3389/fpsyg.2021.737725
is an inner resource that promotes resilience and Austin, J., Drossaert, C. H. C., Van Dijk, J., Sanderman,
the ability to adapt in two major ways. First, it R., Børøsund, E., Mirkovic, J., et al. (2022). Integrating
supports the willingness and ability to acknowl- top-down and bottom-up requirements in eHealth
development: The case of a mobile self-compassion
edge and process the emotional and cognitive intervention for people with newly diagnosed cancer.
suffering that is created by serious negative life JMIR Cancer. doi:24/05/2022:37502
events. This facilitates the recovery aspect of Baker, D. A., Caswell, H. L., & Eccles, F. J. R.
resilience, especially in the context of mental ill- (2019). Self-compassion and depression, anxiety,
and resilience in adults with epilepsy. Epilepsy &
ness. Second, it can be supportive in creating a Behavior, 90, 154–161. https://doi.org/10.1016/j.
context in which humans become more aware of yebeh.2018.11.025
important values in their lives and reengage in Barthakur, M. S., Sharma, M. P., Chaturvedi, S. K., &
meaningful activities. This facilitates sustainabil- Manjunath, S. K. (2016). Posttraumatic growth in
women survivors of breast cancer. Indian Journal
ity and growth aspects of resilience, especially in of Palliative Care, 22(2), 157–162. https://doi.
the context of mental well-being. Self-compassion org/10.4103/0973-1075.179609
promotes a sense of care, fierceness, and courage Bergen-Cico, D., Smith, Y., Wolford, K., Gooley, C.,
to be resilient in the face of adversity. We recom- Hannon, K., Woodruff, R., et al. (2018). Dog owner-
ship and training reduces post-traumatic stress symp-
mend future studies to further investigate the dif- toms and increases self-compassion among veterans:
ferent ways in which self-compassion can Results of a longitudinal control study. Journal of
promote resilience, taking into account both Alternative and Complementary Medicine, 24(12),
mental distress and mental well-being outcomes. 1166–1175. https://doi.org/10.1089/acm.2018.0179
Bluth, K., Mullarkey, M., & Lathren, C. (2018). Self-
compassion: A potential path to adolescent resil-
ience and positive exploration. Journal of Child and
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Self-Compassion and Body Image
11
Tracy L. Tylka and Katarina L. Huellemann
Introduction body-related behaviors and harmful coping strat-

egies (e.g., disordered eating, excessive exercise).
Self-compassion occurs when people are mind- Fortunately, generating self-nurturance, under-
ful, understanding, and nurturing toward them- standing, and mindfulness rather than self-
selves during situations where they experience judgment and criticism may subvert this
distressing feelings and concerns about their deleterious process.
adequacy (Neff, 2003b). Many situations hold The study of self-compassion holds great rel-
the potential to bring forth distressing feelings evance for body image theory, research, and prac-
and concerns that are specific to the body and tice. During body image threats, a person can
appearance. These situations may include a per- activate self-compassion, which facilitates feel-
son being told (or receiving a hint) to go on a diet, ings of being cared for, connected to others, and
not being able to fit into a piece of clothing that emotionally calm, to offset their distress (Gilbert,
used to fit comfortably, being rejected by a love 2005). For example, rather than judging their
interest, realizing age-related changes in their body as deficient, a person high in self-
appearance, and seeing an unflattering photo- compassion might react in kind, warm-hearted
graph of their body. Situations such as these are ways toward their body that nurture their self-
referred to as body image threats (Cash & care (self-kindness) (Neff, 2003b). Rather than
Williams, 2005). Body image represents a per- feeling alone in their experience of body distress,
son’s “inside view” of their body–that is, their a person high in self-compassion is able to under-
feelings, perceptions, thoughts, and beliefs about stand that societal ideals prompt most people to
their body that impact how they behave toward it feel badly toward their body at times (common
(Cash, 2004, p. 1). Body image threats, then, may humanity). Rather than ruminating about their
provoke body-related distress and shame as well negative feelings toward their body or trying to
as negative thoughts and beliefs (e.g., “I’m so avoid their emotional reactions, a person high in
unattractive”), which could encourage negative self-compassion is aware of their feelings in a
more balanced way (mindfulness). Therefore,
T. L. Tylka (*) self-compassion may be an important protective
Department of Psychology, The Ohio State factor that helps build and maintain positive body
University, Marion, OH, USA image and counteract the development of body
e-mail: [email protected] dissatisfaction, especially when confronted with
K. L. Huellemann body image threats (Tylka & Kroon Van Diest,
Western University, London, ON, Canada 2015).

https://doi.org/10.1007/978-3-031-22348-8_11
184 T. L. Tylka and K. L. Huellemann
Within the last decade, there have been many has assessed self-compassion using the 26-item
advances in understanding the connection Self-Compassion Scale (SCS; Neff, 2003a) or the
between self-compassion and body image. 12-item short-form of the Self-Compassion Scale
Several positive and negative body image vari- (SCS-SF; Raes et al., 2011).
ables have been included in this research. Of Research supports the inverse connection
note, positive body image is not simply body sat- between self-compassion and negative body
isfaction (Tylka & Wood-Barcalow, 2015b). image (e.g., body dissatisfaction, weight and
While body satisfaction typically refers to a per- shape concerns) and positive connection between
son’s positive evaluation and perception of their self-compassion and positive body image (e.g.,
appearance, positive body image is more com- body appreciation) (Alleva et al., 2017; Tylka &
plex, reflecting a person’s appreciation, accep- Iannantuono, 2016; Wasylkiw et al., 2012). A
tance, respect, and love for their body regardless recent meta-analysis revealed a strong positive
of their appearance (Wood-Barcalow et al., relationship between self-compassion and posi-
2010). Several key positive body image variables tive body image (r = 0.52) across 20 studies, and
include body appreciation (Tylka & Wood- a moderate inverse relationship between self-
Barcalow, 2015a), functionality appreciation compassion and negative body image (r = −0.45)
(Alleva et al., 2017), body image flexibility across 21 studies (Turk & Waller, 2020).
(Sandoz et al., 2013), body compassion (Altman This meta-analysis also revealed that individ-
et al., 2017), and broadly conceptualizing beauty uals receiving self-compassion-related interven-
(Tylka & Iannantuono, 2016). Table 11.1 pro- tions experienced improved body image
vides an overview of key body image variables compared to those in control groups, with the
(and their corresponding measures) included in degree of difference being small to moderate in
self-compassion research. Most of this research strength (g = 0.39) across 13 studies.
Table 11.1 Body image variables often examined in self-compassion research

Variable Definition Scale
Body (dis)satisfaction (Dis)Satisfaction with overall body shape, size, and/or Many scales have been
(includes appearance weight as well as the shape and size of specific body developed to assess this
satisfaction, appearance areas construct.
evaluation, weight/shape
concerns)
Body appreciation Love and respect for, acceptance and appreciation of, Body Appreciation
and comfort with the body, including its unique Scale-2 (BAS-2)
characteristics (Tylka & Wood-Barcalow,
2015a)
Functionality appreciation Being grateful for, respecting, and honoring the body for Functionality
what it is capable of doing: Its physical capacities (e.g., Appreciation Scale (FAS)
walking), internal processes (e.g., healing from a cold), (Alleva et al., 2017)
sensory and perceptual abilities (e.g., self-soothing),
creative endeavors (e.g., drawing), communication with
others (e.g., laughter), and self-care (e.g., showering)
Body image flexibility A compassionate response to embrace (rather than Body Image-Acceptance
avoid, escape, or change) negative body-related thoughts and Action Questionnaire
and feelings using mindfulness and acceptance while (BI-AAQ) (Sandoz et al.,
pursuing meaningful and valued behaviors 2013)
Body compassion Regarding one’s body with mindfulness, kindness, and Body Compassion Scale
awareness of common humanity in terms of its (BCS) (Altman et al.,
appearance, health, and competence 2017)
Broadly conceptualizing Perceiving a wide range of physical appearances as Broad Conceptualization
beauty beautiful (e.g., body shape, weight, personal style) as of Beauty Scale (BCBS)
well as drawing from inner characteristics (e.g., (Tylka & Iannantuono,
confidence, self-acceptance) when defining beauty 2016)
11 Self-Compassion and Body Image 185
elf-
S compassion appears to both prevent and parison to others may lead a person to overlook
treat body dissatisfaction as well as increase and rather than confront and cope with their personal
maintain positive body image (Braun et al., inadequacies, which is linked to narcissism, bul-
2016). lying, and prejudice (Neff & Vonk, 2009).
In this chapter, we first review the existing Further, self-esteem is often contingent on peer
theory and research investigating the complex approval and success, and deserts people when
connection between self-compassion and body they fail (e.g., experience a body image threat),
image while acknowledging that theoretical and which is when they need emotional support the
empirical advancements in this area continue to most (Neff, 2011).
burgeon. Scholars have used meta-analytic, Other limitations of self-esteem are that it
cross-sectional, prospective, and diary-based emerges early in life, remains stable over time,
designs to study this connection. We then turn to and is highly resistant to intervention (Josephs
examining the effects of self-compassion inter- et al., 2003). Some research has even shown that
ventions on body image and end with discussing experimental efforts to enhance self-esteem have
opportunities for the next generation of research no effects or even increase negative body image
on self-compassion and body image. (Alleva et al., 2015). In relation to body image
and appearance, cultivating self-compassion
instead of self-esteem may instead allow a person
Theoretical Frameworks to become more comfortable with their unique
and Corresponding Research physical features that are inconsistent with soci-
etal appearance ideals. Further, self-compassion
From a theoretical standpoint, attitudes toward may encourage greater awareness and acceptance
the self have long been considered in the context of the emotions associated with not meeting soci-
of body image. One popular self-view that has etal appearance ideals rather than trying to avoid
been examined in the context of body image is these by inflating appearance-related self-worth.
self-esteem, which involves how a person per- Thus, self-compassion represents an alternative
ceives their level of competence and self-worth in way of coping with stressful body image threats,
areas that are personally (and possibly socially) experiences, behaviors, and feelings of
important to them (James, 1890). Simply put, appearance-based inadequacy.
high self-esteem involves a positive evaluation of Body image researchers have proposed that
oneself that has been associated with meaningful self-compassion is protective of positive body
benefits including happiness (Lucas et al., 1996) image in several ways (Braun et al., 2016; Tylka
and life satisfaction (Diener & Diener, 1995). & Kroon Van Diest, 2015). First, self-compassion
Given that self-esteem is influenced by our per- may directly promote positive body image, as it
ceptions of how we think we appear to others helps people remain kind to their bodies during
(Harter, 1999), and that pursuing self-esteem body image threats. Second, having high self-
often involves comparing ourselves to others compassion may make it less likely that people
(Neff, 2011), having low self-esteem may lower a would engage in thoughts or behaviors associated
person’s positive (and heighten their negative) with negative body image (e.g., comparing their
attitudes and feelings about their body specifi- appearance to others). Third, self-compassion
cally (Grossbard et al., 2009). This link may be may help explain how an environment that offers
especially relevant in Western societies where, body acceptance can help cultivate a person’s
for some women, self-esteem has been found to body appreciation, thus acting as a mediator.
be contingent on the degree they evaluate them- Finally, self-compassion may act as a moderator,
selves as meeting societal standards of beauty changing the strength and/or direction of a rela-
(Crocker et al., 2003). There are several problems tionship between a predictor of negative body
linked to pursuing self-esteem. Trying to “keep image (e.g., how much a person compares their
up” with evaluating oneself positively in com- appearance to others) and well-being (e.g., body
appreciation). For example, women high in a way to offset the self-critical and judgmental
self-compassion have been found to still appreci- nature of internalizing appearance ideals and
ate their bodies even when comparing their engaging in appearance-based social comparison
appearance to others, whereas individuals low in (Rodgers et al., 2017). Some research has found
self-compassion report lower body appreciation support for this theory. For example, both Homan
when comparing their bodies to others (Homan and Tylka (2015) and Siegel et al. (2020) found
& Tylka, 2015; Siegel et al., 2020). While theo- that women who frequently compared their bod-
retical conceptualizations of self-compassion ies to others had lower body appreciation, but this
have shown how it may act as a direct predictor, relationship was attenuated for women who were
mediator, or moderator, self-compassion likely high in self-compassion. These two studies also
operates through multiple pathways when it found that self-compassion weakened the link
comes to body image (Tylka et al., 2015). between appearance-contingent self-worth (how
Sociocultural theories, which position media and much a person evaluates their overall sense of
interpersonal contributions as threats to body self-worth based on whether or not they meet cul-
image, have provided the framework for research- tural standards for physical attractiveness) and
ers to integrate self-compassion and investigate body appreciation, demonstrating that self-
the varied ways it could be connected to body compassion can protect positive body image even
image. in the face of threats related to one’s appearance
(Homan & Tylka, 2015; Siegel et al., 2020).
Another study found that self-compassion mod-
The Tripartite Influence Model erated the extent that media pressure to lose
weight was related to women’s disordered eating
The tripartite influence model postulates that a and thin-ideal internalization (how much they
person’s body dissatisfaction can be both directly idealize a thin body type) (Tylka et al., 2015).
and indirectly affected by three social agents When women high in self-compassion felt pres-
(peers, parents, and the media) as well as the sure from the media to pursue thinness, they did
extent to which they internalize (or idealize) soci- not internalize the thin ideal or engage in disor-
etal appearance ideals and compare their appear- dered eating, yet when women low in self-
ance to others (to evaluate whether or not they compassion felt media pressure to be thin, they
“meet” appearance ideals in relation to the per- reported higher disordered eating and thin-ideal
son or image they are comparing themselves to) internalization.
(Thompson et al., 1999). When a person internal-
izes appearance ideals and discovers that they do In their study using an adolescent sample,
not meet these appearance ideals (via comparingRodgers et al. (2017) found that two dimensions
their appearance with others), they may experi-of self-compassion (i.e., mindfulness and com-
ence negative outcomes such as lower satisfac- mon humanity) moderated the mediated relation-
tion with, and appreciation of, their bodies ship between perceived weight status and
(Homan & Tylka, 2015; Schaefer & Thompson, appearance satisfaction through appearance com-
2014). Although the tripartite influence model parison (how often a person compares their
has mostly been tested in samples of women, appearance to others) for boys. Their findings
research has shown support for it in samples ofdemonstrated that boys who perceived them-
heterosexual and gay men (Tylka, 2011; Tylka & selves as “overweight” compared their bodies
Andorka, 2012) and bisexual women (Hazzard more and had lower appearance satisfaction, but
et al., 2019). this relationship was weakened for boys who had
high levels of common humanity and mindful-
Support for Self-Compassion as a Moderator ness. Although the self-compassion dimensions
in the Tripartite Influence Model Self- were correlated as expected for girls (i.e., posi-
compassionate responding has been described as tively associated with appearance satisfaction
and negatively associated with appearance com- when immersed in an appearance-focused cul-
parison), none of the self-compassion dimen- ture. Given that it is likely impossible for most
sions buffered the mediated relationship between women to completely avoid contact with body-
perceived weight status and appearance satisfac- focused others (some of these people may be
tion through appearance comparison for girls. In close friends or family), aiming to cultivate trait
addition, none of the self-compassion dimen- self-compassion as well as daily self-
sions moderated the relationship between appear- compassionate thoughts may help protect women
ance comparison and appearance satisfaction for from body image concerns.
boys or girls. The total self-compassion score
was not assessed in this study. The authors con- Support for Self-Compassion as a Predictor
cluded that (a) the moderation findings for girls within the Tripartite Influence Model There
may have not emerged because they reported has also been some support for self-compassion’s
lower levels of self-compassion compared to role as a predictor of appearance comparison and
boys, and (b) self-kindness may simply not be thin-ideal internalization. Having high self-
potent enough to combat the self-critical nature compassion directly impacts the importance a
of appearance comparison in adolescents. person places on appearance-related information
These cross-sectional studies provide some (i.e., by engaging in less appearance comparison
evidence that self-compassion can buffer the neg- and being less likely to internalize societal
ative outcomes that are associated with body appearance ideals) (Andrew et al., 2016). In a
image threats. Interestingly, one study to date has sample of Australian women, data analysis using
examined the moderating effect of self- structural equation modeling revealed that
compassion at the within-person and the between- women high in self-compassion experienced
person level in the context of the tripartite lower levels of comparing their appearance to
influence model. Kelly et al. (2016) recruited others and internalization of societal appearance
Canadian college women to report on their daily ideals, which then predicted body appreciation
social interactions, affect, self-compassion, eat- (Andrew et al., 2016). However, the conclusions
ing behaviors, and body image for seven consec- that can be drawn from this study are limited
utive nights. The authors found that on days when since a cross-sectional design was used to test
women reported lower self-compassion, interac- mediation, and thus, causal inferences cannot be
tions with body-focused others (i.e., people who made (Maxwell & Cole, 2007).
make self-disparaging comments about their
body, weight, or eating; people who diet) were To examine the within-person fluctuations and
related to higher body image concerns as well as between-person associations of self-compassion
lower intuitive eating (an adaptive way of eating and appearance comparison as predictors of
that involves relying on internal hunger and full- women’s body image and related variables
ness cues rather than external cues such as diet- (appearance anxiety, drive to be thin, and body
ing advice; Tylka, 2006). However, this dissatisfaction), a second study employed a diary
relationship was absent on days when women methodology whereby women responded to brief
reported higher self-compassion. At the between- online surveys three times per day every alternate
persons level, women low in self-compassion day for 1 week (Thøgersen-Ntoumani et al.,
who had more interactions with body-focused 2017). Using a mixed linear modeling approach,
others over the course of the week had lower the results revealed that appearance anxiety,
mean levels of body appreciation and intuitive motivation to be thin, and body dissatisfaction
eating, but these relationships were not observed were negatively predicted by daily self-
for women high in self-compassion. Thus, foster- compassionate thoughts and positively predicted
ing both state (temporary shifts in) and trait (sta- by upward appearance comparison (comparing
ble levels of) self-compassion may have oneself to others perceived as more physically
downstream implications for how women cope attractive). Thus, although it may be important to
cultivate a stable level of high self-compassion to ous ways that self-compassion has been inte-
moderate the prolonged impact of appearance- grated into objectification theory to illuminate
related information from parents, peers, and the whether self-compassion can reduce self-
media, promoting self-compassionate thoughts objectification and mitigate the link between self-
daily can also help to reduce feelings of body objectification and negative body image.
dissatisfaction.
Support for Objectification Theory with Self-
Compassion as a Moderator Some evidence
Objectification Theory suggests that self-compassion may have a moder-
ating effect on the relationship between self-
Objectification theory posits that experiencing objectification and its negative body-related
and witnessing sexual objectification may lead a outcomes. In support of this theory, Liss and
person to consistently think about their body Erchull (2015) categorized women into a low
from an outsider’s perspective and consider self-compassion or a high self-compassion group
themselves and their appearance as an object for and tested a model linking self-objectification
others’ approval and satisfaction, a process (conceptualized as body surveillance) to body
known as self-objectification (Fredrickson & shame, depression, and disordered eating for
Roberts, 1997). When a person self-objectifies, each group. Women in the high self-compassion
they are more vulnerable to negative body-related group reported lower levels of body surveillance,
outcomes such as body shame, body guilt, and body shame, depression, and disordered eating
eating disorder symptoms (Calogero & Pina, compared to women in the low self-compassion
2011). Although objectification theory has been group. Moreover, the pathways between body
contextualized and applied to women’s experi- surveillance and body shame, depression, and
ences (Calogero et al., 2011; Fredrickson & disordered eating were not as strong in the high
Roberts, 1997), research has revealed that other self-compassion group as they were in the low
populations such as gay, bisexual, or transgender self-compassion group, suggesting that self-
men (Wiseman & Moradi, 2010) and transgender compassion moderated these pathways. Daye
women (Comiskey et al., 2020) do experience et al. (2014) found that among college women,
sexual and self-objectification and its negative having a caregiver that was critical of eating hab-
downstream consequences to body image, disor- its was related to higher body surveillance and
dered eating, and psychological well-being. body shame. However, at high levels of self-
Given that self-compassion inherently con- compassion, body surveillance and body shame
trasts the self-policing nature of self-were diminished. These findings suggested that
objectification, it may help to combat women high in self-compassion were less likely
self-objectification and its body-related conse- to experience body shame or surveillance despite
quences. A person who is high in self- receiving disapproving messages about their eat-
objectification engages in body surveillance ing habits as children.
(habitually monitors and checks their body) in
order to anticipate how another person may eval-
uate them, which fosters self-disparaging Support for Self-Compassion as a Predictor
thoughts and feelings and efforts to manipulate of Objectification Theory Constructs Having
their appearance (Calogero & Pina, 2011). In high self-compassion may also predict lower
contrast, a person who is high in self-compassion levels of objectification theory constructs (e.g.,
directs their attention inward, cultivating a more self-objectification, body surveillance). Several
balanced and kind awareness of their thoughts researchers have examined this assertion. First,
and emotions. This may support them to wel- in their model, Andrew et al. (2016) found that
come their body as is, not for how it appears to high self-compassion predicted reduced self-
others. These next sections will discuss the vari- objectifying thoughts and behaviors in college
women. Second, Cox et al. (2019) explored the (including body surveillance), and fear of failure
relationship between women’s self-compassion and negative evaluation (Mosewich et al., 2011).
and intrinsic motivation for physical activity
with body surveillance and body appreciation as Social Media, Self-Compassion, and
mediators in a cross-sectional design (Sample 1) Objectification Theory Constructs Given the
and examined the prospective relationships millions of photos that display attractive people
between these variables throughout women’s with thin and fit physiques on social media plat-
participation in a 16-week yoga course (Sample forms, it is unsurprising that prior research has
2). Analysis using structural equation modeling linked greater social media use to more body
suggested that for Sample 1, self-compassion concerns, thin-ideal internalization, and self-
predicted higher body appreciation, and higher objectification (Fardouly & Vartanian, 2015;
body appreciation predicted greater intrinsic Trekels et al., 2018). Self-compassion may be
motivation for physical activity. In Sample 2, able to help people cope with the inherent prob-
latent growth curve analyses revealed that lem arising from comparing their bodies with
changes in self-compassion over the 16-week others via social media, thereby protecting them-
course predicted higher body appreciation and selves from harmful body-related mental health
lower body surveillance, while higher body outcomes.
appreciation predicted greater intrinsic motiva-
tion for physical activity. Although the cross- To date, two studies have examined this prop-
sectional findings did not find any evidence that osition. Among a sample of community women,
self-compassion uniquely contributed to lower Modica (2019) found that Facebook appearance
body surveillance, an examination of these rela- exposure (engaging in photo-related activity
tionships over time suggested that the yoga compared to all types of activity on Facebook)
environment fostered improvements in self- and Facebook appearance comparison (compar-
compassion, body surveillance, body apprecia- ing one’s body to others’ bodies on Facebook)
tion, and intrinsic motivation. Yoga may were significantly related to greater body surveil-
therefore offer a unique context to practice lance, and high self-compassion was significantly
viewing and appreciating the body more associated with lower body surveillance.
compassionately. Nevertheless, self-compassion did not moderate
the relationship between Facebook appearance
Self-compassion has also been considered as a comparison and body surveillance, suggesting
predictor of lower body surveillance and body that having high self-compassion was not enough
shame among female athletes. Mosewich et al. to attenuate the link between Facebook appear-
(2011; see also Chap. 13) proposed that self- ance comparison and body surveillance.
compassion may be a valuable resource for young Lonergan et al. (2019) revealed that editing/post-
women athletes to harness, given that sport con- ing selfies (photo manipulation) and being
texts emphasize social comparison, self-invested emotionally in others’ responses to the
evaluation, and being evaluated by others. selfies were related to greater body dissatisfac-
Athletes continuously monitor and evaluate their tion in men and women, but self-compassion did
bodies, which can foster negative self-conscious not moderate these relationships even though
emotions (e.g., body shame and guilt), but having greater self-compassion was associated with
high self-compassion may be able to mitigate lower photo manipulation and emotional invest-
self-conscious emotions. In support of their the- ment in others’ responses to selfies. Thus, self-
ory of self-compassion’s important role in pro- compassion appears to be inversely related to
moting lower body surveillance and constructs that indicate self-objectification when
self-conscious emotions, self-compassion using social media (i.e., body surveillance,
explained more variance than self-esteem in manipulating one’s appearance in photos), but
shame, guilt, objectified body consciousness
there is currently no evidence that it has a buffer- have examined the role of fear of self-compassion
ing effect in this context. in relation to body image outcomes. For example,
To date, no other examined variable (e.g., in a sample of Portuguese women, Dias et al.
deriving self-worth from appearance) has been (2020) found that high fear of self-compassion
found to moderate (weaken or strengthen) the had an indirect effect on eating disorder symp-
links between social media constructs, self- toms through feeling ashamed of their body, sug-
objectification, and body dissatisfaction (Modica, gesting that fear of self-compassion drives
2019). It is possible that the high level of appear- negative emotions toward the body. Similarly, in
ance exposure on social media among women, a sample of Canadian women, Huellemann and
the internalization of these appearance ideals, Calogero (2020) found that low self-compassion
and the self-objectification that stems from view- and high fear of self-compassion were indepen-
ing these images are so potent that self- dently related to body checking behavior (con-
compassion and other variables are not strong tinuously critiquing the size, shape, and
enough to reduce women’s appearance compari- appearance of one’s body) through stigmatizing
son or self-objectification. An alternative may be oneself in the forms of self-objectification, expe-
for women to cultivate self-compassion and riencing body shame, and internalizing weight
diversify their exposure to different types of stigma (believing that negative societal stereo-
images on social media (e.g., diverse body types, types about weight apply to oneself). This pre-
nature, motivational quotes), but this has not been liminary research suggests that it may be a fruitful
empirically tested. Exploring social media use on next step for clinicians to develop body image
other image-focused social media platforms (e.g., interventions that cultivate self-compassion and
Instagram, Snapchat, TikTok) and aiming to rep- reduce fear of self-compassion simultaneously,
licate findings are important next steps to verify especially for people who are high in self-
whether self-compassion is protective against criticism or who have experienced unaffectionate
body surveillance after social media use. childhoods.
Additionally, self-critical personality traits,
such as maladaptive perfectionism, may reflect
Social Mentalities Theory what occurs when a person’s threat system has
been continuously activated (e.g., from continu-
Social mentalities theory is derived from evolu- ous appearance comparison to social media
tionary biology, neurobiology, and attachment appearance ideals), and being high in perfection-
theory, and it suggests that being capable of self- ism may adversely impact a person’s body image.
soothing (e.g., self-compassion) is dependent on To test this theory, Barnett and Sharp (2016) con-
prior caregiving and care-seeking experiences ducted two studies. In Study 1, the self-kindness
(Gilbert & Irons, 2005; see also Chap. 4). For and self-judgment components of self-
example, low self-compassion and high fear of compassion mediated the inverse association
self-compassion (believing that one is undeserv- between maladaptive perfectionism and body
ing of self-compassion and that engaging in self- satisfaction in college women. These findings
compassion will make one weak) are thought to were replicated with another sample of college
emerge from anxious and avoidant attachment women in Study 2, which also revealed that self-
styles, or personality traits that stem from unsta- judgment mediated the positive link between per-
ble or unaffectionate caregiving experiences fectionism and eating disorder symptoms. The
(Gilbert et al., 2011; also see Chap. 5). As such, a evidence indicates that self-compassion likely
person may engage in self-criticism when their acts as a mediator in the context of self-critical
threat system is activated (e.g., from a body personality traits, body image, and eating disor-
image threat) but may also have the ability to der symptoms.
activate self-compassion when their self-soothing Furthermore, people adopt various social
system is activated (Gilbert, 2015). A few studies mentalities when interacting with others, with
each triggering different patterns of thinking, likely to occur (e.g., physical activity and health-
feeling, and behaving (Gilbert, 2005). For care settings) (Mensinger et al., 2018; Vartanian
instance, a competitive-based mentality orients & Shaprow, 2008). As such, people with a higher
people to appraise their rank relative to others BMI may have lower body image flexibility,
(e.g., engage in appearance comparisons) and to which refers to the degree a person is still able to
base their behavior on their perceptions of who is engage in meaningful and valued life activities
superior or inferior. In contrast, a compassion- even when experiencing negative body image-
based mentality supports connecting with others related thoughts or feelings (see Table 11.1;
rather than competing with them and is linked to Sandoz et al., 2013). Self-compassion may be
many positive health and well-being effects able to buffer the effect of having a higher BMI
(Salzberg, 1995). Vimalakanthan et al. (2018) on body image flexibility since it involves inter-
explored the effects of cultivating a caregiving preting incoming information about one’s body
versus competitive mentality whenever partici- with openness and kindness. Kelly et al. (2014a,
pants found themselves comparing their appear- b) tested this hypothesis in a cross-sectional sam-
ance to others. Female undergraduate students ple of female undergraduates and found that self-
were randomly assigned to use one of three prac- compassion moderated the relationship between
tices when they found themselves engaging in high BMI and body image flexibility as well as
appearance comparisons: caregiving (cultivating between high BMI and eating disorder symp-
compassion and loving-kindness toward the per- toms. Women with a higher BMI were more
son they are comparing their appearance to), likely to report lower body image flexibility and
downward competition (comparing themselves eating disorder symptoms, but these relationships
favorably to the person in various ways except for were dampened at higher levels of
appearance), and distraction (distracting them- self-compassion.
selves with a counting task). After learning about Webb et al. (2016) examined the relationship
their particular practice in a lab-based setting, between anti-fat attitudes (placing personal
participants committed to engaging in their prac- blame on individuals for being fat, disliking
tice over a period of 48 h whenever they noticed higher weight people, and fear of weight gain)
that they were comparing their appearance to oth- and fat talk (conversations expressing a personal
ers. Results indicated that the caregiving practicedesire to lose weight or that degrade oneself for
improved body dissatisfaction among women their weight) with self-compassion as a modera-
who compared their appearance to others fre- tor. Because Western culture values thinness and
quently; however, the downward competition lean muscularity, people of all sizes may develop
practice improved body dissatisfaction among anti-fat attitudes. Fat talk is problematic because
women who compared their appearance to others it reinforces the belief that slimmer bodies are
less frequently. Therefore, cultivating compas- superior to larger ones. Undergraduate women
sion toward others can especially help women completed a self-report questionnaire with mea-
who have body dissatisfaction and frequently sures of anti-fat attitudes, fat talk, body shame,
compare their appearance to others. and self-compassion. Controlling for BMI, Webb
et al. (2016) found that anti-fat attitudes were
indirectly associated with fat talk via body shame
Weight Stigma Theories but that this mediated relationship was attenuated
at high levels of self-compassion. In other words,
People living in larger bodies are more likely to women with higher anti-fat attitudes reported
experience overt weight stigma (e.g., weight- greater body shame and were more likely to
based discrimination, weight-based teasing, and engage in fat talk; however, these relationships
bullying) and may avoid certain situations where were weaker for women higher in self-
weight-based discrimination would be more compassion. It is important to recognize that
alongside encouraging self-compassion cultiva- ated with more adaptive body image and eating
tion, macro-level changes must take place that behavior. These findings were held even when
publicly discourage weight-based discrimination controlling for self-esteem. Collectively, Kelly
and promote body inclusivity. and Stephen demonstrated that self-compassion
has the potential to make a meaningful impact on
the daily (state) level even if a person is not high
Within-Person Variability in Self- in stable (trait) self-compassion. Therefore, inter-
Compassion, Body Image, and Eating ventions that increase state- and trait-based levels
Behavior of self-compassion may be useful for improving
positive body image and decreasing negative
Although self-compassion is traditionally studied body image.
as a stable characteristic (trait) that differs
between people, daily diary studies are an effec-
tive method to elucidate within-person variability Interventions to Improve Body
in self-compassion and explore how shifts in self- Image
compassion contribute to a person’s daily body
image and eating behavior. To explore the within Given the theoretical and empirical connections
and between-persons relations between self- between self-compassion and body image, sev-
compassion, negative body image, and eating eral research teams have developed and investi-
disorder symptoms, college women participated gated self-compassion-based interventions to
in a 4-day daily diary study (Breines et al., 2014). determine whether these interventions can
Participants completed multiple online surveys increase positive body image (e.g., body appre-
each day on their level of appearance-based self- ciation, body image flexibility) and reduce nega-
compassion (perceiving body flaws in a self- tive body image (e.g., body dissatisfaction).
compassionate way), eating disorder symptoms, Findings from recent reviews (Guest et al., 2019)
and self-esteem. Controlling for self-esteem, the and meta-analyses (Turk & Waller, 2020) of self-
findings revealed that on days when participants compassion- based interventions suggest that
reported higher appearance-based self-these interventions do improve participants’ body
compassion, they tended to also report fewer eat- image, with several studies reporting lasting
ing disorder symptoms. Of note, participants in a effects. Below, we discuss these interventions
second sample who, in a lab setting, reflected on and the studies that have evaluated their impact
a perceived body flaw in a self-compassionate on body image.
way through a writing task reported lower subse-
quent body shame (Breines et al., 2014).
In another study, female college students com- Self-Compassion Meditations
pleted brief surveys for 7 days on self-compassion,
self-esteem, body appreciation, body satisfac- Certain self-compassion interventions have used
tion, intuitive eating, and eating disorder symp- Neff and Germer’s (2013) 20-min guided self-
toms (Kelly & Stephen, 2016). Using multilevel compassion meditations from their Mindful Self-
modeling, the results revealed that daily fluctua- Compassion program as podcasts participants
tions in self-compassion predicted daily fluctua- can listen to daily. As the first study using this
tions in body image and eating behavior. That is, method, Albertson et al. (2015) randomized
higher daily self-compassion was related to women with body concerns to a self-compassion
greater daily body appreciation and intuitive eat- intervention or a waitlist control group. Women
ing as well as lower daily levels of restrained eat- in the intervention group were instructed to listen
ing at the within-persons level. At the to the guided self-compassion meditations once a
between-persons level, higher average self- day for 3 weeks. They received a link to one pod-
compassion scores across the week were associ- cast per week; the first included a compassionate
body scan, the second included affectionate Writing Tasks

breathing, and the third focused on loving-
kindness directed toward the body. Compared to In general, writing exercises are an effective
the control group, intervention participants (who mode of delivering both compassion-based and
reported listening to the podcast 3.6 days a week non-compassion-based body image interventions
on average) experienced greater increases in (Guest et al., 2019). Seekis et al. (2017) investi-
body appreciation and decreases in body dissatis- gated whether a single-session self-compassion
faction, body shame, and self-worth based on writing task would improve body image concerns
their appearance, and these improvements were among undergraduate women. After reading a
maintained when measured 3 months after the negative body image scenario to induce body
intervention. However, the high attrition (48%) concerns (participants imagined themselves
from the initial assessment to follow-up tempered viewing unflattering pictures of themselves
the conclusions. posted on social media by a friend), they com-
Exploring whether a more condensed version pleted measures to gauge their current (state)
of Albertson et al.’s (2015) program would pro- level of body appreciation, body satisfaction, and
duce lower attrition yet similar benefits, Toole appearance anxiety. They were randomly
and Craighead (2016) randomized undergraduate assigned to one of three writing groups: self-
women to either participate in a self-compassion- compassion (designed to induce self-kindness,
based meditation training or a waitlist control common humanity, and mindfulness), self-
group for a 1-week period. They provided the ini- esteem (designed to induce feelings of self-
tial training session in a lab to standardize the competence and value), or control (writing about
first exposure. Once a day, participants in the academic topics). They followed their condition’s
intervention group were emailed a link to Neff prompts and wrote for 15 min. Participants com-
and Germer’s (2013) audio recordings of a completed the state-based body image measures
passionate body scan (days 1–3), affectionate again immediately after the writing task and
breathing exercise (days 4–5), or loving-kindness again at a 2-week follow-up. The self-compassion
body meditation (days 6–7). The shorter time writing group experienced higher state body
frame (compared to Albertson et al., 2015) did appreciation compared to the self-esteem and
not increase participants’ willingness to listen to control groups at posttest, as well as higher state
the podcast on their own (total weekly exposure body appreciation compared to the control group
ranged from 20 to 90 min). Nevertheless, at post- at follow-up. Both self-compassion and self-
test, participants in the intervention group esteem writing groups reported higher body sat-
reported higher body appreciation and lower self- isfaction compared to the control group at posttest
worth based on appearance and body surveillance and follow-up. However, groups did not differ on
compared to the waitlist control group (body appearance anxiety. Therefore, brief self-
shame and body dissatisfaction did not differ compassion- based writing interventions may
between groups). help improve women’s body appreciation and
In sum, self-compassion meditation appears to satisfaction in the face of body image threats, but
be an effective means of improving body image it may not reduce their appearance anxiety.
that can be flexibly delivered using podcasts. Similarly, Moffitt et al. (2018) compared the
Listening to these podcasts have positive effects efficacy of self-compassion and self-esteem writ-
on women’s body image, which may be sus- ing tasks for reducing state body dissatisfaction.
tained, at least over the short term. Further, rela- College women viewed 16 magazine images of
tively brief exposure may be powerful enough to young, thin, female models for 8 min to induce
have an impact. Yet, additional research is needed body dissatisfaction and were encouraged to
to determine whether these podcasts would help compare their bodies with the women in the
diverse groups of individuals and whether they images. Women were then randomized to one of
can be used to prevent negative body image. three 3-min writing interventions:
s elf-compassion (expressing compassion toward with elevated trait body dissatisfaction and may
their weight, appearance, and body shape), self- hold some advantages over self-esteem-based
esteem (describing their positive qualities, such interventions for improving body appreciation.
as personal attributes and accomplishments), or
positive distraction (describing a hobby they
enjoy). Findings revealed that those in the self- Mobile Applications
compassion and self-esteem groups had greater
reductions in state body dissatisfaction. Thus far, one self-compassion-based application
Participants’ trait body dissatisfaction moderated has been developed and studied in its ability to
the intervention efficacy: the benefit of the self- improve body image. BodiMojo is a mobile
compassion intervention became evident at mod- application-based 6-week intervention to pro-
erate levels of body dissatisfaction and was most mote positive body image through self-
apparent at high levels of body dissatisfaction. compassion. The app contains intervention
Self-compassion intervention also appears messages (delivered twice daily in the form of an
beneficial for women undergoing appearance affirmation, behavioral tip, or psychoeducation),
changes due to illness. For example, one study mood tracking and emotional regulation, and
found that women with breast cancer benefited gratitude journaling. Intervention messages are
from writing exercises designed to foster self- focused on building self-compassion, addressing
compassion toward their body-related changes as body image-related content (media literacy, chal-
a result of cancer treatment. Przezdziecki and lenging fat talk, appearance teasing, and appear-
Sherman (2016) randomly assigned female breast ance comparison), and providing healthy
cancer survivors to a self-compassionate writing lifestyle-related content (mindful eating, sleep,
assignment or an unstructured writing assign- hygiene, and physical activity). Rodgers et al.
ment whereby they wrote about an event related (2018) randomized female and male adolescents
to their posttreatment body changes. Women in to BodiMojo or an assessment-only control
the self-compassion condition were prompted, in group; both groups completed measures of
writing, to show understanding and kindness appearance satisfaction and body image flexibil-
toward their bodies, explore their feelings by put- ity at baseline, post-intervention, and 6-weeks
ting space between the event and their reactions, follow up. Compared to the control group, ado-
and express how other survivors may experience lescents in BodiMojo increased their appearance
events where they feel uncomfortable about their satisfaction, but not body image flexibility, over
body. Last, they wrote a self-compassionate letter time. While Rodgers et al.’s study yields promis-
to themselves. The control condition was simply ing results for improving appearance-related
asked to provide details about the event (i.e., body image, more research is needed to explore
what led up to it, who was present, and how they additional body image benefits of self-
felt and behaved). The writing length was stan- compassion- based mobile apps, such as body
dardized to four pages for each condition. appreciation.
Although body image was not explored as an out-
come, the authors found that the self-compassion
intervention reduced negative affect and increased Group-Based Delivery
self-compassion.
Overall, writing tasks that focus on taking a Grounded in self-compassion and cognitive dis-
self-compassionate stance toward the body after sonance principles, Bodies in Motion (Voelker
an imagined or real body image threat help et al., 2019) is a group-based program that
increase state body appreciation and body satis- addresses the unique body-related experiences of
faction, and these positive effects may continue female athletes and teaches them to respond in
after the intervention. Self-compassion interven- more functional ways to sociocultural appear-
tions seem to be the most beneficial for women ance pressures and sports-related body pressures.
In addition to actively challenging unrealistic women without visible differences and who tend
appearance ideals, female athletes also learn how to fall in the middle of the weight spectrum.
to be kinder and more understanding in how they Much more research needs to be conducted in the
evaluate and respond to themselves when exposed area of self-compassion and body image with
to these ideals while also staying present-focused groups who are not represented in this research,
in their self-awareness and nonjudgmental of such as men, transgender and nonbinary folx,
their thoughts and feelings. The small group- children and older adults, as well as those with
based program includes an introductory session, visible differences, limited abilities, higher
followed by four interactive and experiential ses- weights, and of various racial and ethnic cultural
sions led by trained program leaders. In their groups. While it is worthwhile to determine
evaluation study, Voelker et al. randomly assigned whether the findings of the reviewed research
female athletes from nine NCAA athletic depart- replicate with diverse groups, it is also important
ments to Bodies in Motion or a waitlist control to consider experiences (e.g., weight stigma,
group. At posttest, a stringent approach to controlappearance-based stigma, racial discrimination,
family-wise error revealed that groups differed transphobia) that likely impact many of these
on thin-ideal internalization; however, trends individuals within the study design and analyses.
were noted for improved body appreciation, body Second, researchers could investigate whether
satisfaction, and shape and weight concerns. In integrating self-compassion themes within social
other words, athletes who complete Bodies in media could impact body image. Slater et al.
Motion are likely to experience reduced thin- (2017) experimentally examined the impact of
ideal internalization and may also experience exposure to self-compassion quotes on Instagram
increased body appreciation and satisfaction and images, and they found that women who viewed
decreased weight and shape concerns. Bodies in these quotes reported greater body satisfaction,
Motion raises important questions about the body appreciation, self-compassion, and reduced
unique effects of self-compassion to the program negative mood compared to women who viewed
(above cognitive dissonance principles) for future neutral images. In addition, when women viewed
research to disentangle. self-compassion quotes alongside images that
reflect the fit ideal, they experienced more posi-
tive outcomes compared to women who viewed
Conclusions and Future Research only the fit ideal images. These findings suggest
Directions that self-compassion messages within social
media have potential to be beneficial to women’s
A robust literature exists on the link between body image and offset the negative impact of
self-compassion and body image. This link is exposure to thin- and fit-ideal media. More
complex and multifaceted, with self-compassion research is needed to replicate and extend these
often moderating (or buffering) the relationship findings as well as determine who may benefit
between negative environmental influences (e.g., more from these messages.
appearance-related pressures, sexual objectifica- Third, it is important to both investigate and
tion) and body image, mediating the link between create interventions to reduce individuals’ resis-
both modifiable (e.g., meditation exposure, yoga tance to and fears of self-compassion. Those who
practice) and less modifiable (e.g., attachment) misunderstand what self-compassion involves
experiences and body image, and contributing to may believe that it is self-indulgent and could
improved body image via established interven- undermine their personal responsibility for their
tions. Yet, there is much more work ahead. First, problems, thereby interfering with their motiva-
the vast majority of the research on self- tion and success (Robinson et al., 2016). Indeed,
compassion and body image has been conducted when interviewed about their attitudes toward
with samples of predominantly young adult, physical changes in their body as they age, some
White, heterosexual, able-bodied, cisgender physically active women aged 65 and older
reported that having self-compassion for their researchers have explored secure attachment
aging body was “idealistic” and found it difficult (Raque-Bogdan et al., 2016) in this role, other
to respond to their body in a self-compassionate variables may be more amenable to change, such
manner due to being critical of their appearance as exposure to nature. Nature has a salutogenic
and functionality (Bennett et al., 2017). In addi- effect on overall health and well-being (Bowler
tion, self-compassion may be a frightening expe- et al., 2010) and body appreciation more specifi-
rience for some individuals who feel that they are cally (Swami et al., 2018), as being engaged in
undeserving of compassion (Gilbert et al., 2011). nature (e.g., hiking, biking, smelling leaves,
While the fear of self-compassion has been stud- watching birds) helps them appreciate the various
ied in research on eating disorders (e.g., Kelly ways their body functions. Nature also promotes
et al., 2014a, b), researchers have largely opportunities for self-compassion, as it facilitates
neglected to explore its impact on body image as the stillness needed for mindfulness and an emo-
well as its influence on the success of self- tional state focused on self- and other-kindness.
compassion interventions to improve body Among a sample of British women and men,
image. The resistance to and fear of self- Swami et al. (2019) found that self-kindness and
compassion could prevent engagement in self- common humanity, but not mindfulness, partially
compassion interventions as well as lessen any mediated nature exposure’s positive associations
positive effect of these interventions on body with both functionality appreciation (appreciat-
image. ing all the things that the body is capable of
Fourth, longitudinal data exploring the asso- doing; Alleva et al., 2017) and body appreciation.
ciations between self-compassion and body Additional interventions, such as one that pro-
image are lacking to date. In the one study we did moted gratitude, may cultivate self-compassion,
find, Stutts and Blomquist (2018) used a longitu- as well as positive body image through self-
dinal design to examine whether self-compassion compassion (Homan & Tylka, 2018), and thus
moderated the relationship of weight and shape are worthy to explore in prospective and experi-
concern on disordered eating among a large sam- mental research.
ple of college women. For the first year, weight/ Sixth, researchers could study whether self-
shape concern was more strongly linked to disor- compassion aids the maintenance of positive
dered eating for those lower in self-compassion body image by strengthening individuals’ resis-
compared to those higher in self-compassion. tance to internalizing the negative messages
However, this pattern did not emerge during the within an image-focused culture. Those with
second year. Researchers would benefit from positive body image interpret incoming informa-
exploring longitudinal associations between self- tion in a body-protective manner whereby most
compassion and different dimensions of body positive information is internalized, and most
image. Embedded in this research, it would be body image threats are rejected or reframed
valuable to explore “upward spirals,” or combi- (Wood-Barcalow et al., 2010). This process is
nations of protective factors that trigger self- referred to as “protective filtering” (p. 112). To
perpetuating cycles and trajectories of positive date, we know very little about this process, and
psychological growth (Garland et al., 2010), both thus, it would be worthy to explore whether self-
within intervention-based and nonintervention- compassion helps individuals strengthen their
based prospective research. For example, self- protective filter to ward against body-related
compassion may predict increased body threats.
appreciation, which could then predict even We are confident that research within these
higher self-compassion and additional psycho- areas will provide novel contributions to the
logical resources. already rich literature exploring the connection
Fifth, researchers need to explore the variables between self-compassion and body image cov-
that may cultivate self-compassion within the ered in this chapter. The way that individuals
context of enhancing positive body image. While treat themselves (with kindness, humanity, and
attention versus criticism, isolation, and overi- Breines, J., Toole, A., Tu, C., & Chen, S. (2014). Self-
compassion, body image, and self-reported disordered
dentification) maps on to the way they feel about eating. Self and Identity, 13(4), 432–448. https://doi.
and treat their bodies (with appreciation and org/10.1080/15298868.2013.838992
respect versus shame and condemnation). Calogero, R. M., & Pina, A. (2011). Body guilt: Preliminary
Therefore, continuing to study the complex con- evidence for a further subjective experience of self-
objectification. Psychology of Women Quarterly, 35(3),
nections between self-compassion and body 428–440. https://doi.org/10.1177/0361684311408564
image is essential to foster psychological health Calogero, R. M., Tantleff-Dunn, S., & Thompson, J. K.
and well-being among diverse individuals. (2011). Self-objectification in women: Causes, conse-
quences, and counteractions. American Psychological
Association.
Cash, T. F. (2004). Body image: Past, present, and future.
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Self-Compassion, Personal
Improvement, and Motivation 12
Anaïs Ortiz, Aleah Goold, and Jia Wei Zhang
Introduction determined motivation, which is seen to have

both intrinsic drivers and external drivers that
Motivation is the internal desire and drive to cre- align with the values of the individual.
ate change in one’s own self or environment Motivated behavior can be observed in many
(Baumeister, 2015). Theoretical perspectives on contexts, from day-to-day goals to decade-long
motivated or goal-directed behaviors (e.g., Carver pursuits, and there are a variety of factors that can
& Scheier, 1998; Azjen, 1991) suggest that an motivate behavioral change, such as experiencing
individual’s goals are shaped by two primary a failure, transgression, or suffering. For exam-
parameters: the desirability, or attractiveness of ple, some people can be motivated to study harder
goal attainment, and the feasibility, or likelihood by receiving a bad grade, or exercise more after
that one’s goal will be attained. In turn, feasibility being diagnosed with unfavorable health condi-
can be influenced by both pragmatic factors and tions, or an athlete may train longer and harder
individual differences variables such as optimism after losing at a sporting event. What internal fac-
(Scheier & Carver, 1987), self-efficacy, and out- tors motivate some people to improve more than
come expectancies (Bandura, 1977), while the others? Recent research suggests that self-
desirability of a particular goal is influenced by compassion may be one such factor that drives
its alignment with the individual’s values and people to adaptively engage in improvement-
their external context. Motivational theories also related inclinations. In addition to influencing the
suggest that the process and outcomes of moti- types of goals one sets for oneself, evidence also
vated behaviors are influenced by the degree to suggests that self-compassion influences how
which goals are intrinsically or extrinsically people respond to challenges and setbacks that
determined. For example, Ryan and Deci (2000) may impede goal attainment.
contrast controlled motivation – which is driven Self-compassion is rooted in empathy
by the need or desire to satisfy “external demand extended toward the self when one is faced with
or reward contingenc[ies]” (p. 72) with self- a difficult experience (Neff, 2011). Self-
compassion has three interrelated components:
A. Ortiz (1) self-kindness, a tendency to apply a caring
Department of Psychology, University of Florida, and tender, rather than judgmental, attitude
Gainesville, FL, USA toward one’s difficult experiences; (2) common
A. Goold · J. W. Zhang (*) humanity, the recognition that it is only “human”
Department of Psychology, University of Memphis, to make mistakes and that one’s suffering is
Memphis, TN, USA shared by others; and (3) mindfulness or facing

https://doi.org/10.1007/978-3-031-22348-8_12
202 A. Ortiz et al.
one’s failure and observing one’s pain with Self-Compassion

equanimity (Neff, 2011). Thus, self-and Self-Improvement
compassionate people are aware of the emotions
related to experiences (both positive and nega- One of the frequent concerns about self-
tive), recognize that others share these emotions, compassion is that it could lead to complacency
and handle setbacks and failures with more calm- or self-indulgence (Kirby et al., 2019). Thus,
ness and acceptance than those who have less people typically do not associate self-compassion
self-compassion. While self-compassion may be with efforts to improve themselves. However,
incorrectly viewed as going easy on oneself, research has shown a clear link between self-
recent work by Neff (2021) has highlighted both compassion and the motivation for personal
the “tender” and “fierce” sides of self-compassion. improvement. For example, one study found that
Fierce self-compassion, with its focus on asser- participants who were led to write about their
tiveness, determination, and goal-directed behav- moral transgression from a self-compassionate
ior, demonstrates that self-determined motivation perspective reported greater motivation to redeem
is an important way that self-compassion mani- themselves and avoid repeating the same trans-
fests. Indeed, a study of female athletes described gression in the future compared to participants
associations between self-compassion and sev- who used a self-esteem perspective and partici-
eral facets of mental toughness, including taking pants who received no additional reflection
perspective, adequate preparation, perseverance, instructions (Breines & Chen, 2012). Follow-up
and staying present, which together helped ath- experiments found that participants who were led
letes cope with adversity (Wilson et al., 2019). to think about a failed test with self-compassion,
In both its fierce and tender forms, self- compared to self-esteem and control, studied lon-
compassion offers an adaptive way of relating to ger for a subsequent test and were more willing
oneself that can be contrasted with less healthy to interact with someone who shared a similar
forms of self-relation, such as self-criticism. weakness but overcame it (Breines & Chen,
While self-criticism can motivate behavior 2012). Additionally, participants who were
intended to maintain or protect one’s self-image induced to talk about their regret with self-
(e.g., when task performance is driven by avoid- compassion, compared to a self-esteem group
ing failure or negative evaluation; Mongrain & and a control group with no manipulation,
Zuroff, 1995), studies have routinely demon- reported more self-improvement motivation.
strated that self-criticism can undermine autono- Another study found that the connection between
mous motivation and thwart goal progress self-compassion and self-improvement motiva-
(Powers et al., 2007, 2009; Vandenkerckhove tion was explained by greater acceptance of
et al., 2019). In contrast, self-compassion is asso- regret (Zhang & Chen, 2016). In this series of
ciated with several important motivation-related three studies, the authors first coded descriptions
constructs: it is positively related to grit, personal of regret posted on a website. Those who were
growth initiative, self-efficacy, and goal engage- coded as describing their experience with greater
ment, and inversely associated with fear of fail- self-compassion were more likely to also be
ure and maladaptive perfectionism (Neff et al., coded as demonstrating more self-improvement.
2018). In this chapter, we bring together recent This was supported by the second study, in which
scientific studies of self-compassion and motiva- self-compassion was associated with both self-
tion by summarizing the latest research on self- reported and observer-coded personal improve-
compassion and its impact on goal setting, ment following the recall of a regret experience.
pursuit, and persistence. Further, we discuss the The third study suggested that the link between
reasons why self-compassion might be associ- self-compassion and personal improvement was
ated with more adaptive motivational processes mediated by increased acceptances of the regret
and outcomes and highlight key directions for experience (Zhang & Chen, 2016).
future research.
12 Self-Compassion, Personal Improvement, and Motivation 203
In the context of relationships, self-compassion exercise-related self-regulation in a sample of US

has been closely associated with motivation to adults. Self-regulation refers to the degree to
correct mistakes. For example, one study demon- which individuals can flexibly adapt their cogni-
strated that self-compassion was associated with tions, emotions, and behaviors to achieve their
greater motivation to correct interpersonal mis- goals. Self-regulatory capacities are therefore
takes among women, although among men this critical to motivating behavior, underpinning
relationship was only found for men high in con- one’s capacity to both monitor progress toward a
scientiousness (Baker & McNulty, 2011). In the goal, and adjusting one’s behavior in the face of
same study, self-compassion was also associated challenges and setbacks (Baumeister &
with observations of more constructive problem- Heatherton, 1996; Ryan & Deci, 2000). Biber
solving behaviors among men high in conscien- (2020) also found that self-compassion predicted
tiousness. More recently, Zhang and Chen (2017) less anxiety, depression, and self-blame related to
conducted a study of individuals who attributed health, in addition to greater health satisfaction.
personal responsibility for a recent breakup, and Moreover, self-compassionate people reported
compared outcomes across three different condi- fewer negative emotions to mild illness and were
tions in which participants were assigned to a more willing to see a medical provider to address
self-compassion or self-esteem induction, or no- their symptoms sooner than less self-
induction control (Zhang & Chen, 2017). It was compassionate counterparts (Terry et al., 2013).
found that the self-compassion group reported Lastly, Terry et al. (2013) demonstrated that self-
greater self-improvement motivation and compassion was associated with less negative
intended appreciation for a future romantic part- emotional reactions to serious illness via positive
ner than either the self-esteem or no-induction thoughts and the intention to treat oneself kindly.
control groups (Zhang & Chen, 2017). Also, self-compassionate people were more
likely to follow doctors’ recommendations for
the treatment of their illness compared to their
Self-Compassion and Health less self-compassionate counterparts (Terry et al.,
2013). In short, this evidence suggests that self-
Another good indicator of self-compassion’s role compassion enables people to engage in healthier
in motivating people toward self-improvement self-regulation that can, in turn, lead to more con-
rests in the emerging connection between self- sistent and persistent exercise habits, as well as
compassion and health outcomes, as well as more adaptive coping and adherence (i.e., follow-
health-related outlooks. In one study, participants ing a doctor’s orders) in the face of unfavorable
were instructed to recall a recent time where they health diagnoses. Evidence supporting the rela-
experienced an exercise setback (e.g., not meet- tionship between self-compassion and health
ing a goal of going to the gym regularly; behaviors is described in greater detail in Chap.
Semenchuk et al., 2018). The authors found that 18.
self-compassion inversely predicted negative
emotional experiences related to recalling the
abandoned goal, such that those with higher self- Self-Compassion and Academic
compassion were less likely to experience rumi- Motivation
nation or negative affect. They also found that
self-compassion was positively associated with Another line of research points to self-
greater goal reengagement (e.g., setting a new, compassion’s role in academic achievement and
more attainable exercise goal; Semenchuk et al., motivational outcomes that are relevant in aca-
2018) and that these relationships were main- demic contexts, such as procrastination, test anx-
tained after controlling for self-esteem. iety, and academic self-regulation. Academic
More recently, Biber (2020) found that self- environments are frequently characterized by
compassion was significantly associated with high levels of external pressure, including
204 A. Ortiz et al.
recurrent deadlines, achievement expectations, associated with perceived competence and mas-
and the message that future opportunities are tery goals, and inversely associated with fear of
contingent on current performance. Responses to failure in a sample of college students. This was
such environmental pressures are influenced by supported by Kotera and Ting’s (2019) findings
the implicit goals that individuals hold regarding that people who are more self-compassionate are
their achievement in goal-oriented settings (Elliot more intrinsically motivated. In another example,
& McGregor, 2001). Implicit goals may be cate- trait self-compassion predicted greater score
gorized along two main dimensions: performance improvement on a difficult test regardless of
oriented, in which individuals compare their per- whether people were induced with a mastery or
formance to others, and mastery oriented, in performance goal (Shimizu et al., 2015). More
which individuals focus on change in their own recently, a study found that self-compassion
personal competencies, regardless of others’ per- moderates the pathway from extrinsic to intrinsic
formance. These dimensions can be further clas- motivation, indicating that those with greater
sified into approach and avoidance dimensions, self-compassion are more able to transfer extrin-
to create four types of goals: (i) performance sic goals to intrinsic ones (Kotera et al., 2021).
approach, in which individuals aim to demon- Together, this evidence suggests self-compassion
strate their comparative competence; (ii) perfor- promotes dedication to pursuing intrinsic aca-
mance avoidance, in which individuals aim to demic goals and to aligning one’s internal moti-
avoid appearing incompetent relative to others; vation with external demands.
(iii) mastery approach, in which individuals aim Self-compassion has been linked to making
to develop their own competence; and (iv) mas- more meaningful goals and being more persistent
tery avoidance, in which individuals aim to avoid in the face of failure, as well as less concern with
performing worse than they have previously peer perceptions (Neely et al., 2009). In a study
(Elliot & McGregor, 2001). These goals can be of college students, Neely et al. (2009) found that
characterized as a type of coping strategy for self-compassion was positively associated with
dealing with challenges, which determine an goal reengagement, and together, these variables
individual’s motivation and behavior (Babenko were associated with student well-being. Goal
et al., 2018), and align with intrinsic (i.e., reengagement is a useful coping strategy in the
mastery-oriented) and extrinsic (i.e., face of failure or disappointment, and these find-
performance-oriented) models of goal attainment ings align with other work demonstrating that
(Korn & Elliot, 2016). self-compassion is associated with more adaptive
Prior research has found that while both types responses to difficulties in an academic context.
of approach goals are associated with academic For example, one study found that self-
achievement, mastery-approach goals are more compassion predicted adaptive coping techniques
likely to be linked to adaptive outcomes, such as (i.e., acceptance and positive reframing) in stu-
curiosity, engagement, and academic self- dents who performed poorly in a previous exam
regulation (Senko et al., 2011). Similarly, while (Neff et al., 2005). Other studies showed that
intrinsic and extrinsic motivations are not incom- self-compassion was associated with the use of
patible, intrinsic motivations have been linked cognitively demanding desirable difficulties, or
more consistently to greater well-being and self-imposed challenges used during the learning
higher retention in academic settings. Conversely, process to optimize comprehension and memory
there are concerns that performance-oriented encoding and retrieval (Wagner et al., 2017).
goals may increase competitive and dishonest Moreover, self-compassion predicted less pro-
behavior, such as cheating. In an early study, Neff crastination in three separate student samples
et al. (2005) found that self-compassion was (Sirois, 2014).
Pathways Underpinning pants in the other three conditions (Leary et al.,

the Relationship Between Self- 2007). In short, self-compassion successfully led
Compassion and Motivation people to acknowledge that they were the person
who made the mistake. It is possible that those
There are several, interconnected reasons why who were induced to be more self-compassionate
self-compassion may support more adaptive were more able to acknowledge their mistake
motivational processes and outcomes, including because they saw themselves as a human being
more adaptive goal setting and greater well-being who, like all human beings, are fallible. The mis-
in the face of blocked goals. Potential mecha- take was reparable and reflected on their actions
nisms include greater capacity to admit responsi- rather than their intrinsic value as a person. By
bility for mistakes, higher self-efficacy, less fear reducing self-criticism about one’s mistakes
of failure, better self-regulatory capacity, and (which is generally experienced as aversive),
more adaptive affective responses to stress. These self-compassion may also reduce the likelihood
pathways are likely interconnected and share that people avoid thinking about or engaging
dynamic relationships with motivated behaviors with their errors.
over time. However, most of the available litera- Another study examined the relationship
ture involves cross-sectional observational between self-compassion and self-handicapping
research or performance-associated mood induc- and sandbagging, two behaviors designed to alter
tions (e.g., recalling a failure, receiving negative performance expectations and shift responsibility
feedback on a performance). Further, few studies for inadequate performance away from the self
have examined these potential pathways simulta- (Peterson, 2014). Self-handicapping involves
neously. Nevertheless, exploration of the sup- engaging in behaviors (such as failing to study
porting evidence provides guidance for path for an exam) that can be used to provide an expla-
analysis in future longitudinal and experimental nation for one’s failures and therefore protect
work. self-esteem (Jones & Berglas, 1978). Sandbagging
is aimed at lowering expectations by feigning
inability or predicting subpar performance
Taking Responsibility (Gibson & Sachau, 2000). Like self-handicapping,
for Performance Outcomes sandbagging is designed to protect self-esteem
but can also result in performance being under-
One of the reasons why self-compassion leads to mined (Gibson et al., 2002). Among a student
self-improvement motivation may be attributed sample, Peterson (2014) found that self-
to enhanced willingness to take responsibility for compassion was inversely correlated with both
performance-related outcomes, including under self-handicapping and sandbagging, suggesting
circumstances of failure. In one early study, par- that people with self-compassion are more likely
ticipants were asked to describe a personal to take a realistic perspective of their own perfor-
humiliation, failure, or rejection in detail (Leary mance and less likely to try and manipulate oth-
et al., 2007). Participants were then randomly ers’ perceptions of them.
assigned to respond to their personal humiliation,
failure, or rejection from a self-compassionate
perspective, induced self-esteem perspective elf-Efficacy, Performance Appraisals,
S
(e.g., led to feel good about themselves), through and Failure Construals
expressive writing (e.g., exploring their deepest
emotions), or with no follow-up response (i.e., A second potential pathway underpinning the
control). The results showed that the self- relationship between self-compassion and goal
compassion induction led participants to report maintenance is self-efficacy. A recent meta-
greater willingness to admit and accept responsi- analysis found that self-compassion is moder-
bility for the negative event compared to partici- ately associated with self-efficacy (Liao et al.,
206 A. Ortiz et al.
2021), including across educational (Iskender, taking a self-compassionate rather than self-
2009) and occupational (Latorre et al., 2021) set- evaluative approach may confer benefits for well-
tings. Accordingly, people with greater self- being as well as for goal-related behaviors such
compassion may feel more confident in their as procrastination (for more on the difference
ability to achieve their goals, thereby motivating between self-compassion and self-evaluation, see
them to take the required action to do so. Chap. 3).
Similarly, self-compassion may promote more Available evidence demonstrates inverse rela-
adaptive motivation in the face of setbacks by tionships between self-compassion and maladap-
changing the way that individuals appraise their tive perfectionism (Neff et al., 2018; Tobin &
performance. The way that people appraise or Dunkley, 2021; Wei et al., 2020), and there is
interpret stressors, such as failures or poor per- some evidence that self-compassion can protect
formance, is an integral part of their coping against its negative psychosocial consequences.
response. In a recent study, Miyagawa et al. In a study of undergraduate students, Ong et al.
(2020) found that self-compassionate people (2021) examined psychological flexibility, self-
were more likely to report seeing personal fail- compassion, distress, and symptom impairment in
ures as a learning opportunity and have less mal- groups of students who had low, average, or high
adaptive failure beliefs. In a follow-up perfectionism scores. They found that while self-
experiment, the same authors showed that people compassion appeared to confer protective benefits
who were led to talk about a personal failure with among individuals with average perfectionism,
self-compassion, compared to self-esteem and those with high perfectionism benefited more
control, reported less likely to perceive failure as from psychological flexibility. This suggests that
aversive or to be avoided. In this way, individuals at higher levels of perfectionism, self-compassion
with greater self-compassion are more likely to alone may not be enough to protect against its del-
be able to recover from performance setbacks eterious effects. Nevertheless, given the close
and may experience less self-doubt than those relationship between self-compassion and psy-
who are less self-compassionate. chological flexibility (e.g., Marshall & Brockman,
Closely linked to these outcomes is the rela- 2016), future research may wish to explore
tionship between self-compassion, performance whether self-compassion intervention leads to
anxiety, and perfectionism. When coupled with changes in psychological flexibility among those
goal flexibility and tolerance for mistakes, adap- with different levels of perfectionism.
tive perfectionism can support healthy striving In one of the few studies to examine multiple
toward goals while also feeling accomplished mediators of the relationship between self-
with one’s achievements (Lo & Abbott, 2013). compassion and goal-related outcomes, Neff
Conversely, maladaptive perfectionism entails et al. (2005) found that among undergraduates,
excessively high standards, low tolerance for the relationship between self-compassion and
errors, and an inability to feel satisfied with per- achievement goals was mediated both by fear of
formance, regardless of outcome (Lo & Abbott, failure and perceived competence. More recently,
2013). The links between maladaptive perfec- the self-compassion-fear of failure link has been
tionism and performance expectations, such as tested experimentally. In a study of entrepre-
self-efficacy, fear of failure, and performance neurs, Engel et al. (2021) randomized partici-
anxiety are complex (Flett et al., 1992). However, pants to engage in loving-kindness meditation or
there are some facets of fear of failure – such as to listen to recorded talks about meditation, with-
fear of shame and embarrassment (Conroy, out engaging in meditation practice. Entrepreneurs
2001) – that appear closely linked to maladaptive are a group for whom fear of failure is a highly
perfectionism (Conroy, 2004; Sagar & Stoeber, salient outcome given the uncertain and high-
2009). Fear of failure and performance anxiety pressure environment that entrepreneurs operate
have been associated with the tendency to equate in. Engel et al. (2021) found that, as hypothesized,
personal worth with performance. Accordingly, participants randomized to the loving-kindness
condition reported significant improvements in regulation failure (Steel, 2007), is linked to nega-
self-compassion relative to controls, with parallel tive affective outcomes (Klibert et al., 2011), and
reductions in fear of failure. Further, they found that may represent an ineffective emotion regula-
that the effect of loving-kindness meditation on tion strategy (Sirois et al., 2019). Accordingly,
fear of failure was almost entirely meditated by procrastination may be implicated in a vicious
self-compassion. cycle, in which low mood leads to procrastina-
tion, which exacerbates negative affect. Sirois
et al. (2019) described bedtime procrastination as
Self-Regulation and Adaptive one example of how procrastination might be
Affective Responses to Challenges enacted to regulate negative mood. In support of
a self-regulation model of self-compassion and
Across contexts, having unattainable or thwarted motivation, they found that one of the reasons
goals can harm well-being (Wrosch et al., 2013), individuals with higher self-compassion were
however, some people are more able to recover less likely to procrastinate was because they had
from these setbacks than others (Carver & Scheier, greater access to adaptive emotion regulation
2016). When individuals fixate on unattained strategies and were less likely to experience neg-
goals or when progress toward goals is misaligned ative affect. Similarly, other studies with student
with internal expectations, they may be more samples have reported inverse associations
likely to experience negative affect stress, dis- between self-compassion and negative affective
tress, or burnout. Conversely, individuals who are responses to stress (Zhang et al., 2016), as well as
better able to regulate their emotions and behav- procrastination and performance anxiety
iors may be flexible in the face of setbacks and (Williams et al., 2008; Zhang et al., 2021a, b).
less likely to experience negative well-being out- Further, in a sequential mediation model, Yang
comes. It follows that another way in which self- et al. (2021) found that the link between social
compassion might promote more adaptive support and lower procrastination in college stu-
motivational processes and outcomes is via its dents was mediated first by self-compassion and
association with enhanced self-regulatory capaci- then by negative affect.
ties. As reviewed by Terry and Leary (2011) in the Arguably, by reducing negative affect in the
context of health behaviors, self-compassion is face of stress, adaptive emotion regulation can
associated with several processes underpinning also lead to more reasoned decision-making (e.g.,
adaptive self-regulation toward health behaviors, setting feasible, health-promoting goals) and pro-
including setting safe, realistic goals, seeking nec- mote goal engagement in the face of setbacks.
essary support, and reducing negative feelings, Miyagawa et al. (2018) proposed that students
such a shame or anger that can interfere with with greater self-compassion would be more
one’s capacity for self-regulation. They also pro- likely to disengage from an unattained goal and
pose that because the focus of self-compassion is to reengage with an alternative goal, thereby
on alleviating one’s suffering, self-compassion is reducing negative affect following goal non-
more likely to promote disengagement with harm- attainment. They found support for this hypothe-
ful and unproductive goals, and a heightened sis; in an undergraduate student sample, students
focus on goals that are more likely to promote were instructed to recall a failure to attain their
well-being (Terry & Leary, 2011). goals. Findings showed that self-compassion was
Self-regulation models of self-compassion are associated with both goal disengagement, and
supported by evidence that self-compassion is reengagement with an alternative goal. Further,
associated with more adaptive emotional and the authors found that self-compassion was
behavioral regulation in the face of stress (see inversely associated with negative affect after
Ewert et al., 2021; Finlay-Jones, 2017; Inwood & recalling the failed goal, as well as indirectly
Ferrari, 2018, for reviews). Procrastination is one related to negative affect through goal
behavior that is proposed to arise because of self- disengagement.
208 A. Ortiz et al.
These findings align with those of Hope et al. continue to illuminate and solidify the connec-
(2014) who found that college students who tion between self-compassion and motivation
reported more daily self-compassion were less toward self-improvement.
vulnerable to the affective consequences of
thwarted daily goal progress. The authors also
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Self-Compassion in Competitive
Sport 13
Amber D. Mosewich, Leah J. Ferguson,
and Benjamin J. Sereda
he Case for Self-Compassion

T well-being, among others. Self-compassion has
in Sport been introduced as a potential resource or
approach1 to help manage the demands of the
Sport is replete with instances of evaluation and sport domain, support sport performance, and
comparison, successes and failures, uncertain- foster well-being in sport. Self-compassion can
ties, and sacrifices. Sport can elicit a range of be soothing, offering support, and understanding,
emotions – positive and negative – as a by- while “fierce self- compassion” enables active
product of participation. Through the positives and direct responses directed toward one’s best
and negatives of sport, and everything in between, interest in pursuit of potential (Neff, 2021).
we find athletes, and others involved in sport, Current and ongoing events have brought
navigating a range of situations, including conse- media and, by extension, public attention to the
quences of the past and the goals they are work- challenges faced by many athletes when it comes
ing toward. While many involved in sport are to their mental health. Athletes from all types of
privy to traditional mental skills and have adopted sport, at all levels of play, and at various stages of
individualized practices in self-talk, goal setting, their careers have spoken about their personal
performance planning, and other strategies, there mental health experiences. It would be remiss to
are still recognized gaps in athletes’ abilities to assume these experiences are similar, as they are
manage the emotional, physical, and social not; each is complex, unique, and multifaceted.
demands of sport (e.g., Mosewich et al., 2014). However, the desire to offer support to those in
Tales of punishing self-criticism and overwhelm- need remains universal. In a domain where high
ing self-evaluation are all too common. The con-
sequences often manifest in burnout, poor
performance, injury, and poor mental health and 1 While initially conceptualized from a trait perspective
(Neff, 2003a, b), there is evidence to support that self-
compassion can also be prompted or applied as a resource
or strategy (e.g., Mosewich et al., 2013). Some people
A. D. Mosewich (*) · B. J. Sereda
engender self-compassion automatically as a function of
Faculty of Kinesiology, Sport, and Recreation,
their disposition, while others adopt or engage in the
University of Alberta, Edmonton, Canada
approach when coping with difficult events and pursuing
goals (Ingstrup et al., 2017). Most research in sport posi-
L. J. Ferguson tions self-compassion as a resource or an approach, and
College of Kinesiology, University of Saskatchewan, such a conceptualization is adopted in the present
Saskatoon, Canada chapter.

https://doi.org/10.1007/978-3-031-22348-8_13
214 A. D. Mosewich et al.
performance is the focus, the importance of well- tant to embrace self-compassion (Mosewich
being cannot be overlooked. Additionally, it must et al., 2019a). For example, some athletes have
be remembered that those involved in sport are expressed concern that being too self-
not immune to mental health concerns. A recent compassionate may lead to settling for medioc-
study by Åkesdotter et al. (2020) indicates more rity or complacency in sport (Ferguson et al.,
than 50% of athletes will experience a mental 2014; Sutherland et al., 2014). Fear of self-
health issue in their lifetime. What’s more, symp- compassion – characterized by being fearful of or
toms often manifest at a young age and recurrent resistant to extending compassion toward oneself
episodes are common. There is a need to support (Gilbert et al., 2011) – is often marked by high
athlete well-being alongside their performance, self-criticism and associated with psychological
and self-compassion may be one approach to fos- distress in athletes (Ceccarelli et al., 2019;
ter both of those aims. Ferguson et al., 2015; Walton et al., 2020). Fear
The present chapter will overview self- of self-compassion has also been found to explain
compassion research and practice in sport. additional variance beyond self-compassion on
Although self-compassion is relevant in other some maladaptive thoughts and behaviors in an
areas of physical activity and human movement, athlete sample (Röthlin & Leiggene, 2021). This
such as exercise and physical education, this speaks to the importance of addressing fear of
chapter will focus on the domain of competitive self-compassion among athletes, particularly
sport. We will begin with addressing what we where there are concerns that self-compassion
feel often needs to be discussed up front when may undermine performance. Inadequate under-
working in a sport domain: acknowledging the standing of self-compassion presents a challenge
challenges of presenting self-compassion to the to its use among athletes and others involved in
culture of sport, which is one that often possesses sport; accordingly, a key goal is “convincing”
and values the norm of self-criticism. We will those involved in sport that being self-
then overview how self-compassion has been compassionate is beneficial.
assessed in the sport domain, as this framing is Fear of self-compassion in the sport domain
key to the conceptualization of the sport self- may be exacerbated by a perceived language bar-
compassion literature. What will follow is a sum- rier. That is, the idea – and corresponding lan-
mary of the empirical findings. We provide an guage – of self-compassion may not “fit” within
overview of cognitions, emotions, behaviors, and sport participants’ typical conceptual models of
outcomes associated with self-compassion, and sport and achievement. The competitive sport
the accompanying implications for well-being environment is replete with extreme training
and performance. We then present self- demands, performance expectations, and set-
compassion development and intervention backs, which may appear incompatible with a
research that is specific to the sport domain and kind, connected, and balanced self-attitude.
consider its use in applied sport psychology prac- While some athletes believe they need to be hard
tice. The chapter concludes with considerations on themselves to achieve their goals, it is impor-
regarding the adoption of self-compassion in tant to clearly differentiate between harsh or
sport and areas for future inquiry. debilitating self-criticism and constructive evalu-
ation of the self (Mosewich, 2020). Wilson et al.
(2019) found that an elite group of women ath-
Challenges for Self-Compassion letes identified the merits of both mental tough-
in Sport ness and self-compassion, indicating that the two
can even be compatible processes that work in
Despite the relevance of self-compassion within tandem with one another in the pursuit of athletic
the sport domain, not everyone is receptive to the achievement. It is therefore important to explore
approach. Researchers have identified that at effective ways to introduce and talk about self-
least some individuals involved in sport are hesi- compassion with those involved in a sport
13 Self-Compassion in Competitive Sport 215
c ontext. Reis et al. (2022) flagged the need for level to capture shifts in an individual’s self-
adequate education about self-compassion from compassionate mindset across different situations
knowledgeable sources to help sport participants or over time. Neff et al. (2021) recently devel-
accurately learn what self-compassion is and how oped and validated long and short forms of state-
to apply it in their sport experiences. Doing so in specific measures of self-compassion that are
a way that stays true to the tenets of self- positioned to assess changes in self-compassion.
compassion and is meaningful to athletes and It is important for researchers to include Neff
others involved in sport is paramount. et al.’s (2021) state-specific measures in future
self-compassion in sport research, particularly
when examining self-compassion’s malleability
Measurement of Self-Compassion through inductions and interventions.
in Sport There are at least two critical questions for
researchers to consider when measuring self-
Neff (2003b) originally conceptualized self- compassion in sport. First, is self-compassion
compassion as trait-like, suggesting that individ- domain specific? Some researchers have
uals have general tendencies to be more or less attempted to enhance the relevance of their self-
compassionate toward themselves. Accordingly, compassion measures to the sport context by
Neff developed a trait-like, domain-general mea- priming participants to think about their self-
sure of the construct, the Self-Compassion Scale compassionate tendencies in sport. Both Killham
(SCS; Neff, 2003a), intended to assess stable et al. (2018) and Lizmore et al. (2017) modified
individual differences in self-compassion. While the language of domain-general self-compassion
other measures have been developed (e.g., the measures (i.e., SCS and SCS-SF, respectively) so
Sussex-Oxford Compassion for the Self Scale; the items referred specifically to the sport con-
Gu et al., 2020; The Compassion Motivation and text, rather than life in general. Mosewich et al.
Action Scales; Steindl et al., 2021), most self- (2021) recently investigated whether a sport-
compassion in sport research has used Neff’s specific measure of self-compassion provides
measure or a short form of the scale (i.e., SCS-SF; insight beyond that obtained from a domain-
Raes et al., 2011; see Röthlin et al., 2019, for a general measure of self-compassion (i.e.,
review). SCS-SF; Raes et al., 2011). Composite self-
Within the self-compassion in sport literature, compassion scores did not differ between the
many researchers have positioned self-sport-specific measure and domain-general mea-
compassion as a coping resource that can be used sure. As a result, there is currently no evidence to
after a situation has been appraised, and respond- support adopting a sport-specific measure of self-
ing self-compassionately is an option to manage compassion over the domain-general measures of
the athlete’s experience. In line with this concep- self-compassion, but given the limited research,
tualization, some researchers have assessed the further attention is warranted.
extent to which individuals respond to a given The second important question to consider is
situation (e.g., “being responsible for losing an whether the language of self-compassion aligns
athletic competition for your team”) with state with the competitive sport context. Researchers
self-compassion (e.g., “I tried to be kind to want to ensure that the language in their mea-
myself”; e.g., Leary et al., 2007; Reis et al., sures accurately reflects the underlying con-
2015). Similarly, self-compassion has also been structs they are studying. At the same time, it is
positioned as a mental performance skill (or col- important that researchers use language that reso-
lection of skills) or an approach that can be nates with and is appropriate for their participants
taught to athletes to use when experiencing a set- and research contexts. Researchers need to be
back (e.g., Ingstrup et al., 2017; Mosewich et al., mindful of participants’ reception to the concept,
2013). Given these conceptualizations, it may be measurement, and application of self-compassion
important to assess self-compassion at a state- in sport. There is the risk that some sport
p articipants may perceive the language of self- et al., 2017; Tingaz et al., 2022; Wasylkiw &
compassion as “too soft” or incompatible with Clairo, 2016). Sereda et al. (2022) found that ath-
the competitive sport environment (Ferguson letes high in self-compassion can adaptively
et al., 2014; Sutherland et al., 2014). Researchers appraise the unexpected stressors they encounter,
need to constructively consider the self- through balanced perspectives and logical analy-
compassion measures used in their research, sis, and effectively cope with them. In contrast,
including, but not limited to, issues around lan- athletes with lower self-compassion report more
guage and domain specificity, to strive for appro- burnout, concern over mistakes, shame, interper-
priate and optimal assessment. sonal and emotional exhaustion, psychological
distress, somatic anxiety, state self-criticism, fear
of failure, fear of negative evaluation, maladap-
Cognitions, Emotions, Behaviors, tive perfectionistic concerns, worry, rumination,
and Outcomes Associated pessimism, and negative affect along with exter-
with Self-Compassion nally regulated motivation and use of avoidance-
focused coping approaches than athletes high in
The sport domain requires athletes, and others self-compassion (Amemiya & Sakairi, 2020;
involved in sport, to navigate many types of expe- Barczak & Eklund, 2020; Casali et al., 2022;
riences. Given the difficulty in managing evalua- Ceccarelli et al., 2019; Fontana et al., 2017;
tion, comparison, and setbacks, many researchers Huysmans & Clement, 2017; Jeon et al., 2016;
have focused on the potential of self-compassion Lizmore et al., 2017; Mosewich et al., 2011;
as a resource or approach to address sport-related Mosewich et al., 2019b; Reis et al., 2019; Tarasoff
challenges to better support performance and et al., 2017; Walton et al., 2020; Walker, 2021).
well-being in sport. The connection of self- Overall, when it comes to cognitions, emotions,
compassion to performance and well-being, as and behaviors among sport participants, self-
well as to cognitions, emotions, and behaviors compassion appears to have potential to not only
that are viewed as both directly and indirectly attenuate the negative but also promote the
related to performance and well-being, are accu- positive.
mulating in the sport domain. Self-compassion also appears to foster posi-
Collectively, research has been used to build a tive body image among athletes (see Chap. 11 for
case for self-compassion as a resource to help a complete discussion of self-compassion and
athletes manage difficult cognitions and emo- body image literature). Athletes with higher self-
tions, as well as to promote adaptive thoughts, compassion have greater body appreciation,
feelings, and behaviors, particularly in the face of adaptive eating attitudes and behaviors, and
challenges. Adaptive perfectionistic strivings lower social physique anxiety, self-conscious
(aspects of perfectionism associated with a self- emotions, objectified body consciousness, com-
oriented high achievement striving and high per- pulsive exercise tendencies, and disordered eat-
sonal performance standards; see Stoeber, 2011), ing behaviors than those lower in self-compassion
behavioral equanimity (remaining calm and com- (Adam et al., 2021b; Mosewich et al., 2011; Pila
posed in responses), positive affect, authentic et al., 2022). Mosewich et al. (2009) suggested
pride, happiness, persistence of effort, self- that the promotion of a “self-compassionate mus-
determined motivation, positive attitudes toward cularity” (p. 113; i.e., approaching one’s muscu-
help-seeking, cognitive reappraisal, and use of larity with self-compassion) could attenuate the
emotion- and problem-focused coping expectations and evaluation many women ath-
approaches are typical of self-compassionate athletes encounter surrounding their bodies through
letes (Barczak & Eklund, 2020; Ceccarelli et al., enabling women to acknowledge and respect the
2019; Doorley et al., 2022; Jeon et al., 2016; body and what it can and cannot do, bypassing
Lizmore et al., 2017; Mosewich et al., 2019b; harsh self-criticism. Body self-compassion
Mosewich et al., 2021; Reis et al., 2015; Tarasoff among women athletes can promote respect for
and satisfaction with one’s body, supporting compassion was associated with adaptive
emotion regulation and adaptive perceptions responses to stress, specifically a reduction in
around the body and performance (Eke et al., somatic anxiety, and the accompanying worry
2020). Similar sentiments were present among a and concentration disruption, and avoidance-
group of men with spinal cord injury who were coping strategies (Huysmans & Clement, 2017).
former athletes (Smith, 2013). Self-compassion Additionally, the adaptive cognitions, emotions,
surrounding the body, including appreciating and behaviors reviewed earlier both relate and
what the body could do, motivated leisure time contribute to high well-being.
physical activity, and attenuated harsh self- While adaptive cognitions, emotions, and
criticism connected to limitations of the body behaviors and well-being contribute to positive
(Smith, 2013). Thus, these findings suggest that performance, those in the sport domain are
self-compassion promotes acceptance and appre- understandably interested in the direct relation-
ciation regarding the body’s appearance and ship between self-compassion and physical per-
functionality among sport participants. Further, formance outcomes. Although performance
Pila et al. (2022) suggested that self-compassion outcomes are complex and impacted by a variety
intervention may provide protection from nega- of factors, researchers are starting to examine
tive body-related emotional experiences in sport more explicit performance variables. In a group
through decreasing outcomes associated with of women varsity athletes, self-compassion was a
negative body image, as well as preventing body significant prospective predictor of goal progress
image concerns. (Mosewich et al., 2019b). Researchers have also
Self-compassion also appears to support well- found positive associations between self-
being among sport participants. For example, compassion and perceptions of sport perfor-
Ferguson et al. (2014) found that athletes with mance (Barczak & Eklund, 2020; Killham et al.,
greater self-compassion exhibited greater eudae- 2018). Additionally, some athletes have identi-
monic well-being (i.e., autonomy, environmental fied self-compassion as an “energizing internal
mastery, personal growth, positive relatedness, force” (p. 274) that facilitates their performance
purpose in life, and self-acceptance). During through reframing criticism and maintaining a
adversity, being self-compassionate may support determined approach (Adam et al., 2021a).
athletes’ psychological functioning and develop- Research examining the direct links between
ment through increased positivity and persever- self-compassion and performance, as well as fur-
ance, as well as reduced passivity, in reaction to ther establishing self-compassion as an indirect
difficult sport experiences (Ferguson et al., 2015). facilitator of performance in sport, will continue.
Furthermore, athletes with greater self- An important extension of the psychological
compassion at the start of their competitive sea- correlates of self-compassion is the integration of
son have greater autonomy, mastery, purpose, physiological variables into research. Ceccarelli
and self-acceptance at the end of their competi- et al. (2019) examined the relationship between
tive season (Ferguson et al., 2022a). These find- self-compassion and athletes’ physiological and
ings support the contribution of self-compassion psychological responses to a recalled sport fail-
to psychological flourishing throughout a com- ure. Athletes with greater self-compassion
petitive sport season. Huysmans and Clement showed dampened physiological reactivity in the
(2017) suggested that athletes high in self- form of blunted heart rate variability withdrawal
compassion should cope effectively with stress- (i.e., the self-compassionate athletes were better
ors in sport and life, resulting in a reduction of able to regulate their physiological response).
the magnitude of the stress response (e.g., atten- Dysregulation of the parasympathetic system
tion disruption, maladaptive muscle tension) that during a stressor is associated with slower reac-
could increase the risk of injury. While there tion times and decreased accuracy (Williams
were no significant findings pertaining to self- et al., 2016), both of which have implications for
compassion and attenuation of injury risk, self- sport performance. Thus, this study supports
self-compassion as a protective factor for ath- them when they experience adversity in sport, by
letes’ parasympathetic reactivity during a teaching them to be kind to themselves, and to
stressor, suggesting that self-compassionate ath- help them put experiences into perspective.
letes are better able to regulate and balance their In addition to parents, peers also seem impor-
physiological state (Ceccarelli et al., 2019). tant to the development of self-compassion.
Athletes appeared to learn from and engage in
self-compassionate behaviors (e.g., balanced
The Development awareness) modeled by teammates when experi-
of Self-Compassion encing adversity (Ingstrup et al., 2017). In sup-
port of Ingstrup et al.’s (2017) initial qualitative
Given the potential benefits associated with self- findings, Crozier et al. (2019) found that the more
compassion in the sport context, there has been that athletes believed that their teammates were
increased interest centered on understanding how self-compassionate, the more likely it was that
self-compassion may be developed among sport the athletes reported being self-compassionate
participants. Beginning to engage with and foster themselves. Further, Jeon et al. (2016) stated that
a self-compassionate approach may occur in social support had a positive impact on self-
childhood and adolescence (Ingstrup et al., 2017), compassion, suggesting that social support from
as well as during the late teen and young adult others in sport can help athletes to accept and
years (Frentz et al., 2020), leading to the height- endorse a self-compassionate approach.
ened likelihood of typically responding with self- Similarly, men athletes in Reis et al.’s (2022)
compassion across the life span. Based on study noted that seeing their teammates exhibit
interviews with women athletes high in self- self-compassionate behaviors increased their
compassion, Ingstrup et al. (2017) identified the own capacity to engage in a self-compassionate
roles of important others (e.g., parents, coaches, approach to sport-related challenges. Frentz et al.
sport psychologists, peers, siblings) in combina- (2020) also noted that teammates’ social support
tion with athletes’ personal awareness and self- and affirmations facilitated more self-
reflection as key factors in development of compassionate responding.
self-compassion. The authors concluded that Coaches, mental skills consultants, and sport
“self-compassion appeared to be a set of skills or psychologists may also play a role in the develop-
resources that were learned through personal ment of self-compassion (Ingstrup et al., 2017).
reflection and interactions with others” (p. 327). Athletes in Ingstrup et al.’s (2017) study appeared
Although athletes noted the contribution of a to develop self-compassion through skills learned
variety of significant others in fostering their self- in sport psychology sessions. Similarly, Frentz
compassion, Ingstrup et al. (2017) highlighted et al. (2020) suggested that support offered by
the role of parents as particularly important in its sport psychology consultants can aid athletes in
development. Parents appeared to foster an envi- adopting a more self-compassionate approach.
ronment conducive to athletes feeling comfort- Mental performance consultants also attest to the
able seeking and receiving support rather than usefulness of self-compassion in supporting
managing sport-related difficulty in isolation masters-level2 athletes (Makepeace & Young,
(i.e., common humanity). Further, Ingstrup and 2021). Additionally, Frentz et al. (2020) sug-
colleagues noted that parents taught and encour- gested that coaches can significantly influence
aged the athletes to demonstrate kindness toward the development of self-compassion, limiting
the self, particularly during times of failure. athlete self-criticism and aiding athletes in taking
Illustrations of mindfulness appeared as parents a new perspective. Interactions with a range of
assisted athletes in putting events into perspec- significant others is important in sport
tive. As such, Ingstrup and colleagues suggested
that parents can support the development of self- 2 Masters-level athletes are typically over the age of 35 and
compassion in athletes through being available to compete in events designed for older participants.
participants’ learning and engagement with a Mosewich et al. (2013) were the first to
self-compassionate approach. develop and empirically assess a self-compassion
Although the influence of others is sizeable in intervention in the sport context. They examined
the cultivation of self-compassion, there is also the effectiveness of a 7-day psychoeducation and
an internal component to its development (Frentz writing-based intervention in increasing self-
et al., 2020; Ingstrup et al., 2017). Both Frentz compassion and decreasing levels of self-
et al. (2020) and Ingstrup et al. (2017) highlighted criticism, rumination, and excessive concern over
self-awareness as a key factor in becoming more mistakes in women varsity athletes who identi-
self-compassionate. Being able to reflect on pre- fied as being highly self-critical in a way that was
vious negative experiences whilst avoiding “less than constructive” (p. 516). The interven-
engaging in excessive self-criticism permitted tion began with a brief psychoeducation presen-
more self-awareness and self-compassion tation overviewing stress and coping in sport and
(Ingstrup et al., 2017). Being aware of, and introducing the concept of self-compassion. The
acknowledging, other athletes going through athletes were presented with evidence that adopt-
similar challenges fostered not only common ing a self-compassionate approach does not pro-
humanity but also the ability to abandon self- mote passivity and/or complacency, rather that it
criticism for self-compassion (Frentz et al., 2020; can nurture goal progress and a more effective
Ingstrup et al., 2017). Therefore, internal (i.e., focus on sport-related tasks. Such an inclusion
self-awareness and reflection) and external (i.e., was particularly important given some athletes
learning from significant others) factors, in com- may have had apprehension in adopting a self-
bination, contribute toward the development of compassionate approach (Ferguson et al., 2014;
self-compassion among those involved in sport. Sutherland et al., 2014). As noted in the introduc-
As such, athletes should be encouraged to reflect tion, addressing concerns about self-compassion
on their experiences in a kind and mindful man- is important in intervention efforts, as is present-
ner and also share their challenges with others – ing the construct in a manner that will resonate
the sharing can facilitate common humanity, and with athletes (Mosewich et al., 2019a; Röthlin
through sharing, the athlete stands to not only et al., 2019).
learn from others but also teach or model self- Following the psychoeducation presentation,
compassion for others. the athletes participated in a self-compassion
writing exercise pertaining to a sport setback and
were then provided instructions surrounding the
Self-Compassion Intervention five remaining writing tasks that they were to
complete over the next 7 days (Mosewich et al.,
Although it is important to understand how indi- 2013). Writing tasks were modeled after Leary
viduals develop self-compassion through organic et al.’s (2007) prompts designed to encourage
interactions with peers and family members and athletes to think about a negative event in a self-
through other life experiences, not all sport par- compassionate way (Mosewich et al., 2013).
ticipants are provided the opportunity and sup- Reflecting on and processing previous negative
port to develop self-compassion during their sport experiences and setbacks can be valuable in
formative years. Fortunately, there is evidence to promoting self-compassion (Frentz et al., 2020;
suggest that intervention efforts can successfully Ingstrup et al., 2017). Athletes identified a per-
foster self-compassion in individuals who may sonally significant sport setback as their negative
not inherently engage in self-compassionate event. To promote common humanity, athletes
responding. Given the unique demands of sport, were instructed to “list ways in which other peo-
intervention efforts tailored specifically for ath- ple experience similar events.” To evoke self-
letes have been developed, both guided by and kindness, athletes were asked to “write a
contributing to self-compassion intervention paragraph expressing understanding, kindness,
development in other areas. and concern to yourself.” To assist the athletes in
taking a self-kind perspective, they were further concern to a friend who had experienced some-
told to “write as if you are communicating to a thing similar (self-kindness); and write about the
close friend in the same situation.” To encourage event in an objective, unemotional manner
mindfulness, athletes were asked to “describe the (mindfulness). Although self-compassion was
event in an objective and unemotional manner” to positively associated with behavioral equanimity
acknowledge the event without overidentifying and negatively associated with negative affect,
with the negative aspects of the experience. catastrophizing thoughts, and personal thoughts,
Mosewich et al. (2013) found that the self- Reis and colleagues did not observe a significant
compassion intervention was effective for effect of the self-compassion induction on how
improving self-compassion and state self- athletes responded to the hypothetical scenario.
criticism, state rumination, and concern over mis- The researchers noted that although self-
takes compared to an attention-training control compassion predicts adaptive responses to emo-
group. These findings remained one week and tionally difficult sport situations in women
one month after the completion of the interven- athletes (Ferguson et al., 2014, 2015), it may be
tion. Given that self-compassion interventions challenging to quickly induce self-compassion
typically require more time involvement from among athletes, particularly when relying on a
participants (e.g., 6 weeks, Bluth et al., 2016; sole, brief procedure. They further speculated
8 weeks, Neff & Germer, 2013), the format of that as the scenario they presented was hypotheti-
Mosewich et al.’s (2013) intervention was a nota- cal rather than personal, there might have been a
ble strength. Given the time demands and con- lack of personal salience, which could influence
straints faced by athletes and others involved in the response.
sport, the relatively brief, flexible, and accessible Recently, Röthlin and Leiggene (2021)
nature of the intervention may be particularly adapted the psychoeducation and writing inter-
appealing to sport participants interested in incor- vention presented by Mosewich et al. (2013) for
porating the new strategies into existing mental a group of climbers using a pretest and posttest
performance training and routines. assessment and a wait-list control group. The
Building on the work of Mosewich et al. psychoeducation component consisted of a hand-
(2013), Reis et al. (2015) proposed that a brief out describing the three affect regulation systems
self-compassion induction, if effective, may be (soothing, threat, and protection) proposed by
more practical and manageable for athletes and Gilbert (2010) and applied the content to the
researchers relative to the 7-day period in the climbing context. Neff’s (2003b) definition of
Mosewich et al. (2013) intervention. Brief self- self-compassion was introduced, along with
compassion inductions have been successful out- explaining how self-compassion activates the
side of the sport domain (e.g., DeLury & Poulin, soothing system and subsequently stands to deac-
2018; Leary et al., 2007). Thus, Reis et al. (2015) tivate the threat and protection system. The
examined the viability of a brief self-compassion climbers completed the same five writing tasks
induction in influencing athletes’ reactions, presented by Mosewich et al. (2013), this time
thoughts, and emotions following a hypothetical focusing on a climbing experience. All interven-
scenario (i.e., being responsible for losing an ath- tion materials were delivered via email. The
letic competition for their team). Like Mosewich intervention led to an increase in self-compassion
and colleagues, Reis et al. (2015) used writing and a decrease in somatic, but not cognitive, per-
prompts to induce self-compassion informed by formance anxiety (Röthlin & Leiggene, 2021) in
Leary et al. (2007). At a single timepoint, women the self-compassion group, compared to a wait-
athletes were asked to write down the ways that list control. The researchers posited that the
other people also experience similar events (com- reduction of somatic performance anxiety might
mon humanity); write a paragraph expressing be due to self-compassion activating the emo-
understanding, kindness, and concern to them- tional contentment and soothing system, which
selves in the same way that they may express then attenuates the physical effects of the threat
and protection system (Gilbert, 2010). Thus, self- relation to body evaluation. Between sessions,
compassion may be a strategy to help athletes there are self-directed activities and support via
reduce physiological arousal and somatic anxiety social media.
(Röthlin & Leiggene, 2021). While the lack of The intervention was successful, as the experi-
significant reduction in cognitive performance mental group showed significantly higher self-
anxiety was unexpected, the researchers suggest compassion and mindfulness after the program
that an intervention that places more emphasis on compared to baseline, while the control group
cognitive processes, such as systematic mindful- showed no change. The experimental group also
ness practice, might be necessary for significant reported less thin-ideal internalization compared
results (Röthlin & Leiggene, 2021). to the control group after completing the program.
This new intervention adaption by Röthlin and Voelker et al. (2021) interviewed women athletes
Leiggene (2021) provides some important novel who had participated in the intervention and found
contributions. Interestingly, the increase in self- that upon program completion, participants
compassion appeared to be primarily due to a reported increased self-awareness and awareness
strengthening of the positive facets of self- of their relationships with their bodies, under-
compassion rather than to a decrease in its nega- standing of their body’s functionality, appreciation
tive facets (Röthlin & Leiggene, 2021). of common humanity with other athletes, acknowl-
Statistically assessing change in the positive and edgement of the social constructions of beauty in
the negative facets of self-compassion may be sport and society, recognition of the negative
relevant for future research. Additionally, the effects of self-criticism, and ability to apply self-
findings of this study lead to the suggestion that compassion strategies. Positive changes in body
even athletes who do not describe themselves as attitudes, such as acceptance and gratitude, were
self-critical (recall that the athletes in the also reported.
Mosewich et al. (2013) intervention identified The MBSoccerP program is another example
themselves as self-critical) can increase their of self-compassion being integrated into an exist-
self-compassion in a similarly short intervention, ing framework (Carraça et al., 2019). The inter-
delivered remotely. vention was based on Mindfulness-Based Stress
There are also instances of self-compassion Reduction, Acceptance Commitment Therapy,
being integrated into existing intervention and and Compassionate Mind Training. The 8-week,
therapeutic approaches. Bodies in Motion is an 9-session pilot study involved male soccer play-
intervention rooted in Cognitive Dissonance ers and incorporated self-compassion strategies,
Theory that introduces self-compassion princi- including compassionate imagery, writing, and
ples to NCAA women athletes to attenuate body psychoeducation. Mindfulness, self-compassion,
pressures (Voelker et al., 2019). Using self- performance evaluation, and flow increased, and
compassion strategies, athletes build self- experiential avoidance decreased, from pre- to
awareness regarding their cognitive and post-intervention, leading Carraça et al. (2019) to
emotional responses to appearance ideals and attest that self-compassion was an important
cultivate effective coping skills to navigating addition to traditional mindfulness training
such standards. The intervention aimed to have approaches in the sport domain.
athletes learn to be more mindful, self-aware, In addition to ongoing research focused on
nonjudgmental of their thoughts and feelings, fostering self-compassion, individuals in applied
and kind and understanding and less self-critical roles have also documented their insight sur-
in their evaluations and responses to themselves rounding practically integrating self-compassion
while navigating body image messaging. Five in a sport context. Rodriguez and Ebbeck (2015)
sessions address origins of appearance ideals, positioned self-compassion as a potentially valu-
environmental triggers, consequences of ideals, able resource in helping women gymnasts to
and mindfulness and self-compassion practice in attenuate the negative impact of mistakes and set-
backs. They described a combination of activities tinue to grow in number, larger-scale randomized
designed to instill a self-compassionate perspec- control trials with attention to intervention fidel-
tive into both practice and competition contexts. ity are required to advance our understanding of
The strategies adopted from Neff (2003b) intervention effectiveness (Mosewich, 2020;
included a writing exercise that highlighted dis- Mosewich et al., 2019a).
crepancies between how one treats oneself and Mosewich and colleagues (2019a) also
how one would treat a teammate during hardship, stressed the importance of thoughtful engage-
generating and integrating “self-compassion ment with intervention design, including inter-
cues,” and creating more caring “motivators” to vention length and activities (e.g., writing, verbal
replace harshly self-critical ones. Additionally, psychoeducation sessions, strategies embedded
Rodriguez and Ebbeck (2015) created novel in the sport environment), delivery format (e.g.,
strategies tailored to the needs of the athletes that in-person versus remote, self-directed versus
they were working with, including a bead trans- instructor-led), and accessibility (e.g., online
fer exercise to foster awareness and being mind- availability, degree of access restrictions) in sup-
ful of one’s positive and negative self-talk, porting deeper understanding of this area. Since
sport-specific physical examples to counter the athletes with greater self-compassion at the start
perception that self-compassion is self-coddling of their competitive season have been found to
(i.e., “Would you withhold water from yourself have greater well-being at the end of their sea-
during your 4-hour practice to be tough on your- son, embedding self-compassion intervention
self?”), and collaborative, proactive planning to into pre-season activities may have merit
prevent adverse outcomes. Also informed by her (Ferguson et al., 2022a). When designing a self-
applied work, Baltzell (2016) shared that exces- compassion intervention, consideration should
sive and harsh self-criticism inherent in the sport also be given to potential facilitators and barriers
domain might be successfully attenuated with to the adoption of self-compassion. For example,
compassionate attention, reasoning, behavior, given the impact that significant others in sport
imagery, and scripting. As research demonstrat- (e.g., coaches, peers, parents; Crozier et al.,
ing the value of self-compassion in sport contin- 2019; Frentz et al., 2020; Ingstrup et al., 2017;
ues to grow, there will be increased need for Reis et al., 2022) can have on the development
researchers and stakeholders to provide current, of, and engagement with, self-compassion,
empirically informed recommendations for effec- Mosewich et al. (2019a) suggested that involve-
tive self-compassion integration in applied sport ment of such significant others may strengthen
settings. intervention design and efforts. Further, research-
To continue to develop guidelines and strate- ers should thoroughly consider context (e.g.,
gies for successful self-compassion intervention social support, teammates’ self-compassion;
and development in sport, there are many impor- Crozier et al., 2019; Frentz et al., 2020; Reis
tant considerations for researchers and practitio- et al., 2022; Röthlin et al., 2019) and athletic
ners. Mosewich et al. (2019a) asserted that characteristics (e.g., competitive level, gender,
efficacy and effectiveness of sport-based inter- age, culture, past experience with mental skills;
ventions must be thoroughly considered (e.g., Mosewich et al., 2013, 2019a; Reis et al., 2015)
replication, participant adherence and engage- to design robust self-compassion interventions
ment, assessing maintenance of change over in the sport context.
time). Consistent with Kirby et al.’s (2017) rec- Although existing self-compassion interven-
ommendations for compassion-based interventions and inductions in sport have involved writ-
tion research, Mosewich et al. (2019a) highlighted ing exercises and psychoeducation sessions, a
the need for established normative data and cor- variety of intervention activities and modalities
responding clinical cutoffs to assess the effective- could be included in intervention procedures. For
ness and efficacy of interventions in sport. As example, self-reflection and self-awareness exer-
interventions focused on self-compassion con- cises, modeling, smartphone-guided meditation
and journaling, compassionate imagery, cues, as is systematic refinement based on current

affectionate breathing, group-based activities, research knowledge.
proactive planning, soothing touch, and social
media groups have been positioned as potential
approaches within self-compassion interventions Connection to Resilience
(e.g., Baltzell, 2016; Ebbeck & Austin, 2018; and Motivation
Hägglund et al., 2022; Ingstrup et al., 2017;
Rodriguez & Ebbeck, 2015; Schnepper et al., Self-compassion has important implications for
2020; Seekis et al., 2020; Voelker et al., 2019). two psychological constructs that have great rel-
Given the potentially unique nature of environ- evance in sport – resilience and motivation. The
ments, norms, and cultures within and across desire for sport participants to embody resilience
sport types and participation categories, research- and motivation is readily apparent in most, if not
ers interested in self-compassion interventions all, sport contexts. Importantly, resilience and
should consider past research and recommenda- adaptive motivational tendencies have the poten-
tions and be innovative in their efforts to effec- tial to support both performance and well-being
tively and appropriately foster self-compassion in sport. Additionally, connecting self-
in their sporting environments. compassion with the desired attributes of resil-
ience and motivation may also help foster
acceptance and integration of self-compassion
Adoption of Self-Compassion into the sport culture.
in Sport Given the focus of self-support and engaging
in actions that support what is best for the self, it
Self-Compassion Promotion Versus is not surprising that self-compassion is associ-
Intervention ated with adaptive motivation. Self-compassion
is positively associated with self-determined
In considering the adoption of self-compassion in motivation, personal initiative, and responsibility
the sport context, it would be remiss not to dis- and negatively related to passivity, which pro-
cuss the unknowns regarding the appropriateness vides evidence supporting positive motivational
of self-compassion promotion versus interven- tendencies in sport (Ferguson et al., 2014).
tion. That is, should the aim be widespread pro- Outside of sport, a notable finding by Breines and
motion or targeted intervention, or is there merit Chen (2012) was that self-compassion was asso-
in both? There is a need for further examination ciated with self-improvement motivation, which
of when – and for whom – self-compassion might bodes well for continued personal development
be relevant and effective (Mosewich, 2020; and goal progress in sport.
Mosewich et al., 2019a, b). Such a process needs Many of the adaptive cognitions, emotions,
to examine potential drawbacks of self- and behaviors associated with self-compassion
compassion, as it cannot be assumed that self- (see Mosewich, 2020) could be promotive fac-
compassion is an adaptive approach for all tors for resilience (see Fergus & Zimmerman,
involved in sport and across all sport contexts 2005, and Chap. 10 of this handbook). To offer a
(Mosewich, 2020). In terms of self-compassion few specific examples, the positive relationship
promotion, accessibility and effectiveness must between self-compassion and optimism
be a focus, with avoidance of any possible down- (Lizmore et al., 2017), grit (Mosewich et al.,
sides of promotion efforts by engaging in appro- 2021), mental toughness (Stamatis et al., 2020),
priate monitoring. For intervention, we must and help- seeking (Wasylkiw & Clairo, 2016)
identify who should be targeted, how they will be makes a pointed statement regarding self-com-
identified, the temporal patterning of intervention passion and resilience in sport. Research outside
efforts, and best practice in delivery and monitor- of sport has explicitly associated self-compas-
ing. Continual empirical evaluation is necessary, sion with resilience (Bluth et al., 2018). In addi-
tion, resilience is positively related to personal and use in different circumstances and inform
factors such as focus and concentration (Sarkar promotion and intervention efforts.
& Fletcher, 2014), adaptive coping strategies A variety of sport experiences exist as a func-
(Nicholls et al., 2016; Secades et al., 2016), and tion of gender identity. While we do acknowledge
effective emotion regulation strategies (Tugade an increase in research involving men in recent
& Fredrickson, 2007), which exist among self- times, much of the body of research on self-
compassionate athletes (see Mosewich, 2020, compassion in sport has focused on women ath-
for a review). Though resilience is often thought letes (see Mosewich, 2020). There is limited and
of in terms of personal factors, it is also impacted equivocal research pertaining to gender differ-
by the environment (Fergus & Zimmerman, ences in the levels of self-compassion in a sport
2005). Sport environments that exude a positive, context. Jansen et al. (2021) found women had
task-focused motivational climate support resil- higher values in the negative scale of self-
ience (Vitali et al., 2015), and a self-compassion- compassion compared to men. Stamatis et al.
ate sport culture is likely to support such an (2020) reported men NCAA student-athletes as
environment. being higher in self-compassion than their women
counterparts, while Hilliard et al. (2019) and
Ferguson et al. (2022b) found no differences in
Sport-Specific Needs and Factors self-compassion between men and women ath-
letes. A meta-analysis by Yarnell et al. (2015)
Adoption of self-compassion in the sport domain found that women in general had slightly lower
requires careful consideration of the unique self-compassion than men. Regardless, it seems
nature of the sport context. At the present time, prudent to consider issues of gender identity when
there remain some gaps in our knowledge. For integrating self-compassion into a sport context.
instance, an important variable in sport is compe- For example, there may be a complex relationship
tition level. Most sport self-compassion studies between masculinity and self-compassion among
combine athletes participating at various commen involved in sport, with men athletes who
petitive levels of sport, from regional to interna- strongly endorse traditional masculine norms
tional (e.g., Adam et al., 2021b; Reis et al., 2015). experiencing challenges in adopting self-
Only select few studies have focused on particu- compassion (Reis et al., 2019). As such, an inter-
lar levels of competition, such as recreational vention involving inclusive masculinity (i.e., a
(e.g., Fontana et al., 2017), varsity (i.e., compet- version of masculinity that is centered on accep-
ing for university or college teams; e.g., Lizmore tance of varying enactments of masculinities and
et al., 2017; Sereda et al., 2022), and international a view that versions of masculinity should not be
(e.g., Wilson et al., 2019). Studies comparing lev- hierarchical, but equal; Anderson, 2009) would be
els of self-compassion at different competitive valuable in assessing self-compassion in men’s
levels are scarce. While no significant differences sport (Reis et al., 2019).
in self-compassion were found across NCAA Research on sport type is limited and equivo-
Divisions I, II, and III student-athletes (Stamatis cal but stands to be considered as an important
et al., 2020), athletes competing at a local level sport-specific variable. Jansen et al. (2021)
reported higher self-compassion than those com- reported lower self-compassion among individ-
peting provincially, nationally, and internation- ual sport athletes and handball players, while the
ally (Ferguson et al., 2022b). Given this limited soccer players in their sample reflected higher
examination, exploration of key transitional peri- levels of self-compassion. In a study by Ferguson
ods, such as retirement from sport, deselection, et al. (2022b), aesthetic sport athletes had lower
and change in level of competition is needed. self-compassion than non-aesthetic sport ath-
Exploration of self-compassion at different levels letes, but there were no differences between team
of sport and during key periods in a sport career and individual sport athletes. While it remains
trajectory will help to delineate potential needs important to consider factors such as competition
level, gender identity, and sport type, the need for but play a major role in the sport culture. Further,
individualized promotion and intervention they can have a notable impact whether self-
attempts for those involved in sport should not be compassion is modeled, supported, or hindered
overlooked. Traditional mental skills training via cultivation of self-critical norms often (unnec-
recognizes the need for individualization, and the essarily) engrained in the minds of sport partici-
justification – that athlete strengths, needs, and pants as a required characteristic for success
environments differ – holds true for use of self- (Frentz et al., 2020; Ingstrup et al., 2017). Thus,
compassion as a resource as well. Adoption of it is important to think of the sport environment
self-compassion in sport is likely to be impacted when promoting, adopting, and sustaining self-
by several personal and environmental factors. compassion. Including coaches, psychologists,
Although the research on self-compassion in mental skills consultants, parents, and others in
sport has centered on athletes, it is not a stretch to supporting athletes to learn and be self-
suggest self-compassion would also be useful for compassionate is critical – as is their own adop-
others involved in sport. Coaches, sport parents, tion of self-compassion. It is in this way that the
mental performance coaches, and other members broader culture of sport can shift to a more self-
of an integrated support team/performance compassionate approach.
enhancement team, as well as those working in Full adoption of self-compassion requires
the administrative side of sport, could also benefit buy-in, learning, and integration into the sport
from self-compassion. Initial research provides participant’s unique training and competition
support for such an assertion. Hägglund et al. context, both at home and when away for training
(2022) found that high performance coaches who and competition. While likely to be initially
undertook their mindful self-reflection interven- effortful and conscious (and applied like a
tion reported behavior changes indicative of self- resource), the aim is for the approach to become
compassion, such as learning from mistakes and an automatic response. A self-compassionate
avoiding excessive rumination and harsh self- sport environment promotes constructive self-
criticism. Thus, Hägglund et al. (2022) suggest reflection as opposed to harsh self-criticism,
self-compassion may be useful in supporting views challenges as an instance for support and
coach well-being. Teaching coaches, mental per- growth, emulates a balanced perspective, and
formance coaches, sport parents, and other sport acknowledges each sport participant’s back-
personnel about self-compassion and strategies ground and their physical, mental, spiritual, emo-
to apply it could position them to support them- tional, social, and cultural needs. It also honors
selves, and the athletes with whom they work. the interrelatedness between performance in
Essentially, we should encourage a self- sport and well-being in sport.
compassion sport culture – one that promotes
self-compassion within oneself and others.
Successfully embedding self-compassion in Additional Areas for Future
the way those in sport train, compete, and Research
approach life in general requires examination of
the inherent sport culture of the team or training While the previous section has identified several
group. There is the potential for others to pro- future research directions in discussing the adop-
mote or hinder the development of self- tion of self-compassion in sport, there are some
compassion through modeling. Crozier et al. additional suggestions to be made. These sugges-
(2019) found that athletes who perceived their tions further accentuate the need for diverse and
teammates as being self-compassionate were representative samples and innovative research
more likely to exude self-compassion them- designs to better guide appropriate, tailored, and
selves. Parents, coaches, teammates, sport psy- relevant efforts to foster self-compassion in a
chology professionals, and teammates not only variety of sport participants across different sport
form a significant part of the sport environment contexts.
Much of the research on self-compassion in Conclusion

sport has focused on adolescents (e.g., Eke et al.,
2020; Mosewich et al., 2011; Pila et al., 2022) The collective work of researchers and self-
and young adults (e.g., Adam et al., 2021a; compassion practitioners has established self-
Ingstrup et al., 2017; Mosewich et al., 2019b). compassion as a useful resource in sport.
There is a need for more research on younger Researchers will continue to build this case, as
child and youth cohorts, as well as older adult well as further inform how to foster self-
and masters-level athletes. Mental performance compassion in sport. Self-compassion is associ-
consultants who work with masters-level athletes ated with adaptive cognitions, emotions,
have attested to their use of self-compassion with behaviors, and outcomes that stand to support
this population (Makepeace & Young, 2021). The both well-being and performance in sport. As we
mental performance consultants employed self- strive for high performance alongside positive
compassion strategies with their masters-level experiences and well-being, self-compassion can
athlete clients to help them listen to and accept support the resilience of those involved in sport
their bodies and how they function. As such, and motivate participation across the life span in
Makepeace and Young (2021) suggest self- various sporting roles. Self-compassion involves
compassion can help masters-level athletes both evading the negative (i.e., self-judgment,
accept and cope with age-related performance overidentification, isolation) and enhancing the
changes and limitations as they navigate their positive (i.e., self-kindness, common humanity,
unique sport experiences and other life pursuits. and mindfulness; Neff, 2003b). It involves self-
Future research needs to examine self-compassion soothing and support, as well as an active “fierce
across the sporting life span. self-compassion” to allow us to take care of our-
Most studies have adopted a cross-sectional selves and help us reach our potential (Neff,
design (e.g., Hilliard et al., 2019; Mosewich 2021). In sport, we must strive to manage our dif-
et al., 2021), and with the exception of some pro- ficulties and challenges and harness our strengths.
spective designs (e.g., Mosewich et al., 2019b) Self-compassion emulates such an approach.
and follow-up qualitative interviews (e.g., Eke
et al., 2020; Sutherland et al., 2014), most longi-
tudinal research involves some form of pretest/ References
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Caring for the Carer –
Self-Compassion in the Health 14
Professions
Alina Pavlova and Nathan S. Consedine
Introduction risks becoming an “optional extra”. Unfortunately,

while there is a burgeoning literature on the fac-
Caring for the mental and physical health of oth- tors impacting other-focused compassion as well
ers is among the most noble of human endeav- as increasing evidence regarding the importance
ours and is variously a job, a career, and a calling. of self-care among healthcare professionals,
As healthcare costs soar and resourcing become research on self-compassion in this area remains
tighter, however, healthcare is also a profession in its infancy. Prima facie, however, the attributes
in which stress and burnout become ordinary that define self-compassion – perspective-taking,
(Innstrand et al., 2011; Heinemann & Heinemann, self-kindness, and recognition of common
2017) and depression and anxiety are common humanity during failure or difficulties – seem
(Shanafelt et al., 2015; Mata et al., 2015). Burnout well-suited to the challenges that characterise
is more common in healthcare workers than in health work environments (Neff & Pommier,
other professions (Shanafelt et al., 2019), taking 2013).
a huge toll on the physical and mental wellbeing In this chapter, we briefly characterise the
of this critical workforce (Raab, 2014). The challenges facing healthcare professionals and
objective pressures of health workplaces are consider why cultivating self-compassion specif-
likely compounded by professional identities ically may be of benefit. We review existing
characterised by idealism and perfectionism empirical work linking self-compassion to out-
(Enns et al., 2001; Gaufberg et al., 2010). comes relevant to the healthcare professions,
Mistakes are routinely met with rumination, cata- then consider data regarding the efficacy and fea-
strophising, self-blame, and self-criticism (Bria sibility of self-compassion-based interventions in
et al., 2012; Duarte & Pinto-Gouveia, 2017) lead- healthcare groups. Finally, we reflect on what is
ing to issues in performance, absenteeism and known (and not known) about why self-
turn-over not to mention mental health and qual- compassion could work in the very particular
ity of life. context of healthcare, consider whether self-
In this light, sustainably caring for others as a compassion might be more or less beneficial for
part of professional responsibilities poses a very particular groups, and assess the specific out-
particular set of challenges; “caring for the self” comes that self-compassion interventions might
be most useful for. We also consider the intrigu-
A. Pavlova (*) · N. S. Consedine ing possibility of a link between self- and other-
Department of Psychological Medicine, University of focused care. Overall, we suggest that while
Auckland, Auckland, New Zealand conceptual and practical difficulties in defining

https://doi.org/10.1007/978-3-031-22348-8_14
232 A. Pavlova and N. S. Consedine
and applying self-compassion remain, the devel- to “make a difference,” as well as a profound pro-
opment of self-compassion has potential and may fessional idealism (Gaufberg et al., 2010). Self-
usefully be integrated in the daily life and train- selection and training contingencies favour the
ing of health professionals. selection and retention of perfectionistic high-
achievers (Enns et al., 2001) who, when con-
fronted with the realities and constraints of
Can Self-Compassion Solve modern healthcare environments, may struggle to
the Problems of Modern maintain a clear sense of purpose (Mader et al.,
Healthcare? 2014; Triffaux et al., 2019; Dyrbye et al., 2005).
Maladaptive coping styles are evident even
The Challenges of Modern Healthcare among early trainees. For example, while medi-
Environments cal students acknowledge not being able to ‘fix’
everyone, they report finding this difficult and
Continuous exposure to illness and suffering, avoid asking for help because of fears of appear-
long working hours, and increasing workloads ing incapable or weak (Tierney et al., 2018; Singh
put healthcare professionals at high risk for et al., 2018). Similarly, a constant need to “prove
stress-related problems (Innstrand et al., 2011; oneself” among junior doctors may increase their
Heinemann & Heinemann, 2017). Burnout, sec- risk for negative psychological and physical
ondary traumatic stress, depression, and anxiety health outcomes (Brewin & Firth-Cozens, 1997;
are now widely evident (Shanafelt et al., 2015; Neumann et al., 2011; Mahoney et al., 2016;
Mata et al., 2015); rates may be increasing Overland et al., 2019), especially when senior
(Shanafelt et al., 2019), especially under physicians – their role models and educators – do
COVID- 19 (Alrawashdeh et al., 2021). Meta- not exemplify healthy self-care themselves
analyses of global prevalence studies show burn- (Dyrbye et al., 2005; Satele et al., 2014). High
out symptoms in more than one-tenth of nurses workloads and low service resources may com-
(Woo et al., 2020) and one-fifth of physicians pound the effects of dysfunctional coping (Mills
(Zhou et al., 2020), and up to one-third of resi- & Chapman, 2016; Dobkin, 2011; Neff, 2011;
dents, especially those in surgical/urgency (SU) Neff & Seppälä, 2016; Bria et al., 2012; Duarte &
specialties (Rodrigues et al., 2018). Anxiety and Pinto-Gouveia, 2017). In terms of stress-related
depression are similarly high (Alharthy et al., issues then, modern healthcare is a near-perfect
2017), as is secondary traumatic stress, espe- storm.
cially in emergency and oncology staff This problematic dynamic has strong institu-
(Dominguez-Gomez & Rutledge, 2009; Quinal tional and training origins. While compassion for
et al., 2009; Roden-Foreman et al., 2017). others is a moral and professional expectation,
Burnout negatively impacts personal lives, job self-care is only beginning to become a focus in
satisfaction, and health, as well as being linked to medical curricula. Healthcare professionals oper-
other issues such as substance abuse and suicide ate in biomedically-focused competitive environ-
(Raab, 2014; Beyond Blue, 2013). For healthcare ments (Jacobs et al., 2013; De Zulueta, 2015),
systems, burnout and declines in well-being can where idealistic and perfectionistic tendencies
increase error rates, compromise decision- are implicitly or explicitly valued (Haider et al.,
making, and reduce prosocial responding, result- 2020), resulting in avoiding (disclosing) shame
ing in poorer patient care (Raab, 2014). (Lindström et al., 2011). Compassion literacy is
Such contextual issues may well be com- not a priority (Tierney et al., 2018; Burridge
pounded by the personality and coping patterns et al., 2017) and is poorly trained (Mills &
that seem to typify healthcare professionals. Chapman, 2016; Mills et al., 2017, 2015), while
Medical trainees are characterised by the desire prioritising self-care may be seen as selfish (Mills
14 Caring for the Carer – Self-Compassion in the Health Professions 233
• Austerity and understaffing

• Bureaucracy
Organisational • Hierarchical organisational structure
• Biomedical focus/cure culture
Greater healthcare
system cost
• Excessive workloads
• Difficult patient interactions
Interpersonal • Interaction with suffering

• Competitive colleagues
Compromised
patient care
• Demanding superiors
• High achiever personality

• Fear of self-compassion Compromised
Intrapersonal • Maladaptive coping
• Personal characteristics (age, gender,
HCP wellbeing
(burnout)
culture)
Fig. 14.1 – Challenges of modern healthcare
et al., 2015). Thus, healthcare workers often end hy Might Self-Compassion Benefit
W
up at a crossroads where psychologically chal- Healthcare Professionals?
lenging environments, high professional Theoretical Underpinnings
demands, and high achievement cultures are lay-
ered with poor training and suboptimal coping There are good reasons to expect that self-
(see Fig. 14.1). The sustainability of patient care compassion might have benefits for healthcare
and retention of staff are almost certainly affected professionals. For one, the fear of failures in
by this scenario. medicine – some of which can be minor and inev-
itable (i.e., adverse events, communication chal-
lenges, inability to solve all problems) and some
Can Self-Compassion Be a Solution? of which can be fatal – is constant and unavoid-
able. The stress from continuous threat and the
Given this catastrophic characterisation of mod- related negative emotions are said to compromise
ern healthcare, there are still a significant number problem-solving and decision making (Gray,
of healthcare professionals that do not meet crite- 1999), while healthcare professionals’ tendency
ria for burnout and who are also more likely to to self-blame, other-blame, catastrophise, and
flourish (Vetter et al., 2018). The question, of ruminate puts them at risk of negative outcomes
course, is how? What is it about these individuals (Bria et al., 2012; Duarte & Pinto- Gouveia,
that allows them to manage professional demands 2017), further compromising their ability to func-
such that they sustain their commitment and tion under stress and making errors more proba-
care? In this chapter, we consider the possibility ble (Prins et al., 2009; Linden et al., 2005).
that self-compassion might have a role in facili- As a way of relating to the self, self-
tating adaptation to the very real demands of compassion is the antithesis of this manner of
working in healthcare. Below, we (1) offer a the- working. Broadly defined as the ability or ten-
oretical rationale as to why self-compassion dency to respond to one’s own difficulties with
might facilitate adaptation to the challenges con- kindness, self-compassion is thought to allow
fronting healthcare professionals and, (2) review people to remain present with threatening feel-
the empirical literature linking self-compassion ings without self-judgment or criticism, reduce
to outcomes in these groups. overidentification, and decrease feelings of isola-
tion (Neff et al., 2018). Relating to challenges in latter mediating the relationships between low
this way may reduce the need to use finite psy- self-compassion and stress. Self-compassion also
chological resources to protect the self from weakens the negative relationships between poor
threats, such as those that healthcare profession- sleep and mental health problems (Kotera &
als may encounter in their professional environ- Sheffield, 2020), stress and burnout (Abdollahi
ments. Put simply, the challenges of this et al., 2021), exhaustion and burnout (Schabram
professional path seem well-suited to the particu- & Heng, 2021), and burnout and depression
lar benefits self-compassion may bring. (McCade et al., 2021) in nurses and allied health
As a slight digression (but importantly in samples. Moreover, self-compassion weakens the
terms of the specific challenges and obligations relationships between burnout and lower quality
in healthcare), there is also the suggestion that of care (Dyrbye et al., 2005; Satele et al., 2014) in
other-related compassion can be enhanced and medical students and early career physicians, and
sustained among those who can first relate com- reduces the extent to which difficult patient
passionately to themselves (Neff, 2003; Barnard encounters, stress, and clinical complexity inter-
& Curry, 2011; Hofmann et al., 2011; Neff & fere with care (Dev et al., 2020), suggesting that
Pommier, 2013). Contemplative and spiritual it may be protective for patients as well as
practices, along with self-care, are increasingly professionals.
seen as facilitative of compassion towards others Additionally, self-compassion in healthcare
(Maslach & Leiter, 2005; Singh et al., 2018). professionals can be potentially an enhancing trait
Because self-compassion may help us recognise predicting greater happiness (Benzo et al., 2017),
the universality of human suffering, imperfec- resilience (Kemper et al., 2015, 2019, 2020), self-
tions, and (fear of making) mistakes (Neff & care (Mills et al., 2018; Miller et al., 2019), and
Pommier, 2013), it may encourage humbleness, confidence in providing compassionate care
reduced self-judgment and a reduced tendency to (Kemper et al., 2019, 2020). Further, qualitative
blame others for their suffering (Gilbert & work suggests that self-compassion could facilitate
Procter, 2006). Thus, in addition to contributing other-focused care by facilitating the management
to self-care, self-compassion has the potential to of the challenges, including working with suffering
contribute to more person-centred care by in an environment of austerity while unable help
enabling healthcare workers to treat their patients everyone (Patsiopoulos & Buchanan, 2011;
as “people like me”. Wiklund Gustin & Wagner, 2013; McPherson
et al., 2016). Testament to how complex these rela-
tionships may be, however, at least one study has
Empirical Studies of Self- found that self-compassion was weakly (but sig-
Compassion in Healthcare nificantly) associated with lower other-focused
compassion (Mills et al., 2018).
Observational Studies Importantly, in terms of the ability of research
to inform healthcare policy, while there are cross-
Empirically, the small body of available data are sectional works with more robust analyses meth-
consistent with the notion that self-compassion ods (above) and a longitudinal evidence base is
may be beneficial to healthcare workers. emerging (Kemper et al., 2019, 2020; Schabram
Healthcare professionals that report greater self- & Heng, 2021), the large part of available work
compassion also report lower stress (Finlay- remains near-exclusively correlational in design.
Jones et al., 2015; Kemper et al., 2015, 2019, The correlational studies point at associations
2020), lower burnout (Abdollahi et al., 2021; Dev between self-compassion and fewer mental
et al., 2020; Kemper et al., 2020; Schabram & health problems (r = −0.68) (Kotera & Sheffield,
Heng, 2021); a study of psychologists found that 2020), and less secondary traumatic stress
self-compassion predicted fewer emotion regula- (r = −62) (Delaney, 2018), fears of compassion
tion difficulties (Finlay-Jones et al., 2015), the (r = −0.56) (Scarlet et al., 2017), depression
(r = −0.40) (McCade et al., 2021), and shame emotional regulation, and happiness, and reduc-
(Kotera & Sheffield, 2020), as well as with tions in depression, anxiety, and stress (Cohen’s d
greater mindfulness (r = 0.62), resilience CI 95% [0.5–0.7]). However, attrition was high
(r = 0.37) (Olson et al., 2015), engagement (46%) and non-completers were more stressed
(0.24<r<0.33) (Babenko & Guo, 2019; Babenko than completers. Another study tested the effects
et al., 2019), autonomy (r = 0.24), competence of an 8-week Mindful Self-compassion (MSC)
(r = 0.24), relatedness (r = 0.30), and achieve- programme – a face-to-face programme that
ment (vs. avoidance) goals (r = −0.31) (Babenko combines the skills in mindfulness and self-
& Oswald, 2019). However, these correlational compassion to build emotional resilience – in 13
studies do not shed light on the causal direction female nurses (Delaney, 2018). Although con-
of the relationships between self-compassion and ventional significance was not reported and attri-
these outcomes; these effects may therefore be in tion was 28%, analyses suggested the programme
the other direction (e.g., those with lower depres- increased self-compassion and mindfulness,
sion may find it easier to be compassionate reduced secondary traumatic stress and burnout,
towards themselves), bidirectional, or compli- and contributed to resilience and compassion sat-
cated by additional variables (Dodson & Heng, isfaction (d>0.82). In a more robust design, albeit
2021). Hence, randomized controlled trial (RCT) one nonetheless relying on self-reported out-
data in healthcare samples that could help us to comes, Eriksson et al. (2018) conducted an RCT
understand causality are urgently needed. for a shorter face-to-face 6-week programme,
contrasting a “mindfulness and compassion with
self and others” training against waitlist control
Self-Compassion Interventions in a sample of 101 psychologists (97% female,
80.2% retention). Mixed linear models showed
While most of the literature related to self- clear time by group effects, with greater improve-
compassion in healthcare professionals remains ments in self-compassion scores (d=0.94), mind-
observational, interventional studies are starting fulness (d=0.60), and greater reductions in
to emerge. Yet, as is common in early literatures, self-coldness (d=0.73), perceived stress (d=0.59)
the studies that are available are small and involve and burnout (d=0.44) in the experimental group.
weaker designs, while studies directly testing a Subsequently, the 6-week Self-Compassion
possible effect on patient care (see examples of for Healthcare Communities (SCHC) programme
similar research - (Burns et al., 2003; Halbesleben has been developed (Neff et al., 2020). This
& Rathert, 2008)) are completely absent at this framework incorporates “compassion with equa-
point. Yet, even with these limitations in mind, it nimity” practices designed to help carers release
is worth noting that clinicians see the potential feelings of control over outcomes when trying to
merits in self-compassion (Neff et al., 2020; alleviate suffering. Early data are promising.
Tierney et al., 2018), that self-compassion inter- Pre-/post-intervention results in a mixed sample
ventions are well-received by practitioners of physicians, nurses, and other health profes-
(Maslach & Leiter, 2005; Neff et al., 2020; Singh sionals (n = 58, 86% female), showed improve-
et al., 2018; Tierney et al., 2018), and that self- ments in self-compassion, mindfulness,
compassion can be taught (Scarlet et al., 2017). compassion, and reductions in depression and
Below we describe six interventional studies con- stress in the first intervention group (n = 25), and,
ducted to date. additionally, burnout, secondary traumatic stress,
A first study that piloted a self-compassion exhaustion, and feelings of accomplishment in an
intervention among postgraduate psychology additional intervention group (n = 23) with
trainees (n = 20, 89% female) used a pre-post medium-to-large effect sizes (d CI 95%
design based on a 6-week online self-compassion [0.52-0.80]).
intervention (Finlay-Jones et al., 2017). Analyses More recently, a pre-/post- design evaluated
indicated improvements in self-compassion, the results of both 8-week MSC (n = 10) and
6-weeks SCHC programmes in a sample (n = 20) and rely heavily on self-report. Small, self-
of certified nurse assistants working in nursing selected samples increase the odds of Type 1
homes (97% female) (Bluth et al., 2021). While error obscuring clear estimates of interventional
the interventions did not differ from one another, effectiveness (Landers & Behrend, 2015), par-
pooled analyses showed improvements in self- ticularly when changes are well within one stan-
compassion post intervention as well as at 3- and dard deviation from the baseline. If studies are to
6-month follow ups, and reduction in stress and impact policy and interventions of this kind are to
depression scores post intervention and at get traction in healthcare workplaces, more
3-months follow up. Interestingly, there was also robust evidence is needed, as is a focus on the
evidence for a “maturational” type effect in sorts of outcomes that healthcare administrators
which “recognition of personhood” was greater are concerned about.
at 6-months but not at earlier measurement These caveats noted, early data are nonethe-
points. There were no effects on job satisfaction, less broadly consistent with theoretical sugges-
likelihood of leaving one’s job in a year time, or tions and evidence from other populations, and
burnout (except for a decrease in depersonalisa- offer greater confidence in the directionality
tion post intervention that was not maintained). A implied in cross-sectional work; self-compassion-
follow up qualitative study with the participants based interventions appear to be of benefit in
revealed that self-compassion training was feasi- groups of healthcare workers. Studies are gener-
ble and beneficial for the stressors experienced ally acceptable and pose limited risks. Across
by certified nurse assistants (Lathren et al., 2021). studies, evidence suggests improvements in self-
Finally, the most recent study evaluated SCHC compassion, mindfulness, stress, and burnout,
as a one-day face-to-face intervention in paediat- with other effects in mental health (i.e., anxiety,
ric nurses (n = 22, 95% females, 86% White) depression, secondary traumatic stress), wellbe-
with 100% completion rate (Franco & Christie, ing (i.e., personal accomplishment, happiness),
2021). As in other studies, analyses indicated and in other focused care (i.e., compassion, com-
positive changes in self-compassion, mindful- passion satisfaction, recognition of personhood)
ness, and compassion satisfaction, and decreases that are more mixed and evident in fewer studies.
in burnout, anxiety, and stress that were main- While mechanisms remain unknown, that these
tained at 3-month follow up; additionally, interventions increase self-compassion among
increases in compassion and resilience were healthcare professionals is increasingly clear, as
reported at the 3-month follow-up. Other analy- is the likelihood that other outcomes are also pos-
ses contrasted this group with a non-randomised itively influenced.
waitlist control (n = 26). Time by group interac-
tions were evident for self-compassion, mindful-
ness, compassion to others, compassion Commentary and Key Issues
satisfaction, resiliency, burnout, and stress, with
moderate to high effect sizes (Cohen’s d CI 95% In addition to continuing to improve design
[0.59–0.87]). No interactions were evidenced for robustness and outcomes measurement, there are
anxiety, depression, secondary traumatic stress, several questions regarding self-compassion in
resiliency-activation, or job engagement. healthcare that remain unclear. Below, we outline
Methodologically, while designs are improv- the queries we feel will be of particular benefit. In
ing over time (and with the notable exception of developing this agenda, this summative section
Eriksson et al., 2018), caution is needed in inter- will first question and theorise why we should
preting these data. To date, most self-compassion focus on self-compassion specifically (rather
intervention studies lack active controls, employ than focus on other constructs such as mindful-
non-randomized designs, only sporadically ness, compassion, or self-care). Second, bearing
employ appropriate control over confounds, are in mind that healthcare workers are a profession-
limited by issues in retention and self-selection, ally diverse group, we offer some commentary
regarding the subgroups for whom self- unclear whether self-compassion specifically is
compassion might be of greatest benefit. Three, where we should target our efforts. For example,
we consider the outcomes of greatest relevance to self-compassion and mindfulness share many
healthcare professionals (and healthcare environ- conceptual and operational features (Duarte
ments) for which self-compassion is most likely et al., 2016; Duarte & Pinto-Gouveia, 2017;
to be of benefit, given the proposed mechanisms. Sinclair et al., 2017), with both traits implying
Finally, we look at evidence regarding one of the the capacity to keep perspective when experienc-
most poorly understood and contentious areas of ing difficulties and the replacement of reactivity
compassion research in healthcare, the question with acceptance. Similarly, self-compassion and
of whether or not the development of self- other-focused compassion converge in recognis-
compassion is able to positively influence other- ing common humanity in relation to suffering
related compassion. (Neff, 2003; Ling et al., 2021). Experimentally,
prosocial behavior has shown to result in greater
Why Target Self-Compassion (Rather than increases in psychological flourishing than does
Something Else) in Healthcare? One initial kindness related to self (Nelson et al., 2016).
question that arises when considering the possi- Likewise, self- and other-compassion have both
ble role (or benefits) of self-compassion for shown to alleviate burnout, albeit in a different
healthcare professionals regards the focus on ways (Schabram & Heng, 2021).
self-compassion itself. Although it may seem In addition to similarities within the theoreti-
counterintuitive in the context of such a volume, cal constructs, mindfulness and compassion-
we start this discussion by considering the key based interventions seem to arrive at similar
question of why we should focus efforts to results (Kılıç et al., 2020; Kirby et al., 2017;
improve functioning in this key workforce via Ferrari et al., 2019; Wasson et al., 2020;
self-compassion rather than some other outcome. Conversano et al., 2020). In healthcare profes-
In addition to ongoing debates regarding con- sionals, a study by Sansó et al. (2019) evaluated
struct validity and measurement (Muris, 2016; mindfulness-based stress reduction (MBSR) and
Muris & Otgaar, 2020; Neff, 2020, Sinclair et al., compassion cultivation training (CCT) interven-
2017), empirically separating self-compassion tions among 50 Spanish primary care physicians;
from other useful, analytically solid constructs, both programmes increased self-compassion and
notably compassion, mindfulness and self-care is professional quality of life (reduced compassion
challenging and whether self-compassion is fatigue, increased compassion satisfaction, and
inherently positive is also unclear (Dodson & lowered burnout). An interventional CCT study
Heng, 2021). Further, there are fears that self- by Scarlet et al. (2017) among 62 healthcare
compassion might promote selfishness or the workers showed improvements in both mindful-
normalisation of undesirable behaviours (Morton ness and self-compassion as well as reduced fears
& Postmes, 2011; Haslam & Bain, 2007), of self-compassion and giving compassion to
although no empirical studies have yet linked others. In a study by Orosa-Duarte et al. (2021)
self-compassion to these negative outcomes. among medical students (n = 84), both a
mindfulness-based mobile app intervention and
In considering these complex issues some- an in-person mindfulness-based program (IMBP)
what further, it is worth recalling that self- increased self-compassion and mindfulness as
compassion, compassion, mindfulness, and compared to waitlist controls. Comparable effects
self-care often exhibit similar relationships with for diverse interventions highlight the fact that
outcomes (e.g., burnout, depression, empathy) interventions purported to increase self-
(Fernando et al., 2017; Barbosa et al., 2013; compassion have such a broad effect on general
Schneider et al., 2014). Compounded by lack of affective functioning that specificity of effects is
head-to-head trials and limited insight into what obscured; mediation analyses are urgently needed
works best for whom, such a pattern makes it to understand specific effects of self-compassion
as compared to other constructs (Sinclair et al., encourage self-care as self-compassionate action

2017; Kotera & Van Gordon, 2021). (Dodson & Heng, 2021; Gilbert et al., 2017; Gu
Another related dilemma in seeking to under- et al., 2020; Schabram & Heng, 2021), self-com-
standing self-compassion’s effect relates to the passion is a deeper internal practice. Self-care
self-compassion scale itself. Most commonly typically revolves around behaviours and prac-
thought to comprise six dimensions (self- tices that occur outside of the work situation
kindness, common humanity, mindfulness, self- (e.g., exercise, healthy diet, or socializing)
judgement, isolation, and over-identification), (Kravits et al., 2010; Cook-Cottone, 2015;
this complexity makes it difficult to tell which Hernandez, 2009), is often prescriptive, and is an
elements of self-compassion are impacting which additional activity – potentially yet another extra
outcomes. To give an example, a study by Duarte thing on one’s to-do list. Conversely, self-com-
et al. (2016) showed that while lower self- passion can be practiced “in the moment” (K. D.
judgement, isolation, and higher mindfulness all Neff et al., 2020), does not require a commit-
predicted lower burnout, only lower self- ment, and arises from how one relates to oneself,
judgement predicted lower compassion fatigue which is ultimately soothing and supportive.
and only higher mindfulness predicted compas- Moreover, self-compassion entails full presence,
sion satisfaction. Other studies are similarly chal- while self-care does not. Thus, while healthcare
lenging to interpret. For instance, Montero-Marin professionals who engage in self-care may be
et al. (2016) showed that only dimensions of the better able to “tune-out” and be generally less
non-compassionate self predicted burnout, while prone to stress (and may thus be better resourced),
Gracia-Gracia & Oliván-Blázquez (2017) showed self-compassion costs no time and can help to
that the burnout subscales of emotional exhaus- “tune-in”, being deployed at the time of the emo-
tion and depersonalization were affected by self- tionally difficult situations that are so frequent.
kindness/self-judgement and common humanity/ Finally, self-compassion might have a special
isolation dimensions only. Although it has been role in helping to mitigate the effects of compul-
argued that the different components of self- sive caregiving (Hermanto & Zuroff, 2016),
compassion work together synergistically (Neff, “omnipotent saviour” dynamics (Breithaupt,
2022), the question remains whether self- 2019), and pathological altruism (Oakley et al.,
compassion as an undivided phenomenon is as 2011). In some views, individuals have indepen-
effective as its separate parts. dent care-seeking and care-giving tendencies
Difficulties related to the self-compassion (Gilbert, 1989, 2000). While this might mean that
construct noted, the clinical effectiveness of self- self-compassion might not directly predict com-
compassion training seems clear (Neff, 2020). As passion towards others, a “balance” between
such, healthcare professionals who are often self- these systems often appears lacking in the health-
critical, prone to taking unwarranted responsibil- care professions and workers are routinely more
ity and, being the caregivers, may neglect taking compassionate towards others than they are
care of themselves (Beydoun et al., 2019), should towards themselves (López et al., 2018).
find self-compassion beneficial regardless of Empirically, while the marginalisation of one’s
exactly how it is conceptualised or measured. own needs or interests can serve as a means of
Moreover, we posit that self-compassion may be obtaining a sense of control or gaining rewards
uniquely suited to the challenges and personali- (Hermanto & Zuroff, 2016), it has been associ-
ties in healthcare and contribute to worker well- ated with emotional and interpersonal difficulties
being beyond general self-care. Although (Gerber et al., 2015; Hermanto & Zuroff, 2016)
self-care is often prominent among recommended and may contribute to caring in ways that are not
burnout prevention strategies for healthcare pro- necessarily beneficial for the other (Oakley et al.,
fessionals (Kravits et al., 2010; Skovholt & 2011). Combined with the possibility that
Trotter-Mathison, 2014) and self-compassion self-compassion can be stigmatised in the help-
may predict self-care (Mills et al., 2018, 2019) or ing professions (Mills et al., 2015), self-care may
thus be compromised (Hermanto & Zuroff, sionals for whom self-compassion may be of
2016). On the other hand, enhancing self- benefit. There are three reasons to suspect such
compassionate traits may facilitate both physi- variation may be uncovered. First, levels of self-
cian wellbeing, and a more balanced and compassion vary both within (Mills et al., 2018)
sustainable patient-focused practice. and between healthcare occupations (Dev et al.,
However, we should also be mindful of how 2020). Such data, coupled with evidence that
little we know about how self-compassion oper- self-compassion may moderate the associations
ates in contexts where other-focused care is a key between predictors and outcomes ( Dev et al.,
professional responsibility. Because self-2018, 2020; K. D. Neff et al., 2020), creates a
compassion does not specifically call for selfless- prima facie case for the suggestion that self-
ness (MacBeth & Gumley, 2012; Sinclair et al., compassion may have different effects in differ-
2016, 2017), concerns that self-compassion ent groups. Second, work in non-healthcare
might “bleed” into professional styles that justify samples suggests that the links between self-
self-centredness or professional negligence have compassion and outcomes vary as a function of
been expressed. In some views, seeing one’s gender, age, and personality (Baker & McNulty,
flaws as ‘only human’ has the potential to be used 2011; Kelly et al., 2010). Finally, and most
as a justificatory tool to mitigate individual broadly, the specific challenges, systems, train-
responsibility (Haslam & Bain, 2007; Morton & ing, and personalities that predominate in differ-
Postmes, 2011; Zessin et al., 2015). Empirically, ent healthcare specialties create fertile grounds to
the evidence for such a “risk” remains weak expect that the effects of self-compassion might
(Mills et al., 2018) and positive changes in self- vary across professional groups (Mills et al.,
compassion resulting from interventions do not 2018; Gleichgerrcht & Decety, 2013; Dev et al.,
seem to lower one’s ability to care. More broadly, 2019; Fernando & Consedine, 2017; Claxton-
this way of thinking about self-compassion is Oldfield & Banzen, 2010).
inconsistent with the way in which the construct
is generally discussed. In most views, the empha- To exemplify how such personal and contex-
sis in self-compassion training rests on seeing the tual influences may affect how self-compassion
commonalities between our own experiences and relates to outcomes in the healthcare workforce,
those of others (i.e., of not seeing the self or one’s let us first consider the potential relevance of gen-
suffering as unique). It is this tendency that leads der. As was noted above, a large proportion of the
to accepting suffering with kindness and reduc- participants in studies of self-compassion in
tion in self-criticism (Neff & Seppälä, 2016). In healthcare workforces are female, presumably
the healthcare professions, many of which are partly as a result of gender imbalances in the
highly prestigious, staffed by high achievers, and workforce (e.g., nursing, allied health) (Murphy,
in which the risk of failure is high, finding humil- 2019; Snyder & Green, 2008). However, males
ity by accepting one’s own flaws, taking respon- generally report greater self-compassion (Yarnell
sibility for one’s mistakes rather than avoiding et al., 2015). Future research might thus profit-
them or trying to cover them up may help to ably consider whether self-compassion interven-
maintain self-worth and offset some of the risks tions are comparably effective in occupations
posed by styles of functioning that continuously that are predominantly female (or male).
call for perfection. Thus, although some issues Similarly, greater age (Zessin et al., 2015) and
remain, self-compassion may offer a unique set levels of previous exposure to crisis (Tierney
of benefits for health professionals in helping to et al., 2018) tend to predict greater self-
address challenges particular to this workforce. compassion, possibly explaining Dev et al.’s
(2020) finding that medical students have lower
Who is Self-Compassion Good For? A second self-compassion than already established physi-
key question in this area involves systematically cians and nurses. Such a pattern might imply that
identifying the subgroups of healthcare profes- self-compassion interventions may be more
effective in younger groups, possibly because showed that higher self-esteem weakens the cor-
there is more “room to move” for self-compassion relation between self-compassion and well-being
development, because the personality system is (Zessin et al., 2015). Other studies show that
more flexible, or, hypothetically, because resis- health professionals with high trait self-criticism
tance to self-compassion less well-developed. or control/agency perceptions may see self-
More broadly, investigating the possibility compassion as more selfish (Robinson et al.,
that persons who are lower in self-compassion 2016) or see it as stigmatising (Mills et al., 2015).
might derive greater benefit from the develop- Thus, while it is typically of benefit, there is also
ment of this way of relating to the self seems grounds for caution. Well-accepted interventions
likely to pay dividends in healthcare groups such as mindfulness have shown negative effects
known to vary (and lack) in self-compassion. For in some groups (Reynolds et al., 2017) and con-
example, Neff et al. (2020) found that people sidering the possibility that self-compassion
who had lower self-compassion at baseline saw interventions may have different effects (includ-
larger increases in self-compassion (and possibly ing both null or “negative” effects) in some sam-
associated benefits) than people who were ples is important.
already highly self-compassionate. Equally, anal-
yses from a sample of 799 nurses showed that Contextual Factors that Facilitate or Hinder
while self-compassion predicted fewer barriers to the Development and Practice of Self-
care (Dev et al., 2018), the link between burnout Compassion Comparably, just as with personal
and burnout-related barriers to care was stronger factors, contextual factors could also be influen-
among those with greater self-compassion. tial in moderating the effects of self-compassion
Similarly, while self-compassion predicted better within the healthcare domain. Professions, insti-
outcomes in a sample of 1700 healthcare profes- tutions, and even individual wards have their own
sionals and trainees (Dev et al., 2020), the link particularities, training requirements, and unspo-
between stress and burnout was stronger in more ken rules (Boyle, 2011; Daiski, 2004; Reyes,
self-compassionate nurses (but not doctors or 2012; Mills et al., 2015; Robinson et al., 2016)
medical students). While numerous explanatory that structure and reinforce ways of professional
possibilities exist, including a tradition of other- conduct and intrapersonal functioning. Contexts
focused care in nursing (Boyle, 2011), lower exert a huge, albeit poorly understood influence
power (Daiski, 2004), or dynamics in which trait on compassion in healthcare (Fernando et al.,
self-compassion changes how burnout is reported 2016) and there is reason to suspect that organ-
(Dev et al., 2018), findings of this kind suggest isational and professional norms may also influ-
self-compassion may not be comparably benefi- ence whether self-compassion training is of
cial for all groups; other factors (e.g., self- benefit and whether any benefits can be sustained.
compassion at baseline, gender, professional Different healthcare professions and organisa-
cultures) might moderate self-compassion’s tions are quite distinct, varying in the extent to
effects. which self-reflection and self-care are normed
Such analyses are, however, uncommon thus and encouraged, how heavy workloads are man-
far. Yet, moderation analyses are useful both in aged and viewed, how organisational hierarchies
terms of (a) identifying groups that may differen- and team communication dynamics operate.
tially benefit and/or (b) identifying groups in Such factors clearly have the capacity to interfere
whom other associations are differentially altered with self-compassion and its cultivation (Dodson
(e.g., Dev et al., 2020). For example, it may be & Heng, 2021; Egan et al., 2019).
that factors such as self-esteem, self-criticism,
perceptions of agency, and self-stigma – all of Research on compassion in healthcare makes
which relate to professional status – are relevant. it clear that organisational values regarding effi-
Studies in other samples are consistent with these ciency and commerce (over compassion and
possibilities. For example, a meta-analysis humanity) are thought to interfere with patient
care (Pavlova et al., 2021). Ideally, co-operative Although almost nothing is known empiri-
and caring colleagues and superiors serve as the cally, it seems reasonable to suspect that employ-
positive role models, improving other-focused ers and line managers may fear that
care (Dyrbye et al., 2005; Pavlova et al., 2021). self-compassion interventions have negative
Although evidence is absent, it seems likely that effects on productivity. According to Dodson and
both explicit and implicit organisational values Heng (2021) traditional organisational perspec-
regarding the place of compassion in health will tive sees an ideal employee as exclusively dedi-
“echo” through the values regarding self-care and cated to their work (Dumas & Sanchez-Burks,
self-compassion. 2015), effectively ignoring individual needs
Professional healthcare staff do not operate in (Liedtka, 1989). Alternate approaches such as the
cultural vacuums and, even supposing a health- human sustainability perspective (Spreitzer et al.,
care practitioner could soothe their own inner 2012) are available. This view might suggest that
critic following a mistake, error, or failure, exter- incentivising self-compassion in employees
nal criticism might override or undermine any might contribute to a more sustainable work-
benefits. Killian (2008) has previously suggested force, although whether self-compassion is seen
that self-compassion was more likely to be as capable of improving work performance-
engaged when clinicians were surrounded by related outcomes remains unclear (Dodson &
compassionate co-workers and supervisors who Heng, 2021). What is clear is that empirical evi-
were willing to offer emotional support and dence regarding the effects of self-compassion on
advice. Conversely, in organisational cultures the sorts of outcomes that organisations value
manifesting limited compassion towards others (e.g., absenteeism, turnover) is sorely needed
(e.g., patients, colleagues) or where organisations here.
are experienced as machines that “treat individu- Perhaps most importantly, it must be noted
als as automated cogs carrying out rigidly pre- that the deployment of interventions and the
scribed activities” (de Zulueta, 2016, p. 6), both development of self-compassion in a professional
workers and patients risk being dehumanised. workforce is inherently a systemic challenge
Operating in environments characterised by belit- (Sinclair et al., 2021). Attempting to change indi-
tling, blame, or abuse almost certainly under- vidual behaviour and process in the face of
mines self-compassion, as will environments in obstructive systemic dynamics is unlikely to be
which self-compassion is seen as weak, lazy, or effective and multi-level research is clearly
self-indulgent (Gilbert & Procter, 2006; Miron needed. Considering that self- and other focused
et al., 2014; Robinson et al., 2016). compassion share the value of common human-
An emphasis on the likely importance of ity, it is possible that intervening at both organ-
organisational characteristics is consistent with isational and personal level could provide greater
the conclusions of a recent realist review by benefits. Ultimately, however, the question of
Sinclair et al. (2021) suggesting that other- whether self-compassion is of equal benefit to
focused compassion training is more likely to be healthcare professionals as a function of gender,
successful when it is reflected in the infrastruc- specialty, and professional environments remains
ture and values of organisations. The review sug- an empirical one.
gests that organisational contexts can either
hinder or facilitate compassion training and our To Which Outcomes is Self-compassion
sense is that similar perils and promise will con- Primarily Relevant? Related to the issue of
front self-compassion in healthcare. Put simply, which groups of healthcare professionals and
it seems likely that self-compassion training will healthcare contexts are likely to see the greatest
be more successful where self-compassion is benefits from self-compassion are questions
reflected throughout organisations’ broader regarding which outcomes are most likely to be
vision. affected. To date, the outcomes being assessed in
healthcare samples are similar to those studied in Lamothe et al., 2016; López et al., 2018; Raab,
other samples (e.g., anxiety and depression, 2014; Sinclair et al., 2017; Lim & DeSteno,
burnout, and well-being). Objectively, however, 2019) and mindfulness-based interventions with
if we are to suggest that self-compassion is the self-compassion components tend to improve
“right tool for the job,” evidence showing that it prosocial behaviours (Bazarko et al., 2013) and
impacts the specific outcomes that are strategi- promote compassion or motivation to help in
cally important to patients, workers, and health- healthcare (Barbosa et al., 2013; Fernando et al.,
care management are clearly needed. 2017; Schneider et al., 2014). To this point then,
the evidence for a conceptually important link
One possibility proposed in recent research between self- and other-focused compassion is
among healthcare workers is that self-compassion tentatively favourable, but as yet, poorly
will likely be of greater benefit regarding out- understood.
comes impacted by the more internal elements of Equally, it is important when discussing out-
the stress response process. Having found that comes in relation to the place of self-compassion
self-compassion was linked to lower burnout and in healthcare that we do not neglect to consider
patient/family barriers to care (but not clinical or the fact that self-compassionate behaviour occurs
environmental barriers exemplified by clinical within systems; patient, practitioner, and system
complexity, interruptions, hectic environments, outcomes are all simultaneously important. One
bureaucracy), Dev et al. (2018) suggested that intriguing possibility, for example, is that self-
“the capacity to be kind to the self is perhaps compassion enhances patient care indirectly
more relevant to barriers reflecting one’s own through a process in which adaptive ways of
conduct rather than factors in the workplace that responding to the self are modelled by carers.
are outside of the individual’s control” (p.86). Prior work suggests that patients’ perceptions of
Although this report is concentrated on the barri- physician well-being and demeanour influences
ers to other-focused care, the possibility that self- how advice is received (Fraser et al., 2013).
compassion might be less relevant in mitigating Similarly, because senior physicians’ ways of
the impact of external factors is worth further coping with stress are likely transmitted to future
investigation. cohorts of professionals via role modelling, the
More broadly, the question of a possible asso- development of self-compassion may have “spill
ciation between self- and other-related compas- over” effects in subsequent generations (Dyrbye
sion remains unclear. Neff and Pommier (2013) et al., 2005; Satele et al., 2014). Other studies
found a weak correlation between self- and show that individual self-compassionate practice
empathic concern in community (r = 0.15) and improves collegiality within organisations, with
practicing meditators samples (r = 0.28), but no conflicts appearing less frequently and compro-
correlation in students (r = 0.01). López et al. mises more common (Yarnell & Neff, 2013), as
(2018) and Oslon and Kemper (2015) also found well as resulting in lower odds of emotional
no correlation among community and residents’ exhaustion after negative interactions (Anjum
samples (0.10<r<0.17), while the study by Mills et al., 2020). Hence, unless its actively frowned
et al. (2018) showed a weak negative correlation upon (Dodson & Heng, 2021), self-compassion
(r = −0.12) in a sample of healthcare profession- can contribute to outcomes indirectly by improv-
als. Thus, while self- and other-related compas- ing self-management and, as a consequence,
sion stem from the same evolved caregiving organisational working environments. More
systems (Gilbert, 2000), they do not seem to be broadly, it seems clear that “compassion in health
closely related at a cross-sectional level. For is a systemic problem that requires systemic
healthcare employers, the possibility of a nega- solutions” (Dev et al., 2019, p. 2), and we must be
tive link between self- and other-related compas- equally systemic in our thinking about the out-
sion would likely be concerning. However, comes self-compassion may impact in this
self-compassion (Boellinghaus et al., 2014; context.
• Austerity and understaffing

• Bureaucracy ↓ • Compassionate Lower cost to
Organisational • Hierarchical organisational structure
• Biomedical focus/cure culture ↓
organisational
culture
healthcare system
cost
• Excessive workloads ↓
• Compassion
• Difficult patient interactions towards other
Better patient
Interpersonal • Interaction with suffering
• Competitive colleagues ↓
• Allowing
compassion
care
• Demanding superiors ↓ towards self
• High achiever personality ↓

• Fear of self-compassion ↓ Improved
Intrapersonal • Maladaptive coping ↓
• Personal characteristics (age, gender,
• Self-compassion personal
wellbeing
culture)
Fig. 14.2 Systemic framework to organisation pathways linking self-compassion to outcomes in healthcare
Finally, there is a clear need for research that similar issues are seen in mental and physical
considers the sorts of healthcare-specific out- health. Characteristic perfectionism and high-
comes that influence the values and policy of achievement normatively lead to self-blame and
governments and healthcare organisations. self-criticism, compounding the effects of envi-
Demonstrating that the development of self- ronments in which resources are stretched and
compassion in the professional healthcare work- disappointments common; instead of recognising
force impacts the sorts of outcomes that drive the common humanity of negative experiences,
policy (including, most obviously, cost) is critical doctors proceed to treat burnout as a badge of
to ensure “buy in” within bureaucracies and pol- honour (Rowe & Kidd, 2009). While our review
icy makers (Fig. 14.2). Securing data demonstrat- suggests self-compassion research among health-
ing that self-compassion does not pose a threat to care workers remains in its infancy, self-
motivation or performance (Robinson et al., compassion appears acceptable to this group,
2016) as well as assessing links to patient percep- well suited to many of the challenges facing
tions of service quality, absenteeism, complaints, healthcare professionals, and evidence that it
and staff turnover are key agendas for self- may have a host of benefits for practitioners,
compassion research in this applied context. Put patients, and healthcare systems is growing.
simply, we need data to assess whether self- The promise of self-compassion in healthcare
compassion benefits the outcomes this key stake- noted, yet serious challenges remain. Most obvi-
holder group values because it is these concerns ously, its potential is limited by the absence of
that determine how finite healthcare resources are high-quality data demonstrating the efficacy of
prioritised and allocated. this specific class of intervention in managing the
challenges healthcare professionals face.
Similarly, besides a small possibility that self-
Concluding Remarks compassion will differentially benefit healthcare
practitioners earlier in their career, we know little
Although compassion towards patients is regarding for whom self-compassion is of great-
expected, morally mandated, and required in pro- est assistance and/or the sorts of outcomes that
fessional codes of practice, healthcare profes- are affected. These are key agendas for future
sionals routinely neglect treating themselves with work. Perhaps most broadly, however, we must
compassion and care. While this accomplished be careful in assuming that self-compassion can
professional group typically appear competent offer anything approaching a universal panacea
and robust, nearly one-third of some groups of for the ills of modern healthcare. While develop-
healthcare professional suffer from burnout and ing the capacity to be kind to the self during times
of difficulty will likely benefit practitioners and Social Psychology, 100(5), 853–873. https://doi.
org/10.1037/a0021884
(although not all equally) and may have positive Barbosa, P., Raymond, G., Zlotnick, C., Wilk, J., Toomey,
spill over effects for patients and systems, it can R., 3rd, & Mitchell, J., 3rd. (2013). Mindfulness-based
only ever be a part solution. There remain serious stress reduction training is associated with greater
financial, logistical, and ideological barriers to empathy and reduced anxiety for graduate healthcare
students. Education for Health, 26(1), 9–14. https://
compassionate care, with respect to both patients doi.org/10.4103/1357-6283.112794
and carers. Such barriers are yet to be investi- Barnard, L. K., & Curry, J. F. (2011). Self-compassion:
gated; the challenge of self-compassion and care Conceptualizations, correlates, & interventions.
in health is a systemic problem requiring sys- Review of General Psychology, 15(4), 289–303.
https://doi.org/10.1037/a0025754
temic solutions. Our hope is that this chapter con- Bazarko, D., Cate, R. A., Azocar, F., & Kreitzer, M. J.
tribute in some way towards this agenda. (2013). The impact of an innovative mindfulness-
based stress reduction program on the health and
well-being of nurses employed in a corporate setting.
Journal of Workplace Behavioral Health, 28(2), 107–
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Self-Compassion in Relationships
and Caregiving Contexts 15
Christine Lathren
Self-compassion, a personal resource entailing a respond to challenges with harshness or self-

supportive attitude toward oneself during chal- criticism. Thus, the capacity for self-compassion
lenges, contributes to many aspects of individual may be facilitated through parents or caregivers
well-being. A burgeoning area of research who have served as models of compassion.
extends these findings by examining self- However, the connection between self-
compassion’s role in relational well-being. In compassion and relationship health does not end
fact, our capacity for self-compassion may be in childhood; it is likely complex, bidirectional,
rooted in our earliest childhood relationships and and relevant to numerous close relationships in
closely tied to attachment, or the enduring emo- adolescence and adulthood. The tendency to
tional bond a child develops with primary care- relate self-compassionately to one’s own distress
givers (Gilbert & Proctor, 2006). Experiences may be associated with adaptive thoughts, emo-
with warm, supportive parents and primary care- tions, and behaviors that nourish healthy fami-
givers (herein referred to as parents) promote lies, friendships, romantic partnerships, and
secure attachment while simultaneously provid- more. To explore this possibility, this chapter is
ing a foundational “template” for warm, support- organized into two main sections. The first sec-
ive self-directed coping strategies later in life tion theorizes why self-compassion may be ben-
(Shaver et al., 2016). To this point, adolescents eficial to relationship health and describes the
and young adults who rate their childhood expe- current evidence linking self-compassion to vari-
riences with parents as high in warmth and nur- ous interpersonal measures and factors, including
turance are more likely to have high relationship quality and satisfaction, prosocial
self-compassion (Kelly & Dupasquier, 2016; behaviors and attitudes, conflict and transgres-
Neff & McGehee, 2010; Temel & Atalay, 2018). sion behaviors, communication, and autonomy.
Meanwhile, those who report receiving inconsis- The second part of the chapter is dedicated to
tent, harsh, or unsupportive responses to their exploring self-compassion within the special cir-
needs as children are more likely to have low cumstance of caregiving, including parenting,
self-compassion in later years (Pepping et al., formal (i.e., professional) caregiving, and infor-
2015; Tanaka et al., 2011). Without a template for mal (i.e., family) caregiving.
care under distress, we may have a compromised First, why might self-compassion be associ-
ability to self-soothe, and may be more likely to ated with high relationship quality and satisfac-
tion? Potential factors can be framed within the
C. Lathren (*) context of the three components of self-
UNC-Chapel Hill School of Medicine, University of compassion: self-kindness, common humanity,
North Carolina at Chapel Hill, Chapel Hill, NC, USA
and mindfulness. First, self-compassionate peo-
ple are kind to themselves when they make a mis-
https://doi.org/10.1007/978-3-031-22348-8_15
252 C. Lathren
take or are experiencing difficulty. This being (Zessin et al., 2015), adaptive stress coping
self-kindness may steady them and help them to (Allen & Leary, 2010), low psychopathology
feel less threatened in negative interpersonal (MacBeth & Gumley, 2012), and a stable sense
encounters. Indeed, evidence demonstrates that of self-worth (Neff & Vonk, 2009) while linking
individuals with higher self-compassion have to a host of socially adaptive traits such as agree-
adaptive responses to threatening stimuli; they ableness, conscientiousness, and extraversion
are more likely to disengage their attention from (Neff et al., 2007) – arguably all factors that
situations that evoke feelings of inadequacy or should be beneficial to relational health. In sum,
shame (Yip & Tong, 2021) and are quicker to it is likely that compassion toward oneself is not
recover from social evaluative threats (Arch selfish, but rather socially advantageous and
et al., 2014). Importantly, however, this does not connection-building.
negate taking responsibility for one’s actions: in Indeed, current evidence shows that people
fact, people with higher levels of self-compassion high in self-compassion generally report both
have been found to be more likely to take respon- high-quality close relationships and high satis-
sibility for their mistakes than those who are less faction in those relationships. For example, in
self-compassionate (Leary et al., 2007). The self- adolescents and young adults, self-compassion
compassionate person’s ability to self-soothe and has been linked to various indices of positive
avoid harsh self-judgement may mean they family functioning such as family cohesion, sup-
require less reassurance from relationship part- portiveness, and flexibility (Berryhill et al., 2018;
ners, bounce back more easily after relationship Hayes et al., 2016; Hood et al., 2020; Jiang et al.,
ruptures, and have the courage to admit wrongdo- 2016; Neff & McGehee, 2010). College students
ing and address problems constructively. higher in self-compassion report higher levels of
The common humanity component of self- relational well-being – conceptualized as one’s
compassion may help people to accept that, like self-esteem and emotional well-being within the
themselves, relationship partners will make mis- relationship (Yarnell & Neff, 2013) – and rela-
takes, have weaknesses, and feel unpleasant emo- tionship quality, including measures of support,
tions; this ability to view things from a shared depth, and conflict (Huang & Berenbaum, 2017),
perspective may help people to see the best in with a variety of close others in their lives, includ-
others, forgive, and remain steadily satisfied ing friends. In the context of romantic partner-
despite conflicts or upsets. The common human- ships, self-compassion is positively linked to
ity element of self-compassion may also serve to relationship satisfaction (Fahimdanesh et al.,
attenuate feelings of shame and support people to 2020; Maleki et al., 2019; Neff & Beretvas, 2013;
communicate in ways that are likely to promote Shahabi et al., 2019), relational well-being (Neff
trust and intimacy in relationships. For example, & Beretvas, 2013), and to more stable marital
research has found that practicing self- satisfaction over time (Baker & McNulty, 2011).
compassion supports people to disclose experi- These studies point to overall positive connection
ences that threaten their self-esteem (Dupasquier between self-compassion and healthy, satisfying
et al., 2020) and increase the likelihood of dis- interpersonal relationships across contexts.
closing experiences of distress even when they Other evidence describes how self-compassion
fear receiving compassion from others is linked to a variety of prosocial behaviors that
(Dupasquier et al., 2017). Likewise, given self- may facilitate positive emotions between rela-
compassion includes holding difficult feelings tionship partners. For example, Neff and Beretvas
with mindful awareness without avoiding or (2013) studied heterosexual romantic partners
overidentifying with them, it may assist one to be who had been in a relationship for a year or more
authentic and communicative about their feel- and found that individuals who were high in self-
ings, while enabling them to advocate for them- compassion were perceived as behaving more
selves in a constructive manner. The three favorably (i.e., more caring, accepting, and
components work dynamically, facilitating well- autonomy-granting, while also less controlling,
15 Self-Compassion in Relationships and Caregiving Contexts 253
aggressive, and detached) and had partners who compassionate people have lower levels of nega-
were more satisfied in the relationship, compared tive emotional responses to unpleasant
to those lower in self-compassion. Other studies interpersonal events (Leary et al., 2007; Purdie &
have supported these findings, suggesting that Morley, 2015) and are less sensitive to interper-
self-compassion may facilitate having a more sonal rejection (Gerber et al., 2015). Thus, in the
compassionate, accepting view of others’ flaws context of various types of relationship breaches
and shortcomings (Zhang et al., 2019), having or unpleasantries, self-compassion may allow
higher levels of compassionate goals within one to put one’s own weaknesses and the weak-
friendships (Crocker & Canevello, 2008), as well nesses of others in perspective. It may promote
as the ability to be empathetic and see things the emotional stability needed to move forward
from another’s perspective (Fuochi et al., 2018; with kindness and understanding toward both
Neff & Pommier, 2013). Notably, not all studies oneself and relationship partners, leading to more
have found significant positive correlations effective problem-solving, self-improving, and
between self-compassion and compassion for rupture-repairing behaviors.
others (e.g., López et al., 2018); this may be Similarly, self-compassion may be linked to
because many people who are low in self- improved communication in relationship part-
compassion are compassionate toward others. ners, particularly if the discussion topic brings up
However, in many instances, self-compassionate difficult emotions. Given self-compassionate
tendencies may promote healthy relationship individuals are more likely to accept their diffi-
functioning and thus contribute to relationship cult emotions in a supportive and non-avoidant
thriving. manner, individuals who are self-compassionate
Given self-compassion provides anchoring may have more emotional clarity and have an
and self-soothing during times of hardship, high easier time discussing difficulties or admitting
levels of self-compassion are likely to be associ- shortcomings with others without becoming con-
ated with adaptive responses to inevitable rela- trolling or detached. At the same time, self-
tionship difficulties – including conflict and compassion may facilitate improved listening
transgression scenarios. In college students, high skills via emotion regulation and decreased threat
self-compassion is associated with increased perception. Women high in self-compassion who
likelihood to compromise as opposed to either were facing infertility, for example, reported
self-subordinate or self-prioritize when resolving greater ease in talking about infertility with their
conflicts with people close to them; self- romantic partner (Raque-Bogdan & Hoffman,
compassionate respondents also rated their reso- 2015). Likewise, in couples facing lung cancer,
lution choice as more authentic and causing patients’ self-compassion was significantly asso-
lower levels of emotional distress (Yarnell & ciated with better self-reported communication
Neff, 2013). In this case, self-compassion may with their partner about the cancer (Schellekens
promote respect for one’s own needs and well- et al., 2017). Recent examination of communica-
being, while simultaneously recognizing the per- tion styles in organizational contexts also sup-
spectives and “common humanity” of others, ports the link between self-compassion and more
leading to solutions that are sensitive to both par- effective, person-centered listening styles
ties. In challenging romantic contexts, self- (Salazar, 2017). Meanwhile, in parenting con-
compassion is related to decreased jealousy, texts (described in more detail later in this chap-
increased willingness to forgive (Tandler & ter), parent self-compassion is associated with
Petersen, 2018), adjustment after divorce (Sbarra higher self-reported levels of mindful parenting
et al., 2012), and in certain circumstances, moti- behaviors; these behaviors include listening to
vation to repair after a mistake (Baker & McNulty, the child with full attention and being aware of
2011) or to self-improve after a break-up (Zhang and sensitive to the emotional cues from the child
& Chen, 2017). Perhaps related to these findings, (Moreira et al., 2016). Thus, in a variety of con-
several studies have shown that self-texts, self-compassion is associated with the abil-
254 C. Lathren
ity to express oneself and likewise, be mindfully of the flow of care may result in improved rela-
attuned to others. tionship functioning. The mindfulness compo-
Healthy relationships also thrive when there is nent of self-compassion may help caregivers to
a balance between one’s own feelings and needs maintain perspective regarding their role. By
and those of relationship partners. Attending to being aware of emotions without becoming over-
the needs of others to the detriment of one’s own whelmed or ruminating on them, caregivers may
needs or becoming enmeshed with or distressed also be more skillful in challenging interpersonal
by the needs of others can negatively impact rela- encounters and may deescalate emotionally
tional health. Self-compassion has been linked to charged caregiving situations. Finally, common
lower levels of overdependency (Denckla et al., humanity reminds caregivers that their difficult
2017) and greater levels of autonomy, self- feelings make sense and are to be expected under
awareness, and competence, which may protect challenging circumstances, keeping them con-
against caregiving burnout and pathological nected to rather than isolated from others. It may
investment in other needs (Gerber et al., 2015; also help caregivers to remember the humanity
Gerber & Anaki, 2021). Likewise, in families and imperfection of those they care for. This may
where dysfunctional relationships cause overin- engender patience, forgiveness, and compassion-
volvement of family members in one another’s ate caregiving behaviors, which ultimately
lives, self-compassion may be useful in promot- strengthens the relationship. In sum, self-
ing improved mental health outcomes (Berryhill compassion may be an exceptionally well-suited
et al., 2018). resource for overextended parents and caregivers,
Balance may be particularly salient in parent– with interwoven benefits for caregiver, care
child and other caregiving relationships, which recipient, and the relationship between them.
are the topics of the rest of this chapter. Caregiving As expected, the literature supports self-
relationships are unique given they are often high compassion as a beneficial resource for strug-
intensity, with parents and caregivers influenced gling parents, as it promotes healthy stress coping
by societal, cultural, and self-imposed expecta- and adaptive attitudes toward parenting chal-
tions to provide compassionate, selfless care for lenges. Self-compassion is associated with lower
extended periods of time to the detriment of their levels of parental stress in general community
own health. While there are many positive and samples (Gouveia et al., 2016; Moreira et al.,
fulfilling aspects of caregiving, stress, dysfunc- 2015), as well as lower distress and improved
tional coping patterns, caregiving fatigue, bur- well-being for parents of children who are on the
den, and burnout are also common – bringing autism spectrum (Neff & Faso, 2015), have intel-
with them negative consequences for the rela- lectual and developmental disabilities (Robinson
tionship between caregiver and care recipient(s) et al., 2017), and have mental health problems
and the quality of care provided. (Shenaar-Golan et al., 2021). In contexts where
Meanwhile, theoretically, the three compo- children often display challenging emotions and
nents of self-compassion may assuage the diffi- behaviors, parents can be faced with feelings of
cult aspects of the caregiving experience. inadequacy, frustration, self-criticism and self-
Self-kindness may temper caregivers’ perfection- blame, and isolation. Self-compassion allows
ism and self-judgement, allowing caregivers to parents to meet these difficulties with kindness
let go of unrealistic expectations, accept their and understanding, normalizing them as part of
human limitations, and include themselves in the life’s ups and downs rather than abnormal or
circle of care. Moreover, when caregivers can shameful. Parents of children on the autism spec-
meet their own emotional needs, fewer demands trum report feeling less stigmatized (Wong et al.,
may be placed on the care recipient, who may be 2016), more hopeful, satisfied with life, self-
unable (e.g., family members with dementia, efficacious in their parental role (Neff & Faso,
young children) to offer reciprocal emotional 2015), and more forgiving of their perceived
care. These healthy boundaries and rebalancing weaknesses as a parent (Bohadana et al., 2020).
Even in response to everyday parenting chal- iors: (1) listening to child with full attention, (2)
lenges, self-compassion appears beneficial in emotional awareness of self and child, (3) self-
tempering feelings of guilt and shame with regulation in the parenting relationship, (4) non-
respect to not showing up in an ideal way during judgmental acceptance of self and child, and (5)
a difficult parenting event (Sirois et al., 2019). compassion for self and child. Parents who have
Meanwhile, for parents of children with various high self-compassion are more likely to interact
mental health problems, self-compassion was a with their child using mindful parenting practices
stronger predictor of higher levels of positive (Kim et al., 2019; Moreira et al., 2016; Moreira
feelings and lower levels of negative feelings in & Canavarro, 2017). Mindful parenting, in turn,
the parental role than the severity of child mental is linked to adolescents’ secure attachment to
health symptoms (Shenaar-Golan et al., 2021). parents (Moreira et al., 2018).
These findings suggest that self-compassion may Other related research posits that parents who
help parents cope with the demands of parent- have high self-compassion may be generally
hood from a balanced, connected perspective – a attuned to and comfortable with negative emo-
view that may engender more harmony in the tions in both themselves and their child (Lathren
parent–child relationship. et al., 2020), linking to child development litera-
Likewise, parents who are high in self- ture on emotion socialization processes
compassion may extend a kind and understand- (Eisenberg et al., 1998) and emotion coaching
ing orientation toward their children, resulting in behaviors (Gottman et al., 1996). Parents with
a less judgmental and more accepting view of high self-compassion are mindfully aware of
their child’s struggles. For example, Neff and their own negative emotions and related needs,
Faso (2015) showed parents of children with attending to these emotions supportively rather
autism who had high self-compassion were less than avoiding or becoming overwhelmed. It
likely to rate their child’s behavior as difficult or makes sense, then, that these parents would
problematic, and more likely to feel satisfied in approach negative emotions similarly when dis-
their relationship with their child. Similarly, in a played by their child. Parents may play the role of
sample of parents with a history of depression, an “emotion coach” who recognizes, validates,
parents high in self-compassion were gentler in labels, comforts, and welcomes negative emo-
their assessment of their child’s difficult behav- tions in their child as an opportunity for intimacy
ior, attributing the behavior to transient or situa- and problem-solving support. This approach con-
tional factors as opposed to static character traits trasts with parents who themselves are uncom-
(Psychogiou et al., 2016). Thus, by helping par- fortable with difficult feelings, and who may tend
ents remain open and forgiving, allowing them to to minimize or deny feelings like sadness or
see the best in both themselves and their child, anger in their children, or even punish children
self-compassion may promote better functioning for having these emotions (Gottman et al., 1996).
under challenging parenting conditions. Thus, parents with high self-compassion may
Closely connected to adaptive coping and atti- develop stronger bonds with their children
tudes, parents with high self-compassion may through behaviors which are attentive, attuned,
display more sensitive behaviors, as they may be compassionate, and “coach” the child to navigate
better attuned to the emotional cues of their child. emotional challenges in a healthy, validating
Parents with high self-compassion are more manner.
likely to be authoritative in their parenting, a Professional caregivers are another group for
style considered both warm and supportive whom self-compassion is highly relevant.
(Gouveia et al., 2016). Numerous studies have Evidence to date supports the link between self-
also linked high self-compassion in parents to compassion and decreased caregiving stress in a
mindful parenting (Duncan et al., 2009), wide variety of professional caregivers, including
described as a five-dimensional set of practices or nursing home nursing assistants, hospital and
skills that relate to high-quality parenting behav- community nurses, physicians, and health-care
256 C. Lathren
students. These studies have shown self- Other studies provide a more nuanced view of
compassion is associated with lower levels of how self-compassion may be useful in relieving
secondary trauma symptoms (i.e., experiencing caregiver stress by examining impact on unhelp-
trauma due to exposure to the trauma and suffer- ful or unrealistic thought patterns or behaviors
ing of others), compassion fatigue (i.e., exhaus- related to the caregiving role. For example, some
tion and dysfunction due to prolonged exposure family caregivers experience unhealthy guilt –
to the suffering and stress of others), and various feeling guilty for feeling sad or hopeless – related
measures of burnout, while associated with to societal or cultural norms regarding familism
higher levels of compassion satisfaction (e.g., and the importance of honoring and caring for
fulfillment in one’s caregiving role) and quality loved ones (Sayegh & Knight, 2011). Similarly,
of life (Bluth et al., 2021; Delaney, 2018; Duarte family caregiver accounts commonly reveal self-
et al., 2016; Durkin et al., 2016; Upton, 2018). In sacrificing behaviors, a strong commitment to
these settings, self-compassion may improve caregiver identity and reluctance to prioritize
caregiving capacities by strengthening internal oneself due to fear of detracting from one’s
support mechanisms in order to revitalize and responsibilities or becoming selfish (Berardini
fuel outward support. et al., 2021; Diggory & Reeves, 2021). The cul-
Similarly, researchers have developed inter- ture of selflessness and denial of self-needs also
ventions aimed to raise self-compassion levels pervades health-care settings, where providers
for hospital nurses (Delaney, 2018), mixed have high workloads and lack opportunities for
health-care communities (Neff et al., 2020), and self-care; the expectation is to set one’s needs
nursing home nursing assistants (Bluth et al., aside, “people-please” and prioritize caregiving
2021). These studies show self-compassion inter- tasks to the detriment of provider well-being
ventions are feasible and acceptable for profes- (Andrews et al., 2020; Lathren et al., 2021).
sional caregivers and are linked to improvements Self-compassion appears to soften this view,
in well-being, burnout, and compassion-related promoting a more balanced understanding of
measures. However, studies to date have lacked a caregiving situations and acceptance of caregiv-
direct measurement of potential impact on dyadic er’s often limited role in fully ameliorating the
relationships between caregiver and care recipi- challenges faced by the care recipient. This
ent, nor related outcomes such as care quality and reframing is particularly useful for combatting
satisfaction with care. These issues will be impor- caregivers’ feelings of shame or guilt for being an
tant to explore in future work. imperfect human who has needs of their own;
Family caregivers, particularly those caring these findings are similar to themes within par-
for loved ones with dementia or another debilitat- enting literature discussed earlier. For example,
ing illness, similarly experience high levels of for mothers caring for a child on the autism spec-
stress and burden. Evidence suggests self- trum, self-compassion is described as allowing
compassion may help relieve stress and burden in caregivers to challenge unrealistic internal and
family caregivers via connection with lower lev- societal expectations of themselves, helping them
els of dysfunctional coping strategies (Lloyd to forgive their shortcomings, and promoting
et al., 2019), lower caregiver burden (Xu et al., emotional self-care without sinking into self-
2020), and improved quality of life (Hlabangana judgment and despair (Bohadana et al., 2020).
& Hearn, 2020). Other evidence shows that self- Similarly, for nursing home nursing assistants in
compassion moderates the relationship between a professional caregiving context, self-
caregiving stress and depression (Hsieh et al., compassion intervention promoted self-
2021). However, despite high promise, interven- appreciation, validation of one’s needs as a
tions explicitly focused on raising family care- human, and a more realistic view of their capaci-
givers’ self-compassion and improving family ties and limitations as caregivers (Lathren et al.,
relationships have not yet been explored 2021). Caregivers described how practicing self-
(Murfield et al., 2020). compassion alleviated burden and self-imposed
stress and resulted in perceived increases in kind- tance, and self-care. In this way, family
ness, patience, and understanding toward care self-compassion training promotes a powerful
recipients. Thus, whether personal or profes- “dual model” of support by strengthening both
sional, a “rebalancing” of compassion and care the relational support family members provide to
toward the caregiver may ultimately provide the one another and each person’s individual capac-
internal resources to increase compassion and ity for self-directed support.
care toward those they provide for. Moreover, evidence described in this chapter
Surprisingly, while mindfulness studies are suggests that interpersonal, longitudinal effects
relatively common, to date there have been few may be seen. For example, youth who learn self-
self-compassion-focused intervention studies compassion skills early may be more likely to
that target parents and caregivers – despite develop healthy, fulfilling relationships in adoles-
numerous potential benefits for both formal care- cence and adulthood, eventually influencing their
givers and family caregivers. Given the well- own capacity to be a compassionate, nurturing
established benefits of self-compassion, a parent and caregiver. Thus, self-compassion may
pragmatic approach may be appropriate. For have implications across generations, making it a
health-care professionals, these interventions particularly valuable resource for healing cycles
could be woven into educational curricula, proof dysfunction passed on via strained family rela-
fessional development, and in services. To tionships and attachment insecurity. For these
address critical shortages of health-care workers reasons, research that applies self-compassion
and burnout, policies must create a cultural shift interventions to relational contexts and examines
away from self-sacrifice and denial to one of sup- longitudinal, cross-generational effects hold sig-
port and replenishment. Ultimately, a self- nificant promise.
compassionate clinical workplace culture would To summarize, self-compassion and healthy,
benefit all relationships – including relationships satisfying, supportive human relationships appear
between administrators, staff (office staff, physi- to go hand in hand. As human relationships go
cians, nurses, aides, etc.), and with patients and through inevitable periods of hardship – conflict,
their families. Meanwhile, family caregivers transgressions, stress, trauma, illness – self-
could be offered access to self-compassion pro- compassion serves to stabilize, comfort, remind
gramming through physicians’ offices and com- us that we are good enough just as we are, and
munity organizations that offer support and that we are all worthy of giving and receiving
educational programming. For example, organi- love and forgiveness. In a nutshell, self-
zations that provide resources to caregivers for compassion allows us to show up for ourselves,
persons with dementia, cancer, or autism support, so that we can similarly show up for those we
organizations could offer self-compassion train- care about.
ing – in various formats – to supplement tradi-
tional caregiving support services like peer
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Self-Compassion in Parenting
16
Helena Moreira
Introduction and all parents, regardless of their sociocultural

background and mental health status, experience
Being a parent is one of the most significant and some degree of parenting stress at some point in
gratifying experiences in an individual’s life, but their lives (Crnic & Greenberg., 1990; Deater-
it is also one of the most challenging and demand- Deckard, 2004). Parenting stress is one of the
ing tasks. Raising a child takes courage and com- strongest risk factors for a range of adverse par-
mitment, time and dedication, and it is often enting outcomes (e.g., Anthony et al., 2005; Niu
exhausting physically and emotionally. In every- et al., 2018), and consequently, it can seriously
day life, parenting is often experienced more as a affect child development and increase the likeli-
set of tasks to be accomplished than as pleasur- hood of psychopathology and adjustment prob-
able interaction with the child. Most parents lems (Deater-Deckard & Panneton, 2017;
make a concerted effort to reconcile work and Deater-Deckard, 1998). For instance, among
family-related responsibilities and face numerous clinically referred and community samples, par-
daily stressors associated with parenting (e.g., enting stress was shown to be associated with
taking children to different activities on time, children’s externalizing problems (Schleider
preparing meals, soothing a baby that will not et al., 2015; Stone et al., 2016), internalizing
stop crying, dealing with a toddler’s tantrum or problems (Stone et al., 2016; Rodriguez, 2011),
with a teenager’s defiant behaviors). Thus, lower quality of life (Moreira et al., 2015),
although in the relationship with children there aggressive behavior (Krahé et al., 2015), and
are many moments of joy and deep connection, decreased coping competence (Moreland et al.,
there are also many moments of stress that often 2016).
lead parents to experience strong negative emo- Therefore, it is essential to identify modifiable
tions such as anxiety, frustration, sadness, guilt, resources that can help parents experience lower
and even anger and resentment directed at both levels of parenting stress. Self-compassion and
themselves and the child. mindfulness are modifiable internal resources
Experiencing high levels of parenting stress is that can help parents feel less stressed and that
becoming increasingly prevalent in modern soci- can be developed through mindfulness- and
ety (Barroso et al., 2018; Roskam et al., 2021), compassion-based programs, such as the Mindful
Self-Compassion program (MSC; Neff &
H. Moreira (*) Germer, 2013), Compassion-Focused Therapy
Center for Research in Neuropsychology and (CFT; Gilbert, 2009b), the Mindfulness-Based
Cognitive-Behavioural Intervention, University of Stress Reduction program (MBSR; Kabat-Zinn,
Coimbra, Coimbra, Portugal

https://doi.org/10.1007/978-3-031-22348-8_16
264 H. Moreira
1990), or Mindfulness-Based Cognitive Therapy Self-Compassion as an Inner

(MBCT; Segal et al., 2002). In recent years, these Resource Associated with Better
programs and their adaptations have been offered Parenting Outcomes
to parents who experience high stress or specific
challenges in parenting (e.g., Bazzano et al., Self-compassion is an adaptive type of self-to-
2015; Neece et al., 2019; Weitlauf et al., 2020), self relating that involves the recognition of and
showing promising results in reducing parents’ the desire to alleviate one’s own suffering with
stress levels and in improving their well-being. kindness and care and in a nonjudgmental way. It
The inclusion of mindfulness and compassion is grounded in the recognition that we all share a
components in parenting interventions has also common human condition (i.e., that all human
been found to increase the effectiveness of these beings are imperfect; Neff, 2003b). In recent
interventions in reducing parental stress, anxiety, years, research into the role of self-compassion in
and depression and in promoting mindfulness a variety of individual and interpersonal out-
and self-compassion skills (Jefferson et al., 2020; comes has grown exponentially. Self-compassion
Coatsworth et al., 2014). At the same time, mind- has been consistently associated with healthy
ful parenting programs aimed at promoting a psychological functioning (Neff et al., 2007,
mindful approach to parenting (e.g., Mindful 2018) and, although with less empirical support,
Parenting Training, Bögels et al., 2014; Mindful with adaptive interpersonal functioning (Neff &
With Your Baby, Potharst et al., 2017, 2022, Pommier, 2013; Yang et al., 2019).
2019) have also been shown to be effective in With regard to psychological functioning,
reducing parental stress and in improving several there is already solid evidence from meta-analysis
child outcomes (e.g., internalizing and external- studies that self-compassion is strongly associ-
izing problems; Burgdorf et al., 2019). Thus, ated with lower levels of psychological distress in
while parenting stress can be a risk factor for adolescents (r = −.55; Marsh et al., 2018) and
negative parenting, several intervention studies with lower levels of psychopathology (r = .54;
have shown that it is possible to help parents bet- MacBeth & Gumley, 2012) and higher levels of
ter cope with stress by developing skills such as well-being in adults (r = .47; Zessin et al., 2015).
self-compassion and mindfulness. Increasing evidence suggests that self-
In this chapter, we will review the empirical compassion is not only associated with greater
evidence that documents the role of parents’ self- well-being (e.g., Neff et al., 2018) and healthy
compassion in parenting. Then, we propose a psychological functioning (e.g., Bluth et al.,
conceptual model that describes how incorporat- 2017; Krieger et al., 2013; Neff, 2003a) in non-
ing self-compassion and mindfulness into the clinical populations but it also seems to help indi-
parent–child relationship can help parents adopt viduals better cope with challenging life
more positive parenting behaviors and experi- circumstances, including infertility (Galhardo
ence less parenting stress. In this model, we also et al., 2013), cancer (Pinto-Gouveia et al., 2014),
propose that this parental approach contributes to trauma (Thompson & Waltz, 2008), pain (Wren
a child’s secure attachment and the development et al., 2012), divorce (Sbarra et al., 2012), and
of important internal resources (e.g., self- HIV (Kemppainen et al., 2013).
compassion, emotional regulation) and, conse- With regard to interpersonal functioning,
quently, to a better child’s mental health. The some studies have shown that self-compassionate
empirical evidence that supports the associations individuals tend to exhibit more prosocial behav-
established in the model is thoroughly iors (Yang et al., 2019) and to be more compas-
discussed. sionate toward other people (e.g., Crocker &
Canevello, 2008; Gillath et al., 2005; Mikulincer
et al., 2005; see Chap. 15 for a detailed discus-
sion). In addition, it has been demonstrated that
compassion toward the self and others stimulate
16 Self-Compassion in Parenting 265
identical parts of the brain (Longe et al., 2010), which self-compassion may be important, the
which suggests that a common process may role of self-compassion in parenting has only
underlie both self-compassion and compassion recently begun to be explored. Among the extant
toward other people, including toward one’s own literature, several studies suggests that parents’
children. According to this view, Neff and self-compassion can play a key role in how par-
Pommier (2013) found that among adults from ents perceive and experience parenting and their
the general population and practicing meditators, relationships with their children (Jefferson et al.,
higher levels of self-compassion were associated 2020). For instance, studies conducted among
with greater compassion for humanity, empa- parents of school-aged children and adolescents
thetic concern for others, and altruism. Among from the general population have shown that
adults from the general population, practicing higher levels of self-compassion are positively
meditators, and undergraduate students, higher associated with lower parenting stress (Gouveia
levels of self-compassion were also associated et al., 2016; Moreira et al., 2015) and with more
with higher levels of perspective-taking and for- authoritative and less permissive and authoritar-
giveness and lower levels of personal distress. ian parenting styles (Gouveia et al., 2016). In a
The results of studies that explored the contri- study that included parents with a history of
bution of self-compassion to romantic and other depression, greater self-compassion was found to
interpersonal relationships (Neff & Beretvas, be associated with lower levels of mothers’ child-
2013; Yarnell & Neff, 2013) also support the directed criticism and with lower levels of
view that self-compassionate individuals are fathers’ distressed reactions to their children’s
more likely to focus on others’ concerns. For negative emotions (Psychogiou et al., 2016). In
instance, Neff and Beretvas (2013) found that addition, Psychogiou et al. (2016) have found
self-compassionate individuals were described that parents who reported higher levels of self-
by their partners as more caring, accepting, and compassion tended to attribute the cause of their
supportive of their partner’s autonomy. Despite children’s behaviors to external factors (such as
the empirical evidence supporting the view that situational demands and environmental con-
self-compassion and compassion or concern for straints) rather than to internal factors (i.e., global
others are positively related, it is important to and stable personal traits and attributes), which
note that in some studies this association was may have important implications for parenting as
shown to be weak (Mills et al., 2018) or even this external locus of control can promote a less
nonsignificant (Gerber et al., 2015). This is critical and a more open stance toward the child’s
because often people are very compassionate behavior.
toward others but not toward themselves. A key Gilbert’s tripartite model of affect regulation
finding, however, is that self-compassion training (Gilbert, 2005a, 2009a) can offer insight into
increases compassion for others (Neff & Germer, why self-compassionate parents may feel less
2013). Furthermore, it is important to bear in stressed by the daily challenges of rearing a child
mind that the measurement of compassion is still and be better able to be more compassionate
problematic, as different authors operationalize toward their children and other people in general.
and assess compassion for others in different This model postulates three evolved systems ori-
ways (Strauss et al., 2016). In addition, people ented toward threats (the threat and self-
might differ with regard to their fears of express- protection system, which is responsible for
ing and receiving compassion (for others, from detecting threats and quickly selecting a response,
others, and for self; Gilbert et al., 2011), which such as fight, flight, or freeze), resources (the
can make it easier for some people to feel self- drive system, which guides resources seeking
compassion and more difficult to feel compas- and goal attainment), and affiliation (the affilia-
sion for others and vice versa. tive and soothing system, which guides attach-
Although the parent–child relationship is a ment and caregiving behaviors and is responsible
particular type of interpersonal relationship in for generating feelings of contentment, soothing,
266 H. Moreira
safeness, and connectedness). According to this compassion was found to predict fewer symptoms
model, capacities for compassion for oneself and of depression and of posttraumatic stress syn-
others have the same physiological underpin- drome (Hawkins et al., 2019), while in a sample
nings; in other words, they are rooted in the affili-
of parents of children with a range of chronic ill-
ative and soothing system of affect regulation ness, self-compassion was inversely associated
(Depue & Morrone-Strupinsky, 2005; Gilbert, with parental burnout (Gerber et al., 2021).
2005a, 2009a, b). Accordingly, those who are Together, these findings suggest that experimen-
more able to access their affiliative/soothing sys- tal studies examining the impact of self-
tem are more likely to experience higher levels of compassion intervention on parental mental
compassion for self and others. In addition, health and burnout are warranted, particularly
because (self-)compassion facilitates access to among parents who have a child with additional
this soothing system and deactivates the threat needs.
system, self-compassionate individuals can more There is also some evidence that self-
easily regulate their emotions and soothe them- compassion can help parents of children diag-
selves in times of stress and suffering (Gilbert, nosed with autism spectrum disorder be more
2009b). In contrast, individuals with low levels of emotionally resilient and better cope with the
self-compassion usually find it difficult to access stress associated with raising an autistic child.
the soothing system, and the threat and/or drive For instance, Neff and Faso (2015) found that
systems can be easily and frequently activated. parents of an autistic child with greater self-
Therefore, in stressful moments with a child, compassion exhibited less parental stress and
self-compassionate parents may be better able to depression, were more satisfied with life and
deactivate the threat system (which would most more hopeful about the future, experienced
likely lead to a fight, flight, or freeze response, greater goal reengagement (i.e., were more will-
such as screaming, criticizing, or punishing their ing to pursue new goals when prior ones are unat-
child or themselves) and more effectively coun- tainable), and had a more functional relationship
teract the negative emotions that may arise by with their children. In two recent studies also
soothing themselves and, consequently, respond- conducted among parents of autistic children,
ing in a more compassionate, calm, and regulated self-compassion was associated with lower par-
way. enting stress, higher levels of subjective well-
being, and better quality of life (Bohadana et al.,
Self-Compassion and Raising a Child in 2019; Torbet et al., 2019). Similar results were
Challenging Circumstances found in a study that included parents of adults
Many parents face major challenges in raising with an intellectual or developmental disability,
their children. For instance, caring for a child in which self-compassion was shown to be asso-
with a developmental problem (e.g., autism, ciated with lower levels of depressive symptoms
intellectual disability) or with a chronic health and stress (Robinson et al., 2018).
condition is a demanding and potentially stress- Self-compassion also seems to play an impor-
ful task for parents that may result in substantial tant role in how parents of autistic children expe-
levels of parenting stress and adjustment difficul- rience different forms of stigma. Specifically,
ties (e.g., Kiami & Goodgold, 2017; Moreira & self-compassion seems to protect individuals
Canavarro, 2016; Moreira et al., 2013a, b). The against feelings of affiliate stigma (i.e., internal-
results from a few studies suggest that self- ized stigma experienced by family members or
compassion can play an important role in how primary caregivers of stigmatized individuals;
parents cope with the unique challenges of rais- Torbet et al., 2019; Wong et al., 2016), public
ing a child with a developmental or chronic stigma (i.e., negative perceptions directed toward
health problem (Cousineau et al., 2019). For individuals with a disability or with a mental or
instance, in a sample of parents and primary care- physical disease), and courtesy stigma (i.e., nega-
givers of children with a burn injury, self- tive perceptions directed toward individuals
because of their association with stigmatized described by Kabat-Zinn and Kabat-Zinn (1997)
individuals; Torbet et al., 2019). It also seems to as a type of parenting characterized by being
protect parents against psychological distress present and paying nonjudgmental attention to
linked to affiliate stigma. For instance, Wong the child. Based on the work of Kabat-Zinn and
et al. (2016) found that affiliate stigma was sig- Kabat-Zinn (1997) and subsequent research (e.g.,
nificantly associated with greater psychological Duncan et al., 2009; Bögels & Restifo, 2014),
distress only when parents had lower levels of mindful parenting has been described as a parent-
self-compassion; among those who exhibited ing approach that involves not only bringing
high levels of self-compassion, affiliate stigma mindful awareness to the parent–child relation-
was not associated with psychological distress. ship but also adopting a compassionate stance
Taken together, the results of these studies toward oneself as a parent and toward the child.
suggest that self-compassion can serve as an Although the designation mindful parenting
adaptive coping strategy for parents of children highlights only the mindfulness dimension, it is
with additional challenges, including develop- important to note that this approach also implies
mental and/or health difficulties. These parents greater acceptance and compassion for oneself
devote a large part of their time and energy to and for the child. Accordingly, we consider that it
caring for their children and can often feel more can be better described as a mindful and compas-
exhausted and stressed than parents of typically sionate parenting approach, a designation that
developing children (Lindström et al., 2010; we will adopt in the current work. Another impor-
Pinquart, 2018). Arguably, self-compassion can tant defining characteristic of this parenting
help these parents create a healthier balance approach is the parents’ greater ability to regulate
between the demands of caring for their children their emotions and behaviors in interactions with
and caring for themselves. In addition, by culti- the child, as opposed to reacting automatically.
vating self-compassion, parents may feel less iso- Therefore, mindful and compassionate parenting
lated in their suffering because they recognize can be described as a parenting approach that
that suffering is part of the human experience and encompasses three essential components: (1)
that many parents deal with similar difficulties mindfulness (which allows parents to be truly
and circumstances. They may also feel less guilty present when they interact with their children,
or responsible for their child’s problems and dis- listening to them with full attention, and identify-
tress and be better able to accept their mistakes ing their emotional changes even if they are sub-
and limitations as parents as well as their chil- tle), (2) compassion (for oneself and the child),
dren’s limitations and difficult behaviors. and (3) self-regulation (which allows parents to
act calmly and in line with their values and goals
and hinders them from reacting automatically).
A Mindful and Compassionate Grounded in theoretical and empirical research
Approach to Parenting on mindfulness and mindfulness-based interven-
tions (Baer, 2003; Kabat-Zinn, 2003), Duncan
Self-compassion is not only an internal resource et al. (2009) proposed a theoretical model to
that can help parents better deal with the chal- explain how mindful parenting can have positive
lenges of parenting but it can also be a defining effects on the psychological functioning of par-
element of parenting itself. In recent years, there ents and children. According to this model, mind-
has been growing interest among clinicians, ful parenting can influence child psychosocial
researchers, and the population at large in so- adjustment and functioning (e.g., self-regulation,
called “mindful parenting,” a parental approach psychological functioning) through its effect on
that applies mindfulness- and compassion-based several aspects of the parent–child relationship,
principles to the parent–child relationship including parenting (e.g., communication, paren-
(Bögels & Restifo, 2014; Kabat-Zinn & Kabat- tal self-efficacy), child management practices,
Zinn, 1997). Mindful parenting was first parental well-being, and parent–child affection.
268 H. Moreira
According to the authors, mindful parenting Conceptual Model of a Mindful

A
encompasses five interrelated dimensions: (1) lis- and Compassionate Approach
tening with full attention to the child (i.e., direct- to Parenting
ing complete attention to the child and being
fully present during parent–child interactions); To extend the previous work on mindful parent-
(2) nonjudgmental acceptance of the self and the ing, we propose an integrative conceptual model
child (i.e., accepting the characteristics and of a mindful and compassionate parenting
behaviors of the child, the self as a parent, and the approach that aims to highlight the main factors
challenges of parenting); (3) emotional aware- that may account for the individual differences in
ness of the self and the child (i.e., noticing and mindful and compassionate parenting and explain
correctly identifying one’s emotions when inter- how this parenting approach can influence par-
acting with the child as well as the child’s enting behaviors and the socioemotional func-
emotions); (4) self-regulation in the parenting
tioning of children and adolescents (see
relationship (i.e., being able to regulate one’s Fig. 16.1). In developing this model, we drew
own emotions and behaviors in parent–child from the Duncan et al.’s (2009) model of mindful
interactions and being able to pause before react- parenting, the process model of the determinants
ing); and (5) compassion toward the self as a par- of parenting (according to which parenting is
ent and toward the child (i.e., being kind to and multidimensional and can be influenced by inter-
supportive of the child, sensitive and responsive secting parent, child, and social variables; Belsky,
to the child’s needs, and compassionate toward 1984), and the existing empirical evidence on the
oneself as a parent). determinants and effects of mindful and compas-
sionate parenting. Starting from the mindful par-
enting model (Duncan et al., 2009) and taking
into account subsequent studies that showed a
clear separation between child-focused and par-
ent- or parenting-focused mindful parenting
dimensions (e.g., de Bruin et al., 2014; Moreira
Parent variables
Self-compassion
Mindfulness
Attachment
Psychopathology
Emotion regulation
Mindful and
compassionate
parenting Child’s internal
resources
Child variables 1. Listening with Full
Temperament Attention Parenting Child’s Self-compassion Child’s
Mindfulness
Mental and physical behaviors attachment Emotion regulation mental health
health
2. Self-Regulation in Psychological
Sociodemographic Parenting flexibility
characteristics (e.g., 3. Emotional Awareness
age, sex)
of the Child
4. Compassion for the
Contextual Child
variables
Marital quality
Work-family conflict
Culture
Social support
Parenting
stress
Fig. 16.1 Conceptual model of a mindful and compassionate approach to parenting

& Canavarro, 2017), we conceptualize mindful Parent Variables All parents have psychologi-
and compassionate parenting as a multidimen- cal, physiological, and experiential differences
sional construct that encompasses the following that interact with child characteristics to influ-
interrelated dimensions: (1) listening with full ence the parent–child relationship. Certain paren-
attention, which pertains to the ability to listen to tal characteristics, such as self-compassion,
the child with full attention; (2) self-regulation in mindfulness, attachment, emotion regulation,
parenting, which pertains to the ability to self- and mental health, may be particularly important
regulate in parent–child interactions; (3) emo- determinants of the quality of mindful and com-
tional awareness of the child, which pertains to passionate parenting.
the ability to be aware of the child’s emotions; (4)
compassion for the child, which pertains to an
attitude of compassion toward the child (i.e., an Self-Compassion and Mindfulness There is
attitude of kindness, sensitivity, and responsive- some evidence that parents who are more mind-
ness to the child’s needs); and (5) nonjudgmental ful with regard to their own experiences (Gouveia
acceptance of parental functioning, which per- et al., 2016; Parent et al., 2016b) and have high
tains to an attitude of nonjudgmental acceptance levels of self-compassion (Gouveia et al., 2016;
of parental functioning (i.e., accepting without Moreira et al., 2016) are more able to enact mind-
judging the self as a parent and the challenges of fulness and compassion in their parenting rela-
parenting). tionships. While these associations are not
In the following sections, we will analyze in surprising, since mindfulness and self-
detail each component of the model as well as the compassion are essential and defining elements
empirical evidence supporting the proposed asso- of a mindful and compassionate parenting
ciations, as illustrated in Fig. 16.1. approach, they have important clinical implica-
tions, as they suggest that the cultivation of these
individual resources or skills can spill over into
Determinants of Mindful the relational domain and influence the relation-
and Compassionate Parenting ship between parents and children.
According to the model, mindful and compas- Each of the three positive components of self-
sionate parenting, like other parenting styles and compassion (i.e., self-kindness, common human-
practices, is multidimensional and can be influ- ity, and mindfulness; Neff, 2003b) can help
enced by parents’ characteristics (e.g., personal- explain why self-compassion and mindfulness
ity and mental health), children’s characteristics can contribute to mindful and compassionate par-
(e.g., temperament), and contextual sources of enting. First, higher levels of self-kindness (i.e.,
stress and support (e.g., parents’ work context, facing difficulties, failures, and suffering with a
marital relationship, and social networks/sup- caring and understanding attitude rather than
port; Belsky, 1984). Knowing which factors may being self-critical and judgmental) may help par-
account for the variability in this parenting ents accept without judgment, the shortcomings
approach and understanding why some parents and limitations they perceive in themselves as
are more likely to be mindful and compassionate parents and those they perceive in their children.
in the parent–child relationship than others may Rather than criticizing themselves and criticizing
contribute to a better understanding of this con- the child, self-compassionate parents may more
struct and may have important clinical implica- easily adopt an attitude of kindness and accep-
tions, such as the identification of modifiable tance, particularly in times of parenting stress.
factors that can be targeted in mindfulness- and For example, after yelling at her child who was
compassion-based parenting programs. having a tantrum, a mother with higher levels of
self-compassion may more easily view the situa-
tion as a moment of suffering during which she
270 H. Moreira
also deserves comfort and acceptance instead of (Moreira et al., 2016; Moreira & Canavarro,
criticizing herself for her behavior (“I am a terri- 2015). These results are consistent with many
ble mother for screaming at my son”). studies that demonstrate that a secure attachment
Second, a greater sense of common humanity is an important determinant of a caring and sup-
(i.e., acknowledging that one’s painful experi- portive relationship with one’s children (for a
ences are part of a common human condition review, see Jones et al., 2015a, b). In general,
rather than feeling isolated, ashamed, or differ- secure attachment has been consistently related
ent) can help parents understand that difficulties to a wide range of positive parenting characteris-
and suffering are part of parenting, rather than tics and outcomes, such as higher parental sensi-
interpreting their struggles as unique personal tivity, responsiveness, and supportiveness; less
failures. By understanding that all parents fail, parenting stress; and stronger feelings of close-
suffer, and make mistakes, self-compassionate ness to one’s children. Conversely, parents’ inse-
parents may be able to more easily accept their cure attachment (i.e., high levels of
limitations and imperfections as parents without attachment-related avoidance and/or anxiety) has
criticizing themselves and feeling isolated. In been associated with more negative parental
addition, they may be less likely to react to child caregiving behaviors, emotions, and cognitions
misbehavior with anger or punishment as they (Jones et al., 2015a, b). Specifically, it has been
are less likely to interpret these behaviors as a suggested that because avoidant individuals have
parenting “failure.” more difficulty in assuming caregiving roles
Third, the greater capacity of self-(Gillath et al., 2005; Mikulincer et al., 2005),
compassionate individuals to be mindful of their they tend to experience more stress in their par-
painful emotions and thoughts instead of deny- enting roles (e.g., Moreira et al., 2015; Nordahl
ing, avoiding, or ruminating about them can help et al., 2020; Rholes et al., 2006), perceive parent-
them to have a greater ability to decenter and not hood as less meaningful and satisfying (Cohen &
overidentify with negative thoughts about their Finzi-Dottan, 2005; Vieira et al., 2012), and
children or their parental role. For example, such behave in a less mindful (Moreira & Canavarro,
parents might think of a time when they were 2015; Moreira et al., 2015, 2016), warm, close,
unable to validate their child’s emotions without and supportive manner toward their children
engaging in ruminative thoughts about that spe- (Edelstein et al., 2004; Rholes et al., 1995) com-
cific behavior or other negative aspects of their pared with securely attached parents. Avoidant
parenting and without automatically believing parents may also feel more uncertain about or
that moment reflects poor parenting skills. In less interested in having children (Rholes et al.,
addition, this greater capacity for mindfulness 1997, 2006) and they may lack confidence in
may help parents become more aware of their their parenting abilities (Rholes et al., 1995). In
own emotional states and of the emotional states comparison, anxiously attached individuals tend
of their children, allowing them to more easily to be self-centered, worry about their own attach-
regulate their behaviors and emotions in interac- ment needs, and feel distressed when other peo-
tions with the child. As will be discussed later, ple, including their children, need their assistance
this greater capacity for self-regulation is essen- (Gillath et al., 2005; Mikulincer et al., 2005).
tial in enabling parents to be less reactive in inter- Like avoidant parents, they may also report more
actions with the child and to act in accordance negative attitudes toward parenthood than secure
with their true parenting values by adopting more parents do (Rholes et al., 1997), experience
sensitive and responsive parenting behaviors. increased parenting stress (Moreira et al., 2015;
Rholes et al., 2006), and behave in a less mindful
Parents’ Attachment Experiences Parents’ and compassionate manner toward their children
insecure attachment with their own parents has (Moreira & Canavarro, 2015; Moreira et al.,
been shown to predict increased difficulties in 2015, 2016). In contrast to avoidant individuals,
practicing mindful and compassionate parenting they are less able to provide a secure base for
their children’s exploration behaviors (Adam 2012), leading them to experience greater diffi-
et al., 2004) and they tend to have more idealized culty in perceiving their children’s emotional
and perfectionist conceptions of themselves as expressions and to be less responsive and sensi-
future parents (Mikulincer & Shaver, 2016). tive to their children’s needs.
In addition, rumination is associated with
greater attentional bias toward negative informa-
Emotion Regulation Relatedly, some studies tion (Donaldson et al., 2007). This attentional
point to emotion regulation as a key variable bias may, on the one hand, lead parents to focus
influencing one’s tendency to enact mindful and more on their perceived limitations and short-
compassionate parenting practices. Specifically, comings as parents, contributing to lower levels
emotion regulation difficulties such as rumina- of nonjudgmental acceptance of parental func-
tion can significantly interfere with parents’ abil- tioning, and, on the other hand, lead parents to
ity to practice mindful and compassionate focus on the negative aspects of their child’s
parenting. One study has shown that higher levels behaviors, contributing to lower levels of com-
of self-critical rumination, a specific type of passion for the child. Based on Gilbert’s (2010)
rumination focused on the content of self-critical tripartite model of affect regulation, one might
thoughts (Smart et al., 2016), predicted higher think that this greater focus on the negative
levels of parenting stress and that this association aspects of the self or the child may continually
was mediated by two dimensions of mindful and stimulate the threat system, as self-critical dia-
compassionate parenting: emotional awareness logue and rumination are often perceived as
of the child and nonjudgmental acceptance of (internal) threats. This constant stimulation cre-
parental functioning (Moreira & Canavarro, ates a difficult-to-break internal feedback loop
2018a). between the content and focus of thoughts and
the threat system, which maintains the sense of
The hypothesis that rumination interferes with threat (Gilbert, 2010), making it very difficult for
this parenting approach is also supported by stud- parents to implement a mindful and compassion-
ies showing that parents who tend to experience ate style of parenting that calls for the activation
negative affect more frequently and persistently of the soothing system.
(i.e., who present higher levels of neuroticism;
Moreira et al., 2020) and who experience more Parent Mental Health Some studies have sug-
anxious and depressive symptoms are less able to gested that experiencing more anxiety and
be mindful and compassionate in their relation- depressive symptoms (Moreira et al., 2019;
ships with their children (Fernandes et al., 2021; Fernandes et al., 2021) as well as more stress in
Moreira & Canavarro, 2018b). In fact, individu- the parental role (Cheung et al., 2019; Fernandes
als high in neuroticism or who experience depres- et al., 2021; Moreira et al., 2019) can predispose
sive and/or anxious symptomatology tend to parents to more reactive parenting, which is con-
ruminate and worry about negative events and to sistent with previous research that has consis-
get caught in downward spirals of negative mood tently shown that parents with psychopathology
and thinking (Muris et al., 2005). Rumination struggle to engage in optimal parenting (Lovejoy
and worry may occupy the attention and consume et al., 2000). Distressed parents might be more
cognitive resources, thus making it difficult for ruminative (Dar & Iqbal, 2015; Nolen-Hoeksema
parents to redirect their attention to the environ- et al., 2008), and, as explained above, this may
ment and, consequently, to be fully aware of the lead them to be less able to bring mindful atten-
present moment when interacting with the child tion and awareness to interactions with their chil-
(Beebe et al., 2007; DeJong et al., 2016; Moreira dren. In addition, anxiety and depression increase
& Canavarro, 2018a; Stein et al., 2012). Hence, parents’ focus on their own needs and promote
rumination may affect parents’ ability to process self-focused attention (Dix & Meunier, 2009;
children’s cues (Beebe et al., 2007; Stein et al., Ingram, 1990). By focusing their attention on
272 H. Moreira
themselves and on their own needs, distressed sadness) may excessively focus on the child’s
parents are less likely to direct their attention negative behavior and thus find it difficult to
toward their children and to be sensitive and adopt an attentive and compassionate stance in
responsive to their needs. Distressed parents may their parenting interactions or to regulate their
also be more self-critical and, consequently, they emotions and behaviors when the child has, for
may be more likely to endorse a negative view of example, an outburst of anger or a tantrum. In
themselves as parents (Goodman & Gotlib, these situations, it can be particularly difficult for
1999). They may therefore struggle to accept parents to regulate their emotions and to not act
their perceived shortcomings and limitations as automatically in an attempt to regulate their
parents and feel that they fail to meet their self- child’s behavior. Moreover, one may think that
defined high standards in their relationships with parents of children who display high levels of
their children. challenging behavior may be more critical of
their own parental functioning and blame them-
selves for their child’s behavior. Future research
Child Variables Children’s characteristics, par- should investigate the role of other important
ticularly their temperament, can also influence child variables on mindful and compassionate
parenting behaviors. For instance, research has parenting, including their mental and physical
shown that children with a difficult temperament health and sociodemographic characteristics
or who are highly reactive tend to elicit less opti- such as age and sex.
mal parenting behaviors, including harsh control
(Kyrios & Prior, 1990; Porter et al., 2005), puni-
tive and distressed reactions to children’s nega- Contextual Variables The context in which
tive emotions (Eisenberg et al., 1999), or parents are embedded also shapes their parenting
inconsistent discipline (Lengua & Kovacs, 2005; behaviors (Belsky, 1984). For example, the sup-
Lengua, 2006). Conversely, fearful or behavior- port that parents receive from family and friends
ally inhibited children tend to elicit more accep- (Angley et al., 2015), the marital relationship
tance and protective responses from their parents (Gao et al., 2019), and the work context (Perry-
(Kiel & Buss, 2012; Shamir-Essakow et al., Jenkins et al., 2017) have a considerable impact
2005). There is also preliminary evidence that on parenting behaviors and on the overall quality
child-related factors can play a role in parents’ of family life. Research on the role of contextual
capacity to enact mindful and compassionate par- variables in mindful and compassionate parent-
enting. For instance, one study found that moth- ing is still scarce; however, it stands to reason that
ers who have a more negative perception of their parents who experience higher levels of environ-
infant’s temperament presented lower levels of mental stress may experience more challenges to
mindful parenting (Fernandes et al., 2021). mindful and compassionate parenting.
Consistent with our model, this relationship was Accordingly, a study that explored work-related
shown to be both direct and mediated by parent- variables shown that parents with flexible work
ing stress. Similar results were found among par- schedules presented significantly higher levels of
ents of school-aged children, with children’s self-regulation in parenting and nonjudgmental
negative reactivity predicting lower levels of acceptance of parental functioning than parents
mindful parenting (Moreira et al., 2020). These with a shift work schedules (Moreira et al., 2019).
findings are consistent with the previous research This study also found that higher levels of work–
showing that a child’s negative affectivity or family conflict (i.e., a conflict between the com-
reactivity may evoke more negative parenting, peting responsibilities and demands of work and
such as more controlling or hostile parental family contexts, which leads to participation in
behaviors (Rothbart & Bates, 2007). Parents of the family role being hampered by participation
children who frequently express strong and nega- in the work role; Weer & Greenhaus, 2014) were
tive emotions (e.g., irritation, frustration, anger, associated with lower levels of all mindful par-
enting dimensions. These relationships between Mindful and Compassionate

work–family conflict and mindful parenting were Parenting and Parenting Behaviors
mediated by anxiety/depression symptoms and
parenting stress, which is congruent with the con- Based on prior research (e.g., Duncan et al.,
ceptual model we propose. This study shows that 2015; Parent et al., 2016a; Wang et al., 2018), we
experiencing work-related stress can spill over propose that mindful and compassionate parent-
into the parenting context, leading parents to ing can influence other parenting practices and
experience higher levels of parenting stress and, behaviors. We consider that bringing the qualities
in turn, engage in less mindful and compassion- of mindfulness and compassion to parenting can
ate parenting (Moreira et al., 2019). Less is help parents establish a relationship with their
understood about the role of macro-level stress- children guided by greater sensitivity, respon-
ors (such as socioeconomic stress) or protective siveness, acceptance, and connection. For
factors (such as social support or healthy marital instance, listening with full attention can help
relationships) in adopting this parental approach. parents to be more attuned to their child’s verbal
and nonverbal communication, which may help
them to be better able to notice and respond more
Mindful and Compassionate accurately to their children’s needs. Developing
Parenting and Parenting Stress greater awareness of the child’s emotional states
can assist parents in correctly identifying their
As presented in Fig. 16.1, and consistent with child’s emotional states and reducing automatic
previous studies (Beer et al., 2013; Bögels et al., patterns of response that may negatively affect
2014; Fernandes et al., 2021; Gouveia et al., parenting practices. By practicing greater self-
2016; Moreira & Canavarro, 2018a), we propose regulation in interactions with the child, parents
that mindful and compassionate parenting creates might be better able to avoid negative cycles of
favorable conditions for parents to experience reactivity and maladaptive parenting interactions
lower levels of parenting stress. However, we in stressful situations and to choose parenting
also consider that the association between parent- behaviors that are consistent with their parenting
ing stress and mindful and compassionate parent- values (Duncan et al., 2009). Mindful parenting
ing is bidirectional and that parenting stress can is the opposite of automatic or reactive parenting,
impair the ability of parents to adopt a mindful as mindfulness prevents automatic reactions to
and compassionate stance in parenting. parenting stress and creates a “space” between
Experiencing high levels of parenting stress may the stressful event and the response in which par-
lead parents to experience parenting as more ents can intentionally choose how to respond to
stressful and taxing than rewarding, which is not the stressful situation (Bögels, 2020; Bögels &
conducive to them being mindful and compas- Restifo, 2014). Greater compassion for them-
sionate in their relationships with their children. selves as parents helps parents to accept their
Therefore, it can be particularly helpful for these mistakes and limitations more easily and to real-
parents to learn mindfulness and self-compassion ize that all parents struggle and make mistakes in
skills. For instance, mindful parenting training their relationships with their children. Finally,
(Bögels & Restifo, 2014), an 8-week program for greater compassion for the child may allow par-
parents with high levels of parenting stress, based ents to accept their behaviors, thoughts, and emo-
on the MBCT (Segal et al., 2002) and on the tions without judging them and automatically
MBSR (Kabat-Zinn, 1990), has been shown to be reacting to them. This greater acceptance helps
effective in reducing parenting stress in parents parents to truly see and understand their children
of infants (Potharst et al., 2017), toddlers and, consequently, to act in a more sensitive and
(Potharst et al., 2021), and children/adolescents attuned way with the child (Bluth & Wahler,
(Bögels et al., 2010, 2014). 2011). However, it is important to note that
although being a mindful and compassionate par-
274 H. Moreira
ent entails adopting an attitude of compassion Moreira et al. (2020) found that higher scores in
and kindness in the relationship with the child, it the mindful and compassionate parenting dimen-
also entails imposing limits and boundaries that sion pertaining to the nonjudgmental acceptance
teach children social rules (Bögels, 2020; Bögels of parental functioning were negatively associ-
& Restifo, 2014). ated with overprotection behaviors. These results
A growing evidence base suggests that mind- suggest that parents who feel more compassion
ful and compassionate parenting is associated for themselves as parents and are better able to
with more positive parenting styles and practices, accept their limitations and imperfections in the
such as more authoritative and less authoritarian parenting role may feel more confident in their
styles (Gouveia et al., 2016; Williams & Wahler, parenting skills and, thus, more secure about
2010), greater warmth and affection (Duncan granting their children more autonomy.
et al., 2015; Parent et al., 2016a; Wang et al., Interestingly, the results of this study also showed
2018), and positive reinforcement (Parent et al., that being better able to notice the child’s emo-
2016a). It has also been shown to be associated tions and to adopt a compassionate attitude
with less dysfunctional disciplinary practices, toward the child can contribute to higher levels of
such as laxness, overreactivity, and verbosity (de overprotection behaviors. Mindful and compas-
Bruin et al., 2014) or harsh and inconsistent dis- sionate parents are usually more attuned to the
cipline (Duncan et al., 2015; Parent et al., 2016a). child; consequently, they may be better able to
Similarly, intervention studies suggest that mind- detect distress in their child and to connect to the
ful parenting training can help parents adopt par- child’s suffering and thus feel more compelled to
enting styles characterized by less rejection and protect the child from situations perceived as
greater autonomy encouragement (Bögels et al., threatening or that provoke distressing emotions
2014), endorse a less overreactive parenting style in the child. Although overprotection is consid-
(Emerson et al., 2021; Potharst et al., 2017, ered a nondesirable and intrusive parental behav-
2019), and be more responsive and affectionate ior, it has a component of warmth that derives
and less hostile toward the child (Potharst et al., from parents’ intention to protect their child from
2017). Mindful and compassionate parents seem potential threats (Holmbeck et al., 2002). Hence,
also to be more likely to employ supportive emo- overprotection often reflects sensitive parenting
tion socialization practices (e.g., encouraging (Buss & Kiel, 2011), which may explain why
emotional expression, comforting the child, and more compassionate parents can also be more
assisting the child in problem-solving) when the overprotective.
child expresses a negative emotion and less likely By promoting higher quality parenting, the
to employ nonsupportive emotion socialization adoption of this present-centered, compassion-
practices (e.g., being distressed, exhibiting puni- ate, and nonreactive parenting approach is a vehi-
tive reactions, and minimizing the child’s dis- cle for promoting positive interactions between
tress; McKee et al., 2017). parents and children and higher quality parent–
Other studies suggest that higher levels of child communication. A study has shown that
mindful and compassionate parenting may help parents with higher levels of mindful parenting
parents adopt a less controlling parenting were more likely to ask their adolescent child for
approach. Lippold et al. (2015) observed that information (e.g., about school) and that children
adolescents whose mothers reported higher lev- were more likely to disclose routine information
els of mindful parenting viewed their mothers as about their activities with them (Lippold et al.,
less overcontrolling, which, according to the 2015). In a more recent study, Lippold et al.
authors, may suggest that these parents may be (2019) corroborated that mindful parenting may
better able to accept children’s need for auton- foster better parent–child communication by
omy and privacy and feel more comfortable giv- showing longitudinally that mindful parenting
ing their children more independence. Likewise, predicted increased levels of adolescent disclo-
in a study with mothers of school-aged children, sure and parental solicitation.
Mindful and Compassionate Children’s Internal Resources In our model of

Parenting and Children’s Outcomes mindful and compassionate parenting, we con-
sider that this parenting approach can provide the
Attachment Considering the effect that mindful necessary and fundamental foundations for the
parenting may have on parental behaviors and, development of important internal resources (i.e.,
consequently, on the quality of the parent–child characteristics that, when present, help the child
relationship, it has been suggested that mindful better cope with difficult emotions and suffer-
parenting is an important pathway for the devel- ing), such as emotion regulation, mindfulness,
opment of a secure attachment relationship self-compassion, and psychological flexibility.
between the child and his or her parents (Duncan We highlight these variables because they are
et al., 2009). There is some preliminary evidence well-known psychological resources that have a
from cross-sectional studies that mindful and strong protective effect on children’s and adoles-
compassionate parenting, and particularly the cents’ psychological functioning and mental
dimensions of listening with full attention and health (e.g., Bluth & Blanton, 2015; Bluth et al.,
compassion for the child, can contribute to more 2017; Kashdan & Rottenberg, 2010; Livheim
positive and secure representations of their rela- et al., 2016; Muris et al., 2016, 2017; Neff &
tionships with their parents in preschool and McGehee, 2010) and because their relationships
school-aged children and adolescents (Moreira with this parenting approach has already received
et al., 2018; Medeiros et al., 2016; Zhang et al., empirical support. Nevertheless, we recognize
2019). Although most studies are cross-sectional, that other variables may be influenced by parent-
the effect of this parental approach on child out- ing and the perception of security that the child
comes seems to be both direct and indirect, develops in the parent–child relationship and in
occurring through parenting behaviors (Parent turn influence the child’s mental health.
et al., 2016b) and child attachment (Moreira
et al., 2018).
Emotion Regulation Emotion dysregulation or
As will be explained below, secure attachment difficulty-regulating emotions has been consis-
lays the foundation for the development of impor- tently identified as a transdiagnostic vulnerability
tant psychological resources for the child’s men- factor that is linked to numerous difficulties and
tal health, such as dispositional mindfulness, forms of psychopathology across the lifespan
self-compassion, emotion regulation, and psy- (Berking & Wupperman, 2012; Riediger &
chological flexibility. This hypothesis, and our Klipker, 2014; Sheppes et al., 2015). Among
model in general, is consistent with a recent inter- children, maladaptive strategies of emotion regu-
generational model that explains how self- lation (e.g., rumination, catastrophizing) were
compassion develops in the context of the shown to be associated with children’s emotional
parent–child relationship (Lathren et al., 2020). problems and psychopathology, whereas adap-
This model explains that parents with a secure tive strategies (e.g., positive reappraisal) seem to
attachment orientation have higher levels of self- have a protective function with regard to chil-
compassion and, consequently, tend to exhibit dren’s mental health (e.g., Chan et al., 2016;
more supportive responses when their child expe- Garnefski et al., 2007; Legerstee et al., 2010; Liu
riences difficult emotions (e.g., anger, sadness, et al., 2016; Orgiles et al., 2018).
shame). These responses, in turn, promote the
development of a child’s secure attachment, Research indicates that although the transmis-
resulting in higher levels of self-compassion and sion of emotion regulation strategies from par-
more positive socioemotional and behavioral out- ents to children may have a genetic basis
comes across several domains. (Goldsmith et al., 2008), the family context, par-
ticularly parenting practices and behaviors, plays
a critical role in the development of adaptive
276 H. Moreira
emotion regulation ability during childhood and able to regulate their emotions (e.g., Jin et al.,
adolescence (Eisenberg et al., 1998; Jaffe et al., 2017), whereas nonsupportive reactions to chil-
2010; McEwen & Flouri, 2009; Melnick & dren’s negative emotions (e.g., punishing or min-
Hinshaw, 2000; Morris et al., 2007; Rutherford imizing children’s emotional expression) are
et al., 2015; Zeman et al., 2006). A few studies usually associated with children’s emotional dys-
have shown that a mindful and compassionate regulation and internalizing symptoms (e.g.,
approach to parenting may play an important role Sanders et al., 2015). As already mentioned in a
in shaping this capacity. For instance, in a study previous section of this chapter, a study has
with parents of children aged between 3 and shown that mindful parenting is associated with
7 years, mindful parenting and the quality of par- more supportive emotion socialization practices
ent–child attachment mediated the association (e.g., greater encouragement of children’s emo-
between parents’ dispositional mindfulness and tional expression; more emotion-focused
children’s emotional lability/negativity and emo- responses, such as comforting the child; and
tion regulation (Zhang et al., 2019). According to more problem-focused responses, such as help-
the authors, mindful parents tend to accept chil- ing the child solve a problem) and fewer nonsup-
dren’s emotions and fulfill their emotional needs, portive practices (i.e., minimization of child
which are factors known to facilitate secure distress, punitive reactions, and experience of
attachment and the development of adaptive distress; McKee et al., 2017). Thus, it can be
emotion regulation skills (Gottman et al., 1996; hypothesized that mindful and compassionate
Morris et al., 2007). Similarly, in a study that parenting, as a parenting approach that facilitates
included mother–adolescent dyads, Moreira and appropriate emotion socialization, can also con-
Canavarro (2019) found that higher levels of tribute to the development of more adaptive emo-
mindful parenting, particularly in the dimensions tional regulation throughout development.
of compassion for the child, listening with full Second, the emotional climate of the family,
attention, and nonjudgmental acceptance of which is determined by several processes and
parental functioning, were associated with lower dynamics, including the parent–child attachment
levels of emotion regulation difficulty in relationship, the parenting style, the marital rela-
adolescents. tionship, and the emotional expressivity of fam-
The processes through which mindful and ily members (Morris et al., 2007), also plays an
compassionate parenting may foster adaptive important role in how parents influence their chil-
emotion regulation in children and adolescents dren’s emotion regulation abilities. In a positive
can be diverse. Morris et al.’s (2007) tripartite family climate, children feel secure in feeling and
model of the impact of the family on children’s expressing their emotions because they expect to
emotion regulation and adjustment postulates be accepted and understood and they know that
that the family context may affect the develop- their emotional needs will be validated and satis-
ment of children’s emotion regulation via three fied. In contrast, when the emotional climate of
processes: (1) parenting practices, (2) the emo- the family is negative (e.g., due to negative par-
tional climate of the family, and (3) observation. enting practices such as psychological control or
First, parenting practices, particularly emotion- negative affective interactions), children feel less
related practices (i.e., the way parents socialize secure and may experience greater difficulty
their children with emotions; Eisenberg et al., adaptively regulating their emotions (Sim et al.,
2003), may have a profound impact on children’s 2009). Mindful parents seem to create a positive
regulatory ability. The existing research suggests family climate, adopting parenting styles charac-
that parents who employ supportive parental terized by emotional validation, warmth, and
emotion socialization practices (i.e., those who affection (Duncan et al., 2015; Parent et al.,
allow children to express their emotions and who 2016a; Wang et al., 2018), which in turn facili-
comfort, encourage, and help the child solve tates the development of a secure relationship
problems) usually have children who are better with their children (Medeiros et al., 2016; Zhang
et al., 2019) and creates the ideal foundation for one’s own suffering (Neff, 2003b). Therefore,
the development of adaptive emotion regulation. self-compassion allows individuals to have a
Third, children can learn emotion regulation more balanced perception of negative emotions
strategies through observation or modeling. By and to cope with negative emotions without
repeatedly observing how their parents respond avoiding them, amplifying them, or overidentify-
verbally and behaviorally to situations that elicit ing with them. In addition, self-compassionate
emotions (i.e., how they usually regulate their individuals are less likely to criticize, blame, or
emotions), children can internalize these regula- judge themselves in difficult situations and are
tory strategies and begin to use them in the same more likely to view painful situations as a normal
emotion-eliciting situations (Rutherford et al., part of life. Therefore, they usually cope better
2015). Research has shown that mindful and with stress and negative emotions and may con-
compassionate parents are more likely to employ sequently be better able to effectively regulate
adaptive emotion regulation skills (Gouveia negative emotional states when they arise (Allen
et al., 2019). In addition, they tend to present & Leary, 2010).
higher levels of self-compassion (Gouveia et al., Therefore, we propose that because of their
2016; Moreira et al., 2016) and dispositional self-compassion and mindfulness skills, mindful
mindfulness (Gouveia et al., 2016; Han et al., and compassionate parents may be better able to
2021), characteristics that likely help them to regulate their emotions and behaviors in stressful
regulate their negative emotions more adaptively moments, particularly those that arise in interac-
in times of stress or suffering (e.g., Chiesa et al., tions with their children. They may also be less
2013; Fogarty et al., 2015; Roemer et al., 2015), likely to criticize or blame themselves during dif-
particularly those that arise in interactions with ficult times with the child. As they observe their
their children. In fact, mindfulness is associated parents coping with stressful situations in an
with a greater ability to attend to internal and accepting and nonjudgmental manner and with-
external events, which in turn promotes the indi- out acting impulsively, children may learn and
vidual’s ability to detect the need to implement internalize this adaptive way of regulating nega-
emotion regulation strategies (Roemer et al., tive emotions. In contrast, if children observe
2015). By promoting greater sensitivity to affec- their parents being self-critical or unable to regu-
tive cues and an early awareness of subtle changes late their emotions and behaviors in an adaptive
in emotional states that signal the need for con- manner, they may learn and internalize the mal-
trol, mindfulness can enhance executive control adaptive strategies their parents use to regulate
and emotion regulation (Teper et al., 2013). In their negative emotions (Moreira et al., 2018).
addition, as mindfulness involves nonjudgmental
acceptance of emotions and thoughts and psy- Dispositional Mindfulness As depicted in
chological flexibility rather than avoidance, it Fig. 16.1, mindfulness is another psychological
may also decrease the intensity of emotional resource that can be developed in the context of a
responses and increase the tolerance of negative mindful and compassionate parenting, both
affect, which are important aspects of emotion directly and indirectly through parenting behav-
regulation (Roemer et al., 2015) that children can iors and, particularly, through the development of
learn through observation. Previous studies have a secure attachment in children. According to this
also found a consistent link between self- hypothesis, some cross-sectional studies with
compassion and self-report measures and bio- parent–adolescent dyads have already shown that
logical indices of emotion regulation (Diedrich mindful and compassionate parenting is associ-
et al., 2014; Svendsen et al., 2016). Being self- ated with higher levels of adolescent disposi-
compassionate entails not avoiding or repressing tional mindfulness (Moreira et al., 2018; Moreira
negative emotions and, instead, acknowledging & Canavarro, 2018b) and that this association
them, viewing them as part of the human condi- can be mediated by the degree of security the
tion, and experiencing a true desire to alleviate adolescent perceives in the parent–child relation-
278 H. Moreira
ship (Moreira et al., 2018). These results are in develop adequately, allowing the child to culti-
line with previous studies that suggested that the vate compassionate self-to-self relationships
capacity for mindful awareness is related to the (Gilbert, 2005b; Gilbert & Procter, 2006). These
quality of one’s early relationships with attach- positive experiences promote the development of
ment figures (Caldwell & Shaver, 2013; Pepping emotional memories of being soothed, protected,
& Duvenage, 2016; Ryan et al., 2007). Individuals and cared for (Lee, 2012), allowing the individ-
who were raised by sensitive and responsive ual to regulate his or her emotions with affection,
caregivers (i.e., who were attuned to, mirrored, warmth, and care when needed. In contrast, when
and empathized with the child’s experiences) and parents are unresponsive or inconsistently
who developed a secure attachment seem to be responsive or are even neglectful or abusive, they
more likely to develop the reflective, regulatory, do not provide the fundamental conditions for the
and self-observing capacities that characterize development of secure attachment (Mikulincer &
dispositional mindfulness (Caldwell & Shaver, Shaver, 2016) and, consequently, for the develop-
2013, 2015; Melen et al., 2017; Pepping et al., ment of self-compassion (Shaver et al., 2017). In
2013, 2015; Ryan et al., 2007; Shaver et al., such a relational context, the soothing system is
2007). For instance, Pepping and Duvenage underdeveloped and understimulated, and the
(2016) found that adolescents’ recollection or child/adolescent is likely to become more self-
current experiences of parental warmth and rejec- critical and less self-compassionate (Gilbert,
tion were associated with their current levels of 2005a; Gilbert & Procter, 2006). Individuals
dispositional mindfulness through their attach- raised in these relational contexts may have fewer
ment orientations. Although prior research has available emotional memories of being loved and
suggested that mindfulness skills have their roots soothed when they need to regulate their emo-
in family dynamics and parent–child interactions in difficult moments (Lee, 2012).
tions, further studies are needed to establish that
mindful parenting can lead to the development of There is empirical evidence of the associa-
mindfulness skills in children/adolescents. tions among early experiences with caregivers,
attachment styles, and levels of self-compassion.
For instance, some studies have shown that an
Self-Compassion The way parents interact with individual’s level of self-compassion is associ-
their children may also have a strong impact on ated with his or her attachment orientation
the development of children’s self-compassionate (Moreira et al., 2015, 2016; Neff & Beretvas,
or self-critical inner dialogues (Gilbert & Procter, 2013). Neff and McGehee (2010) also found that
2006; Lathren et al., 2020; Neff, 2011). Although adolescents with low levels of self-compassion
limited, existing research found that children of are more likely to have critical mothers, dysfunc-
mindful and compassionate parents also tend to tional family environments, and insecure attach-
report higher levels of self-compassion (Moreira ment styles. Based on these results, the authors
et al., 2018; Moreira & Canavarro, 2019). In fact, concluded that self-compassion can be viewed as
it has been argued that self-compassion develops an “internal reflection of the parent–child rela-
in the context of positive and security-boosting tionship” (Neff & McGehee, 2010, p. 236), which
interactions with attachment figures (Gilbert, means that children with cold and critical parents
2005a; Gilbert & Procter, 2006; Neff & McGehee, may internalize a cold and critical internal dia-
2010; Neff & Beretvas, 2013; Shaver et al., logue, whereas those with warm and caring par-
2017). In an optimal caring environment with a ents are more likely to internalize a
consistently supportive and caring attachment self-compassionate way of relating to
figure, the child may develop internal working themselves.
models of the self and others as being reliable Parents who adopt a compassionate and mind-
and worthy of care and love (Collins et al., 2004), ful approach in parenting tend to be more caring,
and the soothing system of affect regulation may available, and responsive to their child’s needs,
thereby creating the necessary foundation for the sitivity; Hayes et al., 2012) and cognitive fusion
development of a secure attachment (Duncan (a process that refers to an attachment or entan-
et al., 2009; Medeiros et al., 2016) and, conse- glement with the content of private events and
quently, for the development of self-compassion responding to the content of private events as if
(Gilbert, 2005a; Gilbert & Procter, 2006). In they were accurate representations of reality;
addition, as already mentioned, as these parents Greco et al., 2008).
tend to have higher levels of self-compassion
(Gouveia et al., 2016; Moreira et al., 2016) and of The limited research conducted on the rela-
dispositional mindfulness (Gouveia et al., 2016; tionship between mindful and compassionate
Parent et al., 2016b; Zhang et al., 2019), they parenting and children’s psychological flexibility
may also model an adaptive way of coping with suggests that this parenting approach, particu-
stressful life events and with difficult thoughts larly the dimension of listening with full atten-
and emotions. According to Neff (2011), being tion, can indeed foster adolescents’ psychological
self-compassionate in front of a child is one of flexibility (Moreira & Canavarro, 2019). Parents
the most powerful ways to help children develop who are mindfully aware in interactions with
self-compassion. If children see their parents their child may model an attitude of being pres-
coping with difficult situations in a mindful and ent, that is, an attitude of nonjudgmental aware-
compassionate manner, they may learn this adap- ness of psychological and environmental events
tive self-to-self relating through observation. In as they occur, which contrasts with experiential
contrast, children whose parents usually cope avoidance. In addition, as already mentioned,
with difficult situations with self-criticism do not mindful and compassionate parents seem to help
have a compassionate and mindful model to fol- their children develop mindfulness skills
low and, instead, may learn that difficult situa- (Moreira et al., 2018), which may enable their
tions and moments of suffering should be handled children to better notice and observe their
with negative emotions and harsh self-judgment. thoughts and feelings without becoming entan-
gled in the content of those private events and
Psychological Flexibility Finally, our model behaving as if they were literally true.
also predicts that mindful and compassionate
parenting may foster children’s psychological Mental Health The ultimate outcome in our
flexibility, which is another psychological conceptual model is the child’s mental health.
resource know to be associated with several indi- From our perspective and based on the findings
cators of emotional well-being (Kashdan & of various empirical studies, mindful and com-
Rottenberg, 2010; Livheim et al., 2016; Muris passionate parenting can have a beneficial effect
et al., 2017). Psychological flexibility has been on a child’s mental health by enabling the child to
described as one’s ability to stay in contact with develop secure attachment and internal resources
the present moment and to change or persist in a such as adaptive emotion regulation strategies,
certain behavior based on personal values (Hayes mindfulness, self-compassion, or psychological
et al., 2006). The inability to remain in contact flexibility, which are known to promote adaptive
with the present moment and to engage in pat- psychological functioning and child mental
terns of effective action that are linked to one’s health (Bluth & Blanton, 2015; de Bruin et al.,
life values (i.e., psychological inflexibility) 2011; Muris et al., 2016, 2017; Neff & McGehee,
results from several processes, including experi- 2010). In fact, mindful parenting has been associ-
ential avoidance (unwillingness to experience ated with diverse positive adjustment outcomes,
certain unwanted private events, including including lower levels of internalizing (e.g.,
thoughts, memories, emotions, and bodily sensa- depression, anxiety) and externalizing (e.g.,
tions, and efforts to avoid, suppress, or eliminate behavior problems) problems in children (Calvete
those unwanted private experiences or otherwise et al., 2020; Han et al., 2021; Parent et al., 2016b),
control their frequency, form, or situational sen- better generic or disease-specific quality of life
280 H. Moreira
(Medeiros et al., 2016; Moreira et al., 2018; enting stress and adopt more positive parenting
Serkel-Schrama et al., 2016), and a lower likeli- styles and practices. Based on existing research
hood of adolescent substance use (Turpyn & and previous theoretical contributions, we pro-
Chaplin, 2016). Studies assessing the effects of posed a conceptual model that seeks to explain
mindfulness-based parenting programs on chil- how a parenting approach characterized by high
dren’s psychological functioning also support the levels of (self-)compassion and mindfulness (i.e.,
role of this parenting approach on children’s a mindful and compassionate parenting approach)
adjustment (Bögels et al., 2010, 2014; Coatsworth can promote better mental health in children
et al., 2010; van der Oord et al., 2012). For through a set of processes. This model stresses
instance, Bögels et al. (2014) found that after the importance of perceiving parenting as a pro-
completing a mindful parenting program, parents cess resulting from the influence of several inter-
of children with a diagnosed psychiatric disorder related factors, namely, parenting factors (e.g.,
reported that their children less often presented parents’ self-compassion), child factors (e.g.,
internalizing and externalizing difficulties. temperament), and contextual factors (e.g., work
context). According to this model, this parenting
Despite the increasing evidence demonstrat- approach fosters lower levels of parenting stress
ing a positive association between this parenting and parental behaviors that are more sensitive
approach and children’s positive psychosocial and responsive to the child’s needs and that pro-
adjustment, only a few studies have attempted to mote the development and strengthening of a
understand which mechanisms might be respon- secure attachment. In turn, a secure attachment
sible for this relationship. As highlighted in the establishes the necessary and essential basis for
previous sections of this chapter, and consistent the development of critical internal resources,
with our model, different variables (parental such as mindfulness, self-compassion, psycho-
behaviors, child attachment, and child internal logical flexibility, and emotional regulation, that
resources) may explain why mindful parenting protect the child’s mental health throughout
can have such an important effect on children’s development.
mental health. Understanding these mechanisms The proposed model is an intergenerational
can not only contribute to a significant advance of model that highlights the importance of parenting
the scientific knowledge in this area, but also practices as a privileged vehicle for conveying
guide the development of parenting interven- important skills such as self-compassion and
tions. Therefore, future studies should continue mindfulness. In fact, theory and research have
to explore the processes linking this parental shown that we tend to treat our children and our-
approach to the child’s mental health, and partic- selves in the same way that we were treated as a
ularly the processes that explain the therapeutic child. Parents who had sensitive caregivers and
change observed in the psychological adjustment developed a secure attachment learned to regu-
of children whose parents participated in a mind- late their emotions more adaptively and were
fulness- and compassion-based parenting able to develop a compassionate intrapersonal
intervention. relationship. These individual characteristics
decisively influence the way parents later relate
to their children. Secure and compassionate par-
Conclusions ents are more likely to adopt a mindful and com-
passionate stance in parenting, thereby providing
In this chapter, we have sought to demonstrate the ideal conditions for the development of a
how parents’ self-compassion can influence their secure attachment and for the flourishing of com-
parenting. Although research into the role of self- passion and other protective factors of their
compassion in parenting is still in its infancy, child’s mental health. Therefore, learning to be
there is preliminary empirical evidence that self- more mindful and compassionate, both in the
compassion can help parents experience less par- relationship with oneself and children, can help
parents break the maladaptive intergenerational Psychology: Science and Practice, 10(2), 125–143.
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functioning in children, who may later become ferent clinical groups: A systematic review & meta-
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The Psychophysiology
of Self-Compassion 17
Elizabeth T. Slivjak, Alex Kirk, and Joanna J. Arch
Introduction ology, including psychophysiology and periph-

eral immune and inflammatory markers.
Self-compassion has become an established area The stress system in humans is located both
of scientific inquiry. In this chapter, we focus on within the central nervous system and the periph-
the peripheral physiological effects of self- ery. The autonomic nervous system, a division of
compassion, including physiological measures the periphery, is consisted of three branches: the
linked to the autonomic nervous system and to sympathetic, parasympathetic, and enteric ner-
immune functioning. We review the evidence for vous systems. When homeostasis is disrupted by
whether self-compassion affects peripheral stress detection of an internal or external stressor or
and immune response systems in a manner that threat (e.g., infection, emotional distress), the
aligns with greater stress resilience and with sympathetic nervous system and hypothalamic–
more adaptive autonomic and immune function- pituitary–adrenal (HPA) axis are activated (Miller
ing. Studies encompass various forms of self- & O’Callaghan, 2002). Activation of these two
compassion, including dispositional or trait systems results in the body’s stress or fight-or-
self-compassion, defined herein as the self- flight response, wherein the brain stimulates
reported tendency to generally embody a com- changes in behavior and in periphery physiology
passionate state or perspective regarding one’s to enhance survival, including increased heart
own experience; induced state self-compassion, rate, blood pressure, respiration rate, peripheral
which reflects brief inductions or brief trainings vasoconstriction, and reduced appetite. These
in self-compassion intended to produce an imme- changes result in heightened arousal and alert-
diate self-compassionate state; and regularly ness and increased vigilance and attention, facili-
trained self-compassion, which reflects more tating detecting and responding to threat. Threat
ongoing, multi-week, formal interventions that detection also results in decreased parasympa-
aim to increase self-compassion in a more endur- thetic nervous system activation, which is largely
ing manner. This chapter reviews the findings on responsible for bodily functions that occur at rest,
self-compassion with regard to peripheral physi- such as digestion. Whereas time-limited activa-
tion of the autonomic stress response systems
provides benefits for survival, its prolonged or
E. T. Slivjak · A. Kirk · J. J. Arch (*) chronic activation is associated with adverse con-
Department of Psychology and Neuroscience, sequences and poor physical health, including
University of Colorado Boulder, Boulder, CO, USA
e-mail: [email protected];
suppressing key functions such as immune func-
[email protected] tioning. Thus, researchers have been interested in

https://doi.org/10.1007/978-3-031-22348-8_17
292 E. T. Slivjak et al.
understanding the effects of interventions that in cellular signaling and messaging, and has
dampen or enhance recovery of biological received attention as a proinflammatory cytokine
responses to acute and chronic stress. associated with higher levels of psychological
The studies discussed in this chapter evaluate stress (Slavich & Irwin, 2014). Though IL-6 is a
a range of peripheral physiological effects of complicated protein involved in both pro- and
self-compassion. The most common physiologi- anti-inflammatory processes (Del Giudice &
cal measure used in these studies is high fre- Gangestad, 2018), elevations in IL-6 can be inter-
quency heart rate variability (HF-HRV) and preted as a metric of proinflammatory activity
related HRV measures that assess the parasympa- when they occur in conjunction with the activa-
thetic nervous system influence on the time inter- tion of other physiological stress systems, par-
vals between heartbeats via the vagus nerve (the ticularly the sympathetic nervous system
tenth cranial nerve). HF-HRV has been (Michopoulos et al., 2017). Salivary IgA is a
conceptualized as “a transdiagnostic biomarker secreted antibody involved in neutralizing and
of self- regulation and cognitive control” blocking pathogens from accessing various tis-
(Beauchaine & Thayer, 2015, p. 338), with higher sues. As it relates to stress research, sIgA is under
HF-HRV (in general) reflecting greater levels of regulatory control from neuroendocrine circuits
self-regulation and cognitive control. Heart rate activated by psychological stress (Bosch et al.,
(HR), reported in several relevant studies, reflects 2002). Lower levels of sIgA (Phillips et al., 2006)
both sympathetic and parasympathetic auto- are associated with higher rates of illness and
nomic nervous system influences (Berntson infection (Pilette et al., 2001). Thus, sIgA is a
et al., 2007). Skin conductance, the activity of metric of immune activity influenced by neural
sweat glands, reflects sympathetic nervous sys- regions associated with psychological stress.
tem activity (Dawson et al., 2007), and thus is Each of these physiological measures, as well
considered a more direct measure of sympathetic as the biological systems in which they are
activation. Salivary alpha-amylase (sAA), an embedded, is highly complex, responsive to
enzyme found in saliva, also tracks predomi- shifts in environmental demands, and interacts
nantly with the sympathetic nervous system, with with a range of other biological systems, often
higher levels reflecting higher levels of sympa- including one another. However, a full descrip-
thetic activation (Rohleder et al., 2004). Cortisol tion of their complexity lies beyond the scope of
is produced by the body’s other major stress this chapter.
response system, the HPA axis, which in humans Most of the work on self-compassion and
tends to be slower acting than the sympathetic peripheral physiology relies on Neff’s (2003a, b)
nervous system and to respond most robustly to definition of self-compassion, which encom-
stressors characterized as uncontrollable and passes three dimensions: “being kind and under-
socially threatening (Dickerson & Kemeny, standing toward oneself in instances of pain or
2004). failure rather than being harshly self-critical; per-
In addition, significant work has established a ceiving one’s experiences as part of the larger
robust relationship between higher levels of psy- human experience rather than seeing them as iso-
chological stress and increased immune activa- lating; and holding painful thoughts and feelings
tion (Marsland et al., 2017). In regard of this in mindful awareness, rather than overidentifying
connection, research to date has begun to exam- with them” (p. 223). Based on this three-part def-
ine the extent to which self-compassion training inition of self-compassion, Neff (2003a) devel-
can improve immune outcomes, including assess- oped and validated a corresponding 26-item
ing two markers as correlates of immune system Self-Compassion Scale (SCS), which serves as
activation: interleukin 6 (IL-6), measured from the primary self-report measure for trait or dispo-
blood plasma, and salivary immunoglobulin A sitional self-compassion used in the studies in
(sIgA). IL-6 is a commonly studied cytokine, a this chapter.
class of immune system protein broadly involved
17 The Psychophysiology of Self-Compassion 293
While writing this chapter, we identified 23 18–35 years), researchers found that trait self-
studies documenting the relationship between compassion led to lower proinflammatory mark-
self-compassion and physiology. Most of these ers (IL-6) in response to an initial social
were published recently, demonstrating an performance stressor and lower anticipatory pro-
emerging interest in the relationship between inflammatory response to a repeated social per-
self-compassion and physiological outcomes. formance stressor, suggesting greater
The included articles reported on a range of bio- physiological resilience to social performance
markers, and they mostly included healthy adult stress (Breines et al., 2014). Participants took
samples and stress (as opposed to mental health part in two TSSTs over 2 consecutive days to
related) outcomes. Ultimately, we categorized evaluate responses to both a novel and repeated
the included articles into three sections: (1) stressor. On both days, blood draws to assess for
observational studies of trait self-compassion, (2) IL-6 were taken at baseline as well as 30 and
brief laboratory studies and experiments designed 120 min following the TSST. As expected, IL-6
to train self-compassion skills, and (3) lengthier levels increased following the social stressor dur-
clinical interventions. We begin with reviewing ing both laboratory sessions, without evidence of
the evidence for links between self-compassion a habituated IL-6 response to the repeated
and peripheral physiology by focusing on obser- stressor. Additionally, as predicted, baseline trait
vational studies of trait self-compassion and self-compassion negatively predicted day 1 IL-6
stress. response to the TSST, such that higher trait self-
compassion was associated with lower levels of a
proinflammatory response to the novel stressor.
bservational Studies of Trait
O Surprisingly, however, baseline trait self-
Self-Compassion and Stress compassion did not predict Day 2 IL-6 response
to the TSST. In additional analyses conducted to
Observational studies provide insight into the better understand this lack of association, find-
relationship between individual differences in ings showed an elevated IL-6 response prior to
self-compassion and physiological responses to the TSST on Day 2 for individuals with lower
laboratory-induced stressors. Biomarkers that trait levels of self-compassion. The authors
have been studied in relation to self-compassion hypothesized that this elevated anticipatory IL-6
in observational studies include IL-6, sAA, heart response could have been due to anticipatory
rate (HR), HF-HRV, blood pressure (BP), and anxiety of the upcoming TSST or rumination
cortisol. Most of the studies in this area have regarding the previous day’s TSST and prevented
assessed self-reported self-compassion and bio- a more elevated IL-6 response to the TSST.
markers at baseline, followed by exposure to the Having demonstrated a relationship between
Trier Social Stress Test (TSST), a standardized trait self-compassion and proinflammatory
laboratory social performance stressor that responding, Breines et al. (2015) next sought to
includes anticipation, stress, and recovery phases examine whether individuals with greater trait
(Kirschbaum et al., 2008); during the TSST in the self-compassion display less sympathetic ner-
identified studies, tasks typically included a vous system activation in response to novel and
5-min speech and a 5-min mental math task, both repeated stressors. Given that the proinflamma-
performed in front of two or three study judges. tory response to stress is largely driven by
Despite limitations including small, homoge- increased sympathetic nervous system activity,
nous samples and lack of direct manipulation of lower IL-6 in the previous study would suggest a
self-compassion, the available observational lower sympathetic nervous system response, as
studies provide evidence that is consistent with a measured here by lower sAA. Thirty-three
protective role of trait self-compassion in buffer- healthy young adults (ages 18–34 years) com-
ing biological stress responses. For example, in a pleted baseline self-report measures including
study of 41 healthy young adults (ages the SCS (Neff, 2003a). Participants then com-
pleted initial saliva collection, followed by the 33 and 41 healthy young adults, respectively
TSST, with additional saliva collection at multi- (Neff et al., 2018). In their reanalysis, Neff et al.
ple timepoints over a 60-min period. Participants (2018) examined correlations between these
completed the TSST again the following day. As physiological markers and baseline self-
predicted, for each individual day of the TSST, compassion scores, including total SCS, positive
higher levels of trait self-compassion were asso- subscale, negative subscale, and the individual
ciated with significantly lower sAA responses to six subscale scores. For the TSST completed on
the TSST with medium-to-large effect sizes. the first day, total SCS and both positive and neg-
Additionally, unlike the robust IL-6 response ative subscale scores all moderately correlated
observed across 2 days of social stress tasks with sAA and IL-6, with no significant difference
(Breines et al., 2014), sAA responses decreased in the correlations between the physiological
significantly across the repeated stressors, markers and each of the positive and negative
although the overall habituation in sAA from subscale scores. In terms of individual subscales,
Day 1 to day 2 was not associated with baseline two positive subscales (self-kindness and mind-
self-compassion, potentially due to an already fulness) and two negative subscales (isolation
low sAA response to the novel stressor among and overidentification) significantly correlated
self-compassionate individuals. with sAA and IL-6 in the expected direction (i.e.,
Importantly, while these studies have contrib- negative correlations for the positive subscales
uted to our understanding of the relationship and positive correlations for the negative sub-
between trait self-compassion and physiological scales), whereas common humanity and self-
stress, not all researchers view self-compassion judgment did not. On the second day of the TSST,
as a unidimensional construct, but instead as con- only sAA significantly correlated with SCS
sisting of two distinct factors composed of posi- scores; again, total SCS and both positive and
tive and negative characteristics (Costa et al., negative subscale scores moderately correlated
2015; López et al., 2015). Neff’s SCS (Neff, with sAA. Of the individual subscales, only iso-
2003a) assesses a total self-compassion score lation was significantly associated with sAA,
made up of six subscales – three positive (e.g., again in the expected direction. Importantly, the
self-kindness, common humanity, and mindful- authors noted a smaller sample size as well as
ness) and three negative subscales (e.g., self- smaller intercorrelations for the second day of
judgment, self-isolation, and overidentification). the TSST. Given these overall findings, the
Neff et al. (2018) argue that both positive and authors concluded that the positive and negative
negative subscales are central to self-compassion. subscales do not each uniquely predict distinct
Others posit that the SCS’s negative subscales are underlying physiology, as both correlate moder-
significantly more related to psychopathology ately with sympathetic nervous system and pro-
than the positive subscales, thus disproportion- inflammatory responding.
ately increasing the link between a total SCS In addition to sAA and IL-6, researchers have
score and psychopathology (Muris & Petrocchi, examined the relationship between dispositional
2017). Moreover, researchers have argued that self-compassion and vagally mediated heart rate
differential physiological systems might be variability (vmHRV), a biological marker of the
involved for positive versus negative aspects of parasympathetic nervous system control over
compassion (Gilbert et al., 2011). heart rate variability and a proposed indicator of
Given this controversy, Neff et al. (2018) the ability to adaptively regulate emotions and
thoughtfully reanalyzed data from the two afore- stress. In a study of 53 healthy university stu-
mentioned studies (Breines et al., 2014, 2015) to dents, participants completed baseline measure-
evaluate the relationship between physiological ments of trait self-compassion as assessed by the
stress response and various subcomponents of SCS as well as resting vmHRV (assessed with the
self-compassion. A reanalysis was conducted in root mean square of successive differences
which data for sAA and IL-6 were available for [RMSSD], e.g., between R-R intervals in the
ECG), measured during a 5-min interval in which the only physiological measure significantly
participants were instructed to breath slowly and buffered by trait self-compassion, with an inverse
relax (Svendsen et al., 2016). Additionally, a sub- relationship between higher self-compassion and
sample of participants (n = 26) wore heart moni- lower systolic BP. No significant differences
tors to collect physiological data over 24 h. As across the groups emerged in change of HR dur-
predicted, young adults with higher trait self- ing stressor tasks or in HF-HRV. Similarly,
compassion demonstrated higher resting vmHRV despite lower overall cortisol output among the
during the baseline period (r = .52, p < .01). This more highly self-compassionate adolescents, a
positive correlation was also found with a 24-h group difference did not emerge (Hedge’s
measure of vmHRV assessed outside of the labo- g = 0.12). The authors highlighted ceiling effects
ratory (r = .50, p < .02), demonstrating the con- in HR on stressor tasks as well as a lack of gender
tinued association between higher balance between groups (including no male par-
self-compassion and greater vmHRV in a more ticipants in the low self-compassion group) as
naturalistic setting. plausible explanations for a failure to find physi-
Luo et al. (2018) extended the work conducted ological differences across the two groups.
by Svendsen et al. (2016) by examining vmHRV Like adolescence, older adulthood can repre-
in the context of the TSST, as opposed to resting sent a life stage often characterized by unique
and naturalistic vmHRV. In their study, 85 male age-related stressors – in this case, more persis-
university students in China completed the SCS, tent and less controllable stressors like declining
and students with self-compassion scores in the physical health. To examine whether self-
upper and lower 27% were asked to participate in compassion serves a protective function during
a laboratory session as part of high- and low-self- older adulthood, a pioneering study evaluated the
compassion groups, respectively (n = 17 for both relationship between trait self-compassion and
groups). Results showed that HR did not differ diurnal cortisol secretion among 233 community-
significantly between groups but vmHRV did dif- dwelling older adults ages 59–93 years (Herriot
fer. Similar to results from Svendsen et al. (2016), et al., 2018). Five salivary cortisol samples were
baseline vmHRV (assessed via RMSSD) was collected per day over 3 nonconsecutive days in a
higher among self-compassionate students. given week; researchers used area-under-the-
Additionally, self-compassionate students curve (AUC) to calculate daily cortisol levels,
showed significantly higher vmHRV during the and then computed average cortisol secretion
social stressor and recovery phases on the TSST, using daily AUC cortisol levels. Self-compassion
although no difference was found during the was assessed using the 12-item Self-Compassion
anticipation stage of the stressor. Scale (Raes et al., 2011), a short-form of Neff’s
Whereas most studies examined the relation- SCS (Neff, 2003a). The authors found that among
ship between self-compassion and physiological older adults who reported high physical health
functioning among healthy young adults, Bluth problems, functional disabilities, and life regrets,
et al. (2016) hypothesized a protective function only those who were low in self-compassion
for self-compassion during adolescence, a life showed higher levels of cortisol (AUC). Thus, the
stage marked by transitions that can increase detrimental effects of physical health problems
stress. Twenty-eight adolescents (ages and functional disability in influencing cortisol
13–18 years) completed a laboratory session con- levels may be buffered by higher levels of self-
sisting of physiological (e.g., BP, HR, HF-HRV, compassion. Importantly, there was no evidence
and salivary cortisol) and psychological mea- for a main effect of stressors on cortisol levels,
sures as well as the TSST. Analyses were con- indicating that individual differences in interpre-
ducted using a median split approach that tation of stressors in self-compassionate (or non-
categorized adolescents into those with higher self-
compassionate) terms rather than the
(n = 16) and lower (n = 12) baseline trait self- stressors themselves may most significantly
compassion. Systolic BP response to stress was impact physiological responses to stress.
In addition to research among adolescents and among more trait self-compassionate individuals
older adults, one study examined self-compassion both at rest (Luo et al., 2018; Svendsen et al.,
and physiological health in a group that may be 2016) and during a laboratory stressor (Ceccarelli
prone to frequent failure and thus self-criticism – et al., 2019; Luo et al., 2018) and during stressor
athletes (Ceccarelli et al., 2019). Following base- recovery in one study (Luo et al., 2018) but not
line measures of HF-HRV and trait the other (Ceccarelli et al., 2019). In addition, no
self-compassion among 91 adult university or group differences were found in HRV among
national level athletes (ages 18–40 years) across high- and low-self-compassionate adolescents
a variety of sports, participants took part in a completing a social stressor (Bluth et al., 2016);
standardized laboratory stressor where a only systolic BP differed. Two studies similarly
researcher read aloud from a guided imagery found no evidence of a significant association
script, asking participants to recall a recent sport between self-compassion and HR (Bluth et al.,
failure. The researcher prompted athletes to recall 2016; Luo et al., 2018), though both were small
a mistake or setback in as much detail as possi- and thus likely underpowered. Second, two stud-
ble, focusing attention on emotions and physical ies evaluated cortisol as an index of HPA axis
sensations experienced at the time of the failure activity. Herriot et al. (2018) reported a signifi-
as well as reexperienced in the present moment. cant moderation effect in which higher self-
Results showed that baseline trait self-compassion compassion correlated with lower diurnal cortisol
was significantly associated with HF-HRV dur- levels in older adults who reported high physical
ing the brief (2-min) recollection of sport-related health problems, functional disabilities, and life
failure, such that more self-compassionate ath- regrets. Finally, markers of inflammation (IL-6)
letes displayed increased parasympathetic activ- and sympathetic nervous system activation (sAA)
ity (i.e., higher HF-HRV), and thus increased were each examined in only one observational
self-regulation during the stress induction. study (Breines et al., 2014, 2015). Breines et al.
However, this relationship was not found during (2014) found evidence for lower IL-6 response to
a brief (2-min) recovery phase immediately fol- a novel stressor among self-compassionate indi-
lowing the stressor, suggesting that trait self- viduals, though this association was not signifi-
compassion increased athletes’ physiological cant for a repeated stressor. Similarly, Breines
regulation primarily during the stressor itself. et al. (2015) demonstrated an inverse relationship
between trait self-compassion and sAA response
to a social stressor, suggesting a protective role of
ummary of Observational Studies
S self-compassion.
on Self-Compassion and Stress Given the largely small, homogeneous sam-
Physiology ples predominantly focused on healthy adults and
few studies per biomarker, more research is
In summary, although research on the association needed. Future directions might include assess-
between self-compassion and physiology is in its ing the link between trait self-compassion and
early stages, a few trends across studies emerged. longer term health outcomes, examining trait
Across the eight reviewed studies, emerging evi- self-compassion as a continuous variable (rather
dence suggests that dispositional self-compassion than use a median split, for example), and assess-
can buffer physiological responses to laboratory ing the impact of trait self-compassion in
stressors. Specifically, in response to standard- response to more naturalistic stressors. A more
ized laboratory stressors, trait self-compassion direct method of examining the influence of self-
may positively correlate with HF-HRV and nega- compassion to stress responding is to manipulate
tively correlate with systolic BP, cortisol, IL-6, self-compassion directly; we turn next to these
and sAA, though several findings were mixed. studies.
First, examining indices of heart functioning,
studies found some evidence for higher HRV
xperimental Studies Related

E the self-compassion and attention placebo condi-
to Self-Compassion tions completed three 10-min recorded training
and Physiological Stress sessions in their assigned intervention. Finally,
they completed a briefer training session (in
Five laboratory experiments have explored the metta or placebo control) immediately prior to
relationship between self-compassion and physi- being introduced to the TSST. Biomarkers
ological stress responding. These experiments assessed at the second TSST-focused laboratory
are largely characterized by brief manipulations session included sAA and salivary cortisol (col-
of self-compassion in healthy adults to assess lected at 5 points during baseline through 35 min
both physiological and self-reported stress post-TSST) and HF-HRV (collected continu-
responses. Biomarkers from these studies ously during baseline through 10 min post-
included cortisol as a metric of the HPA axis TSST). Results showed that the self-compassion
stress response; sAA, SCL, and HR as metrics of condition endorsed greater trait and state self-
the sympathetic stress response; and HF-HRV as compassion from the first to second laboratory
a metric of the parasympathetic stress response. session relative to both control conditions. The
Although these studies are largely limited in their self-compassion condition also showed a steeper
use of brief manipulation strategies applied to decrease in state anxiety from the TSST speech
healthy adults within laboratory settings, the preparation through the post-TSST recovery
overall results lend greater support to a causal phases but not at other study points, relative to
relationship between increased self-compassion both control conditions. Regarding physiological
and decreased physiological stress responding. outcomes, the self-compassion condition showed
In a study of 105 healthy undergraduate significantly lower sAA (in terms of area under
women, researchers examined the impact of a the curve with respect to increase) relative to both
brief self-compassion training on stress-related control groups in response to the TSST, indica-
biomarkers including sAA, HF-HRV, and cortisol tive of a reduced sympathetic stress response
(Arch et al., 2014). Participants were randomized (Thayer et al., 2012; Thayer & Lane, 2000). In
to either a metta (loving-kindness) meditation addition, the self-compassion condition had a
condition, an attention placebo condition focused more engaged or stable HF-HRV during both the
on cognition and problem-solving, or a control speech preparation phase in anticipation of the
condition receiving no intervention. The metta TSST and in the recovery phase following the
meditation condition used both traditional metta TSST relative to both control groups indicative of
phrases (“May I be happy. May I be healthy and increased or maintained parasympathetic control
strong…”) and study-specific phrases (“May I and associated with improved emotion regulation
know that others struggle along with me. May I in prior studies (Porges, 2007). No group differ-
love and accept myself completely, just as I ences emerged in cortisol responding, perhaps
am…”) that focused on cultivating a sense of because the TSST represents an uncontrollable
common humanity, well-being, and acceptance performance stressor – characteristics that elicit a
toward oneself and, to a lesser extent, toward oth- robust cortisol response (Dickerson & Kemeny,
ers. All participants attended two laboratory ses- 2004).
sions. The first session involved brief In summary, these results suggest that brief
condition-specific training (in the metta medita- self-compassion training can improve both sym-
tion or attention placebo control). The second pathetic (sAA) and parasympathetic (HF-HRV)
session involved completion of the TSST, a stan- markers of stress in the context of a social stress
dardized social stress paradigm that requires par- task, though in this study, did not influence HPA
ticipants to prepare and deliver a speech without axis activation (in the form of cortisol). Together
notes and complete a challenging math task, both with the self-report findings, the study thus sug-
in front of judges (Kirschbaum et al., 2008). gests that brief self-compassion meditation train-
Between the two sessions, participants in both ing led to shifts in how participants responded to
the stressor – that is, with greater self-compassion for paranoid ideation. Skin conductance levels
and self-regulation – rather than in their experi- (SCL) were measured throughout the experiment
ence of the stressor’s controllability. by a recording bracelet. Following baseline
Following this experimental study, the authors assessment, participants underwent a 3–5-min
subsequently examined predictors and modera- negative mood induction in which they recalled a
tors of the beneficial physiological outcomes recent social stressor that induced either fear or
associated with self-compassion meditation shame. Participants were then randomly assigned
(Arch et al., 2016). Specifically, they sought to to either self-compassion imagery (n = 26) or
determine what role two stress vulnerability traits control imagery (n = 25). In the intervention
(social anxiety, rumination) and two resiliency group, experimenters read from a standard script
traits (self-compassion, nonattachment, i.e., the aloud for 10 min, instructing participants to cre-
Buddhist notion of release from mental fixations) ate a mental image of a person or object that elic-
might have in moderating the effects of brief self- its compassion and warmth for the participants.
compassion meditation training on sAA and In the control group, experimenters described a
HF-HRV (vs. control conditions). Results showed chair in the experiment room, matching the self-
that relative to the control groups, higher reported compassion imagery script in style and length.
baseline nonattachment (i.e., lower attachment) Compared to the control group, those receiving
within the self-compassion group predicted lower self-compassion imagery reported significant
TSST-related increase in sAA and lower self- increases in happiness and self-reassurance, but
reported anxiety than did lower baseline nonat- there were no differences between conditions in
tachment (e.g., higher attachment). In contrast, SCL or symptoms of paranoia. Given that this
levels of nonattachment did not influence sAA experiment was conducted in a single session, the
outcomes for the two control groups compared to authors suggest that participants may not have
the self-compassion group. However, trait rumi- experienced sufficient practice creating a self-
nation was significantly more influential in pre- compassionate mental image, resulting in
dicting sAA increases within the control groups increased effort during the intervention that
compared to the self-compassion group. In sum- impeded their ability to relax physiologically.
mary, the physiological benefits of brief self- While these studies support the role of self-
compassion training (relative to the two control compassion in improving physiological markers
conditions) were robust across various levels of of stress, more recent work has begun to eluci-
baseline social anxiety and trait self-compassion date the intervention processes that account for
but were moderated by baseline levels of nonat- these physiological benefits. Specifically, one
tachment and rumination, such that participants study sought to examine the precise intervention
with higher levels of attachment or rumination mechanisms that drive the beneficial physiologi-
benefitted less from self-compassion training cal effects of self-compassion by randomizing
than those with lower levels of attachment or 135 adults in equal numbers (n = 27 per condi-
rumination. As participants with these baseline tion) to five conditions including a loving-
characteristics did not benefit equally, the authors kindness meditation condition where compassion
concluded that individuals with higher levels of is directly instructed (direct compassion), a com-
attachment or rumination might require a more passionate body scan condition where partici-
extensive or tailored self-compassion training. pants attend to bodily sensations with a sense of
Whereas the aforementioned studies exam- calm acceptance (indirect compassion), a
ined self-compassion training in non-clinical positive-excitement condition, a self-critical
samples, Ascone et al. (2017) evaluated the phys- rumination condition, and a neutral control con-
iological impact of a single session of self- dition (Kirschner et al., 2019). Thus, the study
compassion-focused guided imagery among 51 aimed to test whether self-compassion uniquely
psychiatric patients (including 36 psychiatry affects physiological responding, or whether it
inpatients and 15 outpatients) receiving treatment
confers these benefits only to the extent that it attributed simply to increasing positive affect,
increases positive affect. suggesting that inducing self-compassion confers
This study consisted of a single laboratory unique benefits in improving physiological mark-
session where participants listened to one 11.5- ers of stress.
min tape, which guided participants through an Beyond the use of physiological measures
induction specific to their condition. For exam- associated with stress, other work has extended
ple, participants in the direct compassion loving- our understanding of self-compassion into the
kindness condition were instructed to direct study of physical pain. Luo et al. (2019) random-
loving thoughts toward someone close to them ized 29 healthy adults to undergo both compas-
and then to direct those same thoughts toward sionate and neutral self-talk protocols in a
themselves (in the spirit of metta meditation), randomized order to measure their impact on
whereas those in the indirect compassion body HF-HRV and pain ratings during a cold pain
scan condition were guided to direct kind exposure. To accomplish this, these researchers
attention to body sensations. Researchers tracked first had participants generate four self-
HF-HRV, SCL, and HR for the duration of the compassion statements, followed by the start of
taped experimental inductions. Results from this the experimental manipulation trials. For each
brief intervention showed decreased HR through- trial, participants were presented with either a
out the entire audio exercise in the direct loving- self-compassion (e.g., “I understand your pain”)
kindness group and for the first 8 min in the or neutral control (e.g., “The store is selling
compassionate body scan group, relative to the fruits”) statement for 10 s that they were asked to
three comparison groups. Further, HF-HRV was read aloud. After 10 s, participants underwent a
elevated in both self-compassion groups through- 3-min cold pain exposure by holding a bottle
out the exercise (except the final minute of the filled with iced water while recording pain rat-
compassionate body scan) relative to the three ings every 30 s. All four self-compassion state-
comparison groups. Fewer robust differences ments along with four control statements were
were seen in SCL, though the loving-kindness presented three times each, resulting in a total of
group did show a significant decrease relative to 2 min of exposure to self-compassion statements
the neutral control group for the first 7 min of the and 2 min of exposure to control statements.
exercise. Results showed that reported pain was signifi-
Regarding mechanisms, this study found that cantly lower during the self-compassion state-
HR fully mediated the relationship between the ment trials compared to the control statement
loving-kindness condition and self-reported self- trials. In addition, HF-HRV during cold pain
criticism and partially mediated the relationship exposure was higher in the self-compassion trials
between the compassionate body scan condition as compared to the control trials. Further, higher
and self-reported levels of both self-criticism and levels of HF-HRV were more significantly asso-
positive affiliative affect. Thus, inducing self- ciated with lower pain ratings during the self-
compassion may be beneficial in improving self- compassion trials than in the control trials. This
criticism and affiliative affect to the extent that it study thus extends past findings by showing that
calms HR-based physiological arousal. In sum, relative to a neutral control condition, very brief
the authors report that brief self-compassion self-compassion in the context of thermal pain
inductions may confer physiological benefits in can improve both perceived physical pain and
two ways: first, through activation of the para- physiological markers of self-regulation.
sympathetic positive affect system (HF-HRV), The studies described above indicate that brief
which corresponds to reduced stress and self-compassion interventions can improve phys-
enhanced emotion regulation capabilities; and iological markers of stress in response to both
second, by increasing a positive sense of self physical pain and psychological stressors.
while decreasing a negative sense of self. Additional work has sought to examine the extent
Importantly, these improvements cannot be to which small adjustments in self-compassion
exercises bolster these outcomes. One such study Summary of Experimental Studies
by Petrocchi et al. (2016) tested whether repeat- on Self-Compassion and Stress
ing self-generated, self-compassionate phrases Physiology
while looking at a mirror would improve out-
comes as compared to not using a mirror, as is Overall, the limited number of laboratory studies
typically done. They recruited 86 adults from the that manipulate self-compassion show that such
general population and had each of them gener- manipulations often result in improved physio-
ate four phrases they would use to soothe or logical markers of stress, particularly those asso-
encourage a friend going through a difficult time. ciated with sympathetic (e.g., sAA, HR) and
Participants then wrote about a recent situation parasympathetic (i.e., HF-HRV) nervous system
during which they harshly criticized themselves responding. These improvements in physiologi-
out of shame or disappointment. The self- cal stress were observed in the context of both
criticism writing exercise successfully increased psychological and physical stress tasks. Thus,
HR and negative affect, while decreasing positive briefly trained or induced self-compassion
affect and HRV, suggesting that the researchers appears to cultivate resilience in the face of
successfully induced a state of self-criticism. diverse acute stressors.
Participants then were randomized to one of three Research has begun to explore mediators and
conditions for a 5-min experimental manipula- moderators of the physiological benefits of
tion, including repeating their four encouraging induced self-compassion and to elucidate the
phrases toward themselves while looking at specific approaches to inducing self-compassion
themselves in a mirror (n = 30), repeating their that have the greatest effect on physiological self-
four encouraging phrases toward themselves regulation and stress response. Indeed, these ben-
without looking into a mirror (n = 28), or looking eficial effects can be bolstered with minor
at themselves in a mirror without repeating the manipulations, such as reciting self-compassion
phrases (n = 28). Self-report and ECG measures phrases into a mirror as compared to not using a
of HR and HRV were incorporated throughout all mirror (Petrocchi et al., 2016). Importantly, one
procedures. The group that recited self- study found that the beneficial effects of self-
compassionate statements while looking in the compassion training were not attributable solely
mirror showed significantly larger increases in to increased positive affect but rather were unique
HRV and reported more soothing positive affect to self-compassion processes (Kirschner et al.,
relative to the two comparison groups. The rela- 2019).
tionship between condition and increase in sooth- While these initial findings are promising,
ing positive affect was partially mediated by an more work remains to be done in order to better
increased sense of common humanity, a facet of understand the physiological benefits of briefly
self-compassion. Overall, while the precise induced or trained self-compassion. For example,
mechanisms are not fully understood, the authors additional laboratory-based studies are needed to
purport that reciting self-compassionate phrases replicate and extend current findings, and partic-
while looking into a mirror may improve out- ularly to clarify the potential effects of self-
comes by increasing the number of positive compassion training on skin conductance and
social signals being communicated, facilitating a cortisol, which are key indices of sympathetic
sense of self-compassion that extends beyond and HPA axis activation, respectively. In addi-
verbal language, or seeing ourselves from an tion, future studies can attempt to extend these
external, more objective point of view in a man- findings into more vulnerable populations,
ner that reduces self-critical biases. including in clinical groups that are more likely
to suffer from lower levels of self-compassion
(Macbeth & Gumley, 2012).
linical Interventions Related

C first challenge individuals’ preconceived thoughts
to Stress and Mental Health and emotions toward others and then guide them
to develop spontaneous feelings of empathy,
Expanding on brief manipulations in laboratory love, and compassion toward all people, begin-
settings, eight studies examined the impact of ning with the self and expanding to include oth-
lengthier clinical interventions in more naturalis- ers whom individuals dislike or with whom they
tic settings. Similar to most of the aforemen- have conflicts. CBCT was designed to first teach
tioned work, these studies were predominantly attention and mindfulness techniques as a foun-
conducted with healthy adult populations, dation, and then gradually shifted toward focus-
although three focused on populations facing ing on lojong meditations. In addition to 12 h of
potentially heightened stress, recruiting individu- group training, CBCT participants were encour-
als who had experienced early life adversity, par- aged to practice exercises daily at home using
enting stress, or cancer biopsy (Pace et al., 2013; audio recordings. The health discussion groups
Poehlmann-Tynan et al., 2020; Wren et al., 2019). reviewed standardized topics related to mental
Interventions included at-home meditation prac- and physical health among university students,
tice using audio recordings as well as group- and participants wrote weekly papers applying
based self-compassion training, ranging in length material to their lives to control for time and
from a relatively brief manipulation (2 weeks) to practice outside of class. To evaluate the impact
a 15-week course. Self-compassion was culti- of meditation training on physiological response
vated using several formal interventions, includ- to a novel stressor, participants completed the
ing Cognitively-Based Compassion Therapy TSST between 8 and 10 weeks from the initiation
(CBCT; Pace et al., 2009), Emotion Focused of the study. Surprisingly, researchers did not find
Training for Self-Compassion and Self-Protection evidence for a main effect of compassion medita-
(EFT-SC; Halamová et al., 2019), and tion on IL-6, cortisol, or self-reported subjective
Compassionate Mind Training (CMT; Gilbert, distress following the TSST. However, after
2000, 2009, 2010), among others. In addition to examining variability in weekly meditation prac-
self-reported outcomes, the following biomark- tice among participants, researchers conducted a
ers were assessed: sAA and HR to assess sympa- median split analysis for high and low practice.
thetic nervous system response, cortisol as a Using this approach, significant correlations were
marker of the HPA axis, and HRV as an indicator found, demonstrating an inverse relationship
of parasympathetic nervous system response. between practice, IL-6, and distress. Specifically,
Additionally, immune system functioning was a greater number of practice sessions per week
explored through IL-6, salivary C-reactive pro- was associated with lower immune response and
tein (CRP), and sIgA. subjective distress, a finding which highlights the
In one such early clinical intervention study, importance of committed practice of compassion
researchers examined the impact of CBCT train- exercises in improving psychological and physi-
ing on IL-6 and cortisol in response to a TSST cal outcomes.
among 61 healthy university students ages In a subsequent study, Pace et al. (2013) exam-
17–19 years (Pace et al., 2009). Recruited from a ined the impact of CBCT on salivary C-reactive
health education class, participants were random- protein (CRP) among 55 adolescents in the foster
ized to take part in either CBCT (n = 33), com- care system, seeking to understand the impact of
passion meditation training based on Tibetan compassion training in a population impacted by
Buddhist mind-training or lojong practices, or a early life adversity. Adolescents in this trial were
health discussion group (n = 28) over the course randomly assigned to either a 6-week CBCT
of 6 weeks, totaling 12 intervention hours for intervention (n = 29) or a waitlist control (n = 26).
both conditions. In contrast to mindfulness prac- CBCT participants attended class twice a week,
tices that encourage nonjudgmental awareness of completing a total of 12 intervention hours; addi-
thought processes and emotions, lojong practices tionally, they were encouraged to practice daily
exercises at home using an audio recording. To on mindfulness training followed by self-

examine CRP, saliva samples were collected compassion training. In this small, uncontrolled
immediately upon awakening prior to and fol- study, 31 healthy adults (90% female) partici-
lowing the intervention. As with findings from pated in an 8-week group-based program
Pace et al. (2009), no group differences were (Bellosta-Batalla et al., 2018) derived from
found for salivary CRP. However, when research- Mindfulness-Based Stress Reduction (MBSR;
ers examined a subset of adolescents with com- Kabat-Zinn, 1990) and Compassion-Focused
plete data on weekly practice time, an inverse Therapy (CFT; Gilbert, 2010). Participants com-
relationship was found between number of prac- pleted a 2-h group session each week for 8 weeks
tice sessions and morning salivary CRP levels and were assessed at pre- and post-intervention
across the 6-week study, such that more practice on self-reported variables, sIgA, and salivary cor-
was associated with lower CRP levels. Consistent tisol levels. Neither sIgA nor salivary cortisol
with previous findings (Pace et al., 2009), the levels changed significantly over the 8 weeks of
authors concluded that participation in a CBCT the intervention. However, cortisol decreased sig-
class might not be enough to reduce markers of nificantly within the first and last intervention
inflammation; instead, active at-home practice sessions, whereas sIgA levels increased within
may be particularly important. the last intervention session. Though at-home
Like Pace et al. (2009, 2013), Poehlmann- practice was not assessed, this small study sug-
Tynan et al. (2020) also employed CBCT to gests that compassion practice can immediately
manipulate self-compassion, although the authors benefit stress- and immune-related biomarkers,
examined a different population potentially prone similar to previous research (Pace et al., 2009,
to higher stress levels – parents of young chil- 2013). Given that this study was small and did
dren. In a randomized preliminary efficacy study, not include a control group, results should be
39 parents of children ages 9 months to 5 years interpreted with caution.
4 months were randomized to either CBCT Another more recently developed interven-
(n = 25) or a waitlist control (n = 14). Parents in tion, Emotion-Focused Training for Self-
the CBCT condition completed eight weekly Compassion and Self-Protection (EFT-SCP;
group sessions in addition to one full day retreat, Halamová et al., 2019), aims not only to bolster
totaling 20 intervention hours. Hair cortisol con- self-compassion but also to explicitly reduce self-
centration (HCC) was analyzed for both parents criticism by increasing protective anger, or an
and children at pre- and post-intervention assess- ability to stand up and assert oneself in response
ments along with psychosocial measures of stress to self-criticism. In a quasi-experimental study
and parenting stress. Among parents in both evaluating EFT-SCP, 73 healthy university stu-
CBCT and the waitlist control group, average dents were recruited and assigned to the follow-
HCC increased over time, with no significant dif- ing conditions by clustering based on year in
ference between groups. Whereas no main effect school: (1) EFT-SCP (n = 19), (2) an active con-
of the intervention was found for parent HCC, trol consisting of expressive writing (n = 20), (3)
there was a significant group difference in chil- or a no-treatment control condition (n = 34)
dren’s HCC. Specifically, among children of par- (Halamová et al., 2019). During a baseline labo-
ents in the CBCT condition, average HCC ratory session, participants completed psychoso-
decreased from pre- to post-intervention. cial measures followed by a 10-min audio-taped
Furthermore, the average HCC for children of guided imagery task that began with 1-min of
parents on the waitlist control increased across relaxation and then three, 3-min imagery tasks
the intervention, which the authors found surpris- that intentionally cultivated sequential feelings of
ing given that children’s HCC tends to decrease self-criticism, self-protection, and self-
with age after age 1 year. compassion. In the first imagery task, participants
Paralleling CBCT, another study tested the remembered a situation in which they felt self-
effects of group meditation training focused first criticism and were asked to describe their inner
self-critic. Second, participants imagined the part on Compassion included a range of self-
of them that would want to defend or protect compassion, compassion, and mindfulness medi-
them against their inner critic. Third, participants tation and related practices, reading and
imagined the part of them that is self- discussing biographical information on world
compassionate and loving at times of difficulty leaders in compassion, and compassion teachings
and thought about how they might respond to from diverse world religions. In this study, stu-
their self-critic. HF-HRV (via root mean square dents completed a baseline laboratory session at
of successive R-R intervals) was assessed during the end of their fall semester and prior to begin-
this imagery exercise. Following this session, ning the compassion course, consisting of pre-
students in the EFT-SCP condition completed a intervention self-report measures as well as saliva
12-week group course, totaling 1.5 intervention collection to assess sAA. Students in the inter-
hours per week and consisting of experiential vention group were then asked to attend the com-
exercises designed to elicit self-compassion (e.g., passion course twice a week for 80 min per class
self-compassionate body scan and breathing, throughout the semester, totaling 40 intervention
imagining a safe place) and reduce self-criticism hours. During the last week of the spring semes-
(e.g., imagining one’s self-critical part to build ter, post-intervention measures and saliva collec-
awareness). In addition, EFT-SCP participants tion were again completed. Findings showed a
completed daily expressive writing tasks at home significant group difference in sAA, such that
associated with that week’s EFT-SCP content to sAA decreased among students taking the com-
cultivate self-compassion (e.g., writing a letter to passion course, whereas sAA increased among
yourself as a child expressing compassion, prac- students in the waitlist control group.
ticing self-compassion in front of the mirror) or Whereas the aforementioned interventions
lessen self-criticism (e.g., changing your self- utilized group training, a few studies relied
critical dialogue). In contrast, students participat- largely or solely on individual at-home practice
ing in the active control completed a weekly of self-compassion exercises. One of these stud-
at-home expressive writing task. After 12 weeks, ies examined compassionate mind training
all participants returned to the laboratory to com- (CMT), a component of Compassion-Focused
plete the audio-taped imagery exercise for a sec- Therapy (CFT; Gilbert, 2009, 2010), that empha-
ond time, during which HF-HRV was again sizes soothing breathing, attention and aware-
assessed. Findings showed that compared to both ness, and guided imagery to develop
control groups, HF-HRV for students in the EFT- compassionate images of others and self (Matos
SCP intervention condition increased signifi- et al., 2017). Ninety-three healthy adults and uni-
cantly during the imagery exercise from pre- to versity students (ages 18–43 years) were ran-
post-test, specifically during the guided self- domly assigned to participate in either a 2-week
critical imagery task where participants described CMT training program (n = 56) or a waitlist con-
their inner self-critic and the guided self- trol (n = 37). All participants completed a labora-
compassion imagery task, in which participants tory session at pre- and post-intervention. During
took a self-compassionate perspective. This sug- these laboratory sessions, participants completed
gests that the EFT-SCP self-compassion training self-report measures, and resting HRV in the
led to greater self-regulation in the context of form of RMSSD was assessed over a 5-min
both induced self-compassion and induced relaxation period. In between the two laboratory
self-criticism. sessions, participants in the CMT training pro-
Ko et al. (2018) also examined a group-based gram completed an initial 2-h group session
university course of self-compassion, randomly where they learned CMT exercises and were pro-
assigning 41 university students (ages vided with a manual outlining CMT theory as
18–22 years) to either a 15-week academic well as audio recordings of CMT exercises to
Seminar on Compassion (n = 21) or a waitlist facilitate at-home practice. Participants were
control group (n = 20). Content in this Seminar invited to practice the exercises at home over
2 weeks and could independently decide whether participated in a scripted booster phone call to
to use the audio recordings to guide this practice. assess and solve practice barriers. Results indi-
Following 2 weeks, all participants returned to cated a significant group difference in HR for
the laboratory to complete the post-intervention those in the loving-kindness meditation group
assessment, again consisting of self-report mea- compared to the two control groups, where HR
sures and an assessment of resting HRV. As remained stable over time for the intervention
hypothesized, participants in the CMT condition group but increased for both the music and usual
demonstrated a significant increase in HRV from care groups. Furthermore, the authors found that
pre- to post-intervention, whereas there was no within the loving-kindness group, more time
significant change in HRV over time for partici- spent practicing loving-kindness meditation pre-
pants in the control condition. This study sug- dicted a lower HR over time, reflecting findings
gests that self-compassion can be practiced from previous studies regarding the physiological
largely independently over a relatively short benefits of more daily self-compassion practice
period of time, and still provide benefits for (Pace et al., 2009, 2013). However, the authors
physiological self-regulation (in the form of
did not find evidence for group differences in
increases in resting HRV). either diastolic or systolic BP.
Wren et al. (2019) also relied on at-home In summary, more extended self-compassion
meditation practice, reporting on the physiologi- interventions appear to improve some measures
cal response to a loving-kindness meditation of physiological response to stress, particularly
intervention among breast cancer patients. In this parasympathetic (e.g., sAA and HRV) and sym-
study, 56 participants underwent four assess- pathetic (e.g., HR, though HR also reflects para-
ments of diastolic and systolic BP and HR: (1) sympathetic influence) system responses
pre-biopsy and prior to randomization, (2) post- (Halamová et al., 2019; Ko et al., 2018; Matos
biopsy, (3) after learning of biopsy results if et al., 2017; Wren et al., 2019). Whereas no group
abnormal, and (4) 1-week post-surgery. All differences emerged from pre- to post-
assessments of BP and HR were completed dur- intervention on biomarkers assessing immune
ing laboratory sessions, except for the final two functioning (e.g., IL-6, salivary CRP, sIgA) or
assessments, which were taken from patients’ HPA axis stress response (e.g., cortisol; Bellosta-
electronic medical records. Following the pre- Batalla et al., 2018; Pace et al., 2009, 2013), two
biopsy assessment, patients were randomly studies demonstrated the benefits on immune
assigned to receive one of the following condi- system functioning (e.g., IL-6, CRP; Pace et al.,
tions during a biopsy: (1) a loving-kindness med- 2009, 2013) and sympathetic responding (e.g.,
itation administered by audio recording (n = 23), HR; Wren et al., 2019) for individuals within
(2) music from a genre that the patients selected self-compassion interventions who committed
(n = 16), or (3) usual care consisting of support more to daily self-compassion practice.
from the biopsy team (n = 17). Following biopsy, Additionally, one study demonstrated benefits of
patients in the loving-kindness and music condi- self-compassion training for children of parents
tions received condition-specific instructions for undergoing self-compassion training, finding
condition-specific at-home practice. Specifically, improved cortisol response among children with
loving-kindness participants received an audio parents participating in a group-based self-
recording of loving-kindness meditation exer- compassion intervention (Poehlmann-Tynan
cises, a rationale for daily practice, and instruc- et al., 2020). Thus, pending replication, self-
tions for at-home 20-min daily practice, whereas compassion intervention studies point toward
the music control group received an audio record- greater physiological benefits for those who prac-
ing with their selected music genre, a rationale tice more in their daily lives, an important but
for the soothing effect of music, and instructions unsurprising finding, and extend to those who are
to listen every day at home for 20 min. Both the being parented by the practitioner, suggesting the
loving-kindness intervention and music groups broader benefits of parenting training.
Ultimately, extant findings suggest that train- improve such functioning. Thus, future research
ing in self-compassion can improve biomarkers can build on the small body of physiologically
associated with stress and immune response sys- focused self-compassion studies that target these
tems, likely reflecting greater physiological resil- more vulnerable populations (e.g., Arch et al.,
ience. Caveats include the fact that research in 2014; Wren et al., 2019) with the intention of
this area is still emerging, and that most studies including those who stand to benefit the most
did not use acute stress or criticism paradigms to from training in self-compassion.
evaluate whether benefits extend to the contexts
in which they are most needed. Future self-
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A Triadic Pathway Model
of Self-Compassion and Health 18
Fuschia M. Sirois
Introduction Although there are different perspectives on

what comprises self-compassion (e.g., Gilbert,
In recent years, self-compassion has emerged as 2019), one conceptualization that is most com-
an important quality for promoting mental health monly used in research investigating the links
and well-being, with a growing evidence base with health is that of Neff (2003). Self-
providing robust support for its links with higher compassion is defined as responding to difficul-
levels of well-being, less psychopathology, and ties, suffering and perceived personal
greater life satisfaction (MacBeth & Gumley, shortcomings in a kind, connected, and mindful
2012; Zessin et al., 2015). Parallel to this research manner. As a positive self-evaluation, self-
is a growing interest in and examination of the compassion is further posited to be comprised of
potential benefits of self-compassion for promot- three bipolar components that operate synergisti-
ing physical health. Research has demonstrated cally to improve well-being and motivation to
that self-compassion can have positive conse- persist despite difficulties: self-kindness versus
quences for a range of inter-related physical self-judgment, common humanity versus isola-
health trajectories and outcomes including sub- tion, and mindfulness versus over-identification
jective health, stress, sleep, and health behaviors (Neff, 2011). Self-compassion can also be viewed
(Brown et al., 2021; Phillips & Hine, 2019; as an enduring trait-like quality that nonetheless
Sirois, 2020). Although the pathways explaining can be developed through practice and interven-
why self-compassion may promote physical tion (e.g., Wilson et al., 2019). It is this latter
health are continuing to be explored, current the- property of self-compassion that makes it partic-
ories on the role of self-regulation in health, and ularly valuable as a target for maximizing health-
specifically linking individual differences to promoting trajectories and minimizing health-risk
health, offer insights for understanding the pos- trajectories.
sible ways in which self-compassion can contrib- This chapter will discuss current evidence and
ute to better overall physical health. theory supporting a role for self-compassion in
promoting physical health. Drawing on insights
from relevant theories on self-regulation and
behavior change, this chapter will outline and
review the key pathways and processes that may
F. M. Sirois (*)
Department of Psychology, Durham University, explain how and why responding to one’s failures
Durham, UK and shortcomings with kindness, connectedness,
e-mail: [email protected] and mindfulness may promote physical health. In

https://doi.org/10.1007/978-3-031-22348-8_18
310 F. M. Sirois
doing so, it will present a new model of self- the degree to which they are able to treat them-
compassion and health that incorporates these selves compassionately. Pain is one of the more
insights to provide a provisional framework to common physical symptoms that people report
guide further research in this rapidly growing when they are ill (Taylor et al., 2020). Several
research area. studies have found that self-compassion is asso-
ciated with less pain (Allen et al., 2011; Carvalho
et al., 2018), and less pain intensity (Gregory
urrent Evidence on the Role
C et al., 2017; Wren et al., 2012), in both general
of Self-Compassion for Physical and clinical samples (See Chap. 19 for a more
Health complete review).
There is also evidence that self-compassion
The idea that self-compassion may be beneficial may be beneficial for physical health when mea-
for physical health has gained considerable atten- sured with composite measures of physical
tion from researchers in recent years. This inter- symptoms that include fatigue, nausea, head-
est has generated a growing body of research that aches, and general discomfort. For example, in a
largely supports this notion and provides evi- study that includes matched samples of psychiat-
dence of the links between self-compassion and ric patients and adults from the general popula-
array of outcomes relevant for physical health tion, self-compassion was associated with fewer
states. In general, this research has examined physical health symptoms in both samples
self-compassion with respect to two key indica- (Dewsaran-van der Ven et al., 2018). Similar
tors of physical health states: physical symptoms results have been found with undergraduate stu-
and subjective health status. Whereas physical dent samples (Dunne et al., 2016). Whether par-
symptoms refer to the perception of physical dis- ticular components of self-compassion might
comfort in specific areas of the body (e.g., diffi- account for the link with fewer health symptoms
culty breathing) which are perceived as a sign of has yet to be fully explored. However, at least one
an underlying illness, subjective health status is study has examined this issue. In a cross-sectional
an overall perception of one’s general state of study of college students, the self-kindness/low
health (e.g., feeling generally unwell; Jylhä, self-judgment and common humanity/low isola-
2009). Although each of these markers of physi- tion components of the self-compassion scale
cal health are subjective in nature, a number of were associated with fewer self-reported physical
studies have also demonstrated that they have symptoms, whereas the mindfulness/low over-
reliable links to more objective measures of identification component was not significantly
physical health (see Jylhä, 2009 for a review), related to symptoms (Hall et al., 2013).
and therefore can be considered reasonable prox-
ies of people’s overall state of physical health.
elf-Compassion and Overall Physical
S
Health
Self-Compassion and Physical
Symptoms The potential benefits of self-compassion for
physical health have also been investigated in
Physical symptoms can vary widely as a function relation to measures of overall health. Overall
of the underlying illness or physical health issue physical health is often assessed using either a
that they reflect and are also influenced by indi- multi-item composite score, such as the physical
vidual differences in the way that people experi- health subscale of the SF-12 (Ware et al., 1996),
ence, interpret, and respond to physiological or the SF-36 from the Medical Outcomes Survey
stimuli. Research on self-compassion and physi- (Ware & Sherbourne, 1992), or a single-item rat-
cal symptoms indicates that people’s experience ing of global or self-rated health taken from these
of physical symptoms may vary as a function of same measures. The multi-item, composite mea-
18 A Triadic Pathway Model of Self-Compassion and Health 311
sures are well-known to predict consequential people with chronic illness, including over 6000
health outcomes such as hospitalization and mor- people (Sirois, 2020). Self-compassion was sig-
tality (e.g., Thombs et al., 2008). However, the nificantly associated with better self-rated health
self-rated health single item is also a robust mea- across the samples, and this average association
sure of physical health. Despite the apparent sim- was not influenced by gender, age, or the sample
plicity of this approach, decades of research have population. Because self-reports of health can be
demonstrated that assessing health in this manner influenced by positive and negative states
provides a highly reliable index of health (Jylhä, (Howren & Suls, 2011), further analyses were
2009). For example, single-item self-rated health conducted to control for positive and negative
is known to predict a number of objective mea- affect in the associations of self-compassion with
sures of physical health including cortisol self-rated health. These analyses yielded the
responses to stress, health behaviors, morbidity, same significant associations, suggesting that
mortality, and even future health (Benyamini, self-compassion is linked to self-rated health in
2011; Kristenson et al., 2005; Mora et al., 2013; meaningful ways that go beyond possible report-
Tamayo-Fonseca et al., 2013). ing biases.
Several studies have examined how self- When taken at face value, this evidence might
compassion relates to composite measures of suggest that self-compassion is associated with
physical health across a range of populations. For better overall physical health, insomuch that self-
example, cross-sectional studies have demon- compassionate people tend to not report many
strated that self-compassion is associated with general physical symptoms. However, because the
better overall physical health in older adults evidence presented above relies on cross-sectional
(Allen et al., 2011; Smith, 2015), middle-aged data collected at a single time point, these “snap-
women (Brown et al., 2016), and among commu- shots” of the links between self-compassion and
nity adults (Homan & Sirois, 2017). Importantly, health tell us little about whether self-compassion
there is also evidence that self-compassion pre- contributes to better physical health in the form of
dicts better overall physical health over time. In fewer symptoms. One could potentially argue that
one 7-year longitudinal study of adults ranging in not experiencing physical symptoms may make it
age from 27 to 101 years, both baseline self- easier to have a mind-set that is conducive to being
compassion and changes in self-compassion over self-compassionate. For example, someone strug-
the course of the study were associated with gling with pain, fatigue, and other uncomfortable
improved physical health at the 7-year follow-up, physical symptoms that are known to contribute to
but only for those under 60 (Lee et al., 2021). negative mood states may be more likely to engage
Research on the health benefits of self- in thoughts focused on self-blame and feeling iso-
compassion for self-rated health has yielded sim- lated and have difficulty disengaging from the
ilar findings. For example, self-compassion was negative states brought on by their physical symp-
associated with better self-rated health in health- toms. Such negative states can in turn potentially
care social workers (Lianekhammy et al., 2018), amplify the intensity of these symptoms, increase
and men living with HIV (Skinta et al., 2019). vigilance to them, and affect the extent to which
The former study also examined the subscales of they are reported (Howren & Suls, 2011). While
the self-compassion scale in relation to self-rated hypothetically it is in these very instances of suf-
health. Interestingly, only the over-identification fering that self-compassion is proposed to be most
and self-judgment subscales were associated beneficial, evidence based on cross-sectional data
with self-rated health, with low scores on these is limited in terms of addressing the potential
two components linking to better overall self- directionality of effects in the link between self-
rated health. In one of the most comprehensive compassion and physical symptoms.
investigations of self-compassion and self-rated To address this important issue, at least two
health, associations were meta-analyzed across studies have investigated the effects of self-
26 samples of students, community adults, and compassion interventions on physical health
312 F. M. Sirois
symptoms over time. Bellosta-Batalla et al. of self-compassion increasing during the inter-
(2018) tested the effects of a one-week mindful- vention, there was no significant change in self-
ness and self-compassion-based intervention on compassion at either of the follow-ups, leaving
several health outcomes, including a composite open the question of the mechanisms through
measure of physical health symptoms, in a small which the improvements in physical health
sample of adults. Compared to the baseline occurred.
symptom reporting, the levels of postintervention Thus, current research provides compelling
symptoms were significantly reduced. It is worth evidence of the benefits of self-compassion for
noting though that the study did not include a physical health, whether health is assessed via
control group as a comparison for the changes in symptom reporting, or composite or summary
symptoms, and that the effectiveness of the inter- measures of overall health status. However, phys-
vention for increasing self-compassion was not ical health can be assessed using a variety of
directly tested. This latter point raises the issue of methods, including measures of psychophysio-
whether it was in fact self-compassion that was logical reactivity to stress. Indeed, a recent meta-
contributing to the improvement in physical analysis of self-compassion and health took a
health, or mindfulness, a synergy between the very inclusive approach to assessing health across
two, or some other factor. Although the a number of domains, that included such physio-
compassion-focused therapy integrated into the logical markers (Phillips & Hine, 2019). This
intervention is effective for cultivating self- yielded an overall small, but significant associa-
compassion (Wilson et al., 2019), its use along- tion (average r = 0.18). In the current chapter,
side mindfulness-based stress reduction muddies these psychophysiological markers will be cov-
the conceptual waters in terms of understanding ered in a later section on self-compassion and
the unique contribution of self-compassion to the stress, as arguably, measures such as cortisol lev-
improvements in physical health observed. els and immunological responses are considered
Reductions in negative affect and anxiety as a key indicators of the presence and extent to which
result of the intervention were tested as possible stress is perceived and experienced. Moving from
pathways and did explain in part the improve- the descriptive to the explanatory, the next sec-
ments in health; however, it is unclear what con- tions will examine theoretical perspectives to
tribution self-compassion alone had on these answer the important question of why self-
effects. compassion may promote physical health.
Some of the strongest evidence of the effects
of self-compassion on physical health symptoms
were demonstrated in a longitudinal intervention hy Is Self-Compassion Associated
W
study conducted with university students (Wong with Physical Health?
& Mak, 2016). This study had a number of meth-
odological strengths, including randomization to Despite the surge of research interest into the role
a control versus intervention group, a manipula- of self-compassion in health in recent years,
tion check of the effectiveness of the interven- investigations into why self-compassion leads to
tion, and 1-month and 3-month follow-ups to important health outcomes are limited (e.g.,
assess whether any effects were maintained over Dunne et al., 2016; Homan & Sirois, 2017; Sirois
time. The intervention involved a 3-day self- et al., 2015a). The first wave of research into a
compassion writing intervention that asks partici- new domain generally seeks to establish linkages
pants to reflect on a difficult situation and reframe with the outcomes of interest, in this case whether
it using a self-compassionate attitude. The self-compassion is associated with physical
researchers found that the intervention was effec- health. Investigating such associations across a
tive in reducing physical symptoms compared to variety of contexts, and using different method-
the control group at both the 1-month and the ological approaches are also essential to build a
3-month follow-up. Although there was evidence strong evidence base and lay the foundation for
research into whether self-compassion stress becomes chronic, the repeated activation of
interventions can be harnessed to improve health, the HPAC can contribute to dysregulation of cor-
especially among those most vulnerable for poor tisol responses to stress, and inflammatory
health outcomes. responses in the long-term (Cohen et al., 2012;
The second wave of research into a new McEwen, 2007). These can be particularly dam-
domain then focuses on addressing the important aging to health, as both are known precursors to
question of which factors and processes contrib- the development of a number of chronic diseases,
ute to and explain the association established in including cardiovascular disease, diabetes, and
the first wave. It is this second wave of research even cancer (McEwen, 2007).
on self-compassion and health that is still evolv- Health behaviors are another important path-
ing and that requires further theoretical develop- way for understanding health trajectories. Often
ment to galvanize its continued growth both referred to as modifiable risk factors for the
within the field of self-compassion research, and development of disease, health behaviors play a
the field of health psychology more generally. central role in promoting life-long health and pre-
Understanding the processes and contributing venting illness (World Health Organization,
factors that underpin the effects of self- 2015). The practice of health-promoting behav-
compassion on health is crucial for theoretical iors such as healthy eating and engaging in regu-
development. But these insights are also valuable lar physical activity contributes to better health
from an applied perspective. For example, in outcomes, whereas health-risk behaviors such as
addition to physical health status, self-compassion excessive alcohol use, smoking, and substance
interventions may also have immediate effects on use create vulnerability for poor health and
intermediate or process-related outcomes, such increase risk for disease. Unlike stress which can
as stress and health behaviors (e.g., Biber & Ellis, have both immediate and long-term effects on
2019), which contribute to better physical health. health, the benefits or risks of health behaviors
One way to understand how self-compassion tend to accumulate over time after repeated
can contribute to better physical health is to con- instances, often culminating in their full effects
sider this question from the lens of models that on health at midlife or later.
link personality and individual differences to
health. Although self-compassion can be culti-
vated, it is also commonly measured as an endur- Triadic Pathways to Health
ing tendency or mind-set that shapes people’s
responses to failures, difficulties, and personal In addition to these two key pathways, there is a
shortcomings across a variety of contexts. third route to health outcomes that has relevance
Generally, these models suggest that enduring for understanding the potential health benefits of
characteristics and tendencies influence health self-compassion: sleep. Sleep quality is an impor-
through two key pathways that are well-known to tant and widely recognized factor for understand-
have consequences for the promotion and main- ing health trajectories. As a key factor that
tenance of health, namely stress and health contributes to health trajectories, sleep quality
behaviors (Friedman, 2000; Smith, 2006; Suls & includes not only the duration of sleep but also
Rittenhouse, 1990). whether sleep is broken, and if there are difficul-
The psychophysiological arousal associated ties falling and staying asleep (St-Onge et al.,
with stress is well-known to have both immediate 2016). Poor sleep quality not only compromises
and downstream effects on health. The activation health (Reidy et al., 2016), but can also signifi-
of the hypothalamic-pituitary-adrenal-cortical cantly impact daily functioning in ways that cre-
(HPAC) axis as a result of acute stress can have ate further risks for poor outcomes (Daley et al.,
several adverse health impacts, including sup- 2009). For example, poor sleep quality and insuf-
pressing immune functioning and increasing vul- ficiency are linked to greater risk for health prob-
nerability for infections in the short-term. When lems (Zuraikat et al., 2020). However, the reasons
314 F. M. Sirois
why sleep increases vulnerability for poor health significant promise for gaining a more complete
are complex and involve multiple psychological understanding of how self-compassion may con-
and physiological pathways that are often recip- tribute to health outcomes.
rocally related to both stress and health behav-
iors. Sleep disturbances can interfere with the
self-regulation capacities necessary to maintain he Role of Self-Regulation in Linking
T
exercise routines and resist unhealthy behaviors, Self-Compassion to Health
such as smoking and heavy alcohol use (Strine &
Chapman, 2005), which in turn can further con- How might self-compassion reduce stress,
tribute to poor sleep (Haario et al., 2013). improve sleep quality, and promote engaging in
Current evidence supports the idea that self- health behaviors whilst minimizing health-risk
compassion contributes to better sleep quality. behaviors? One important capacity that has rele-
For example, across two studies, people with vance for self-compassion and that is known to
major depressive disorder and students who play a central role in each of these health path-
received a brief or daily self-compassion inter- ways is self-regulation. Often defined as the pro-
vention reported increases in sleep quality (Butz cesses involved in regulating thoughts, emotions,
& Stahlberg, 2018). The links between self- and behaviors while working toward one’s goals
compassion and better sleep quality were sum- (Carver & Scheier, 1982), self-regulation is an
marized in a recent meta-analysis which found important capacity for understanding health tra-
that across 17 studies, self-compassion had a jectories. Self-regulation encompasses several
small to moderate average association with self- key processes including setting goals, engaging
reported sleep quality (Brown et al., 2021). The in action to reach these goals, monitoring and
researchers also conducted further tests to exam- evaluating progress toward these goals, regulat-
ine whether it was the positive or negatively ing emotional responses to the inevitable ups and
worded items in the self-compassion scale that downs of goal pursuit. Not surprisingly, previous
were linked to better sleep quality. Although both research has found that self-compassion is posi-
were significantly linked to sleep quality in the tively associated with a number of processes
expected directions, the associations with nega- involved in self-regulation (Terry et al., 2013).
tively worded items were stronger, suggesting It is worth mentioning that the goals set do not
that a lack of self-coldness may better account for necessarily need to be health-focused for the pro-
why self-compassion can promote quality sleep. cesses involved in self-regulation to impact
Stress is known to disrupt the quality of sleep health. Difficulties and challenges experienced
(Kashani et al., 2012). Indicators of poor sleep with any goals can be stressful and therefore
quality, such as insomnia and sleep deprivation, potentially impact health outcomes such as sleep
can lower the stress tolerance threshold, leading and health behaviors. From this perspective, self-
to stressors being perceived as more stressful and compassion may provide benefits for health
intense (Minkel et al., 2012; Morin et al., 2003). through several key processes tied to self-
Importantly, stress is implicated in the mecha- regulatory abilities. Figure 18.1 provides an over-
nisms through which poor sleep contributes to view of three of these processes - coping
metabolic issues (Hirotsu et al., 2015). If we also strategies, emotion regulation, and efficacy
consider that stress is linked to poor health behav- beliefs – and how they link self-compassion to
iors in general (Homan & Sirois, 2017), less fre- health through the triadic pathways. As will be
quent exercise (Ng & Jeffery, 2003; discussed in the following sections, theory and
Stults-Kolehmainen & Sinha, 2014), and research suggest that self-compassion has robust
unhealthy eating habits (Ng & Jeffery, 2003; links to each of these key self-regulation factors,
Steptoe et al., 1998), then it becomes clear that as well as the triadic pathways that contribute to
this triad of pathways to physical health holds physical health.
Fig. 18.1 A triadic model of self-compassion and physical health. Dashed lines indicate provisional linkages
Self-Compassion and Stress Researchers have also investigated whether

and how self-compassion might play a role in
A growing evidence base supports the role of reducing stress by examining physiological mea-
self-compassion for reducing stress across mul- sures of stress. This research has the advantage of
tiple context and populations. This research has measuring stress using more objective means that
demonstrated that self-compassion is associ- are free from the reporting biases that can plague
ated with lower self-reported perceived stress self-report measures. It also provides key insights
in university students (Sirois, 2014; Stutts into how self-compassion is implicated in the
et al., 2018; Zhang et al., 2016), community physiological processes involved in stress that
adults (Homan & Sirois, 2017), athletes have relevance for physical health (for a more
(Mosewich et al., 2019), and those with chronic complete review, see Chap. 17). For example,
health conditions (Pinto-Gouveia et al., 2014; one study found that adolescents who were high
Sirois & Hirsch, 2019; Sirois et al., 2015b; in self-compassion demonstrated lower physio-
Trindade & Sirois, 2021). Although much of logical reactivity in response to the Trier Social
this research has been cross- sectional and Stress test, a standard procedure for inducing
examined dispositional self-compassion, there stress in a lab setting (Bluth et al., 2016).
is also some evidence that interventions Although the differences in changes in salivary
designed to increase self-compassion can be cortisol, heart rate, blood pressure, and heart rate
effective for reducing perceived stress (Ferrari variability in comparison to a control group were
et al., 2019). For example, in a randomized con- small, the findings supported an overall profile of
trolled trial of the Mindful Self-Compassion less reactivity to stress for those with higher lev-
intervention, those in the treatment group els of self-compassion. Similar results were
reported higher self-compassion and less stress found with young adults exposed to stress-
following the intervention, and these improve- inducing lab tasks, with those scoring higher on
ments were maintained at the 6-month and self-compassion having lower levels of stress-
1-year follow-up (Neff & Germer, 2013). induced inflammation (as measured by interleu-
Similar results in terms of reducing stress have kin-6) compared to a control following the stress
been found for Mindful Self-Compassion induction (Breines et al., 2014).
Training among practicing psychologists at risk However, it is unclear whether self-compassion
for burnout (Eriksson et al., 2018). may be more beneficial for attenuating activation
316 F. M. Sirois
of the sympathetic nervous system or the HPAC (Lazarus & Folkman, 1984). Effective coping is
axis or engaging parasympathetic responses that achieved when the source of stress is eliminated
quiesce physiological reactivity. One study found or diminished, or one interacts or views the
that brief self-compassion training reduced sym- stressor in a way that is no longer harmful or
pathetic (salivary alpha-amylase), and cardiac threatening. Self-compassion may promote both
parasympathetic responses to a stress-inducing healthy cognitive responses and behavioral
lab task, but had no effect on HPAC axis activity responses to stress in several ways. Appraising a
as measured by salivary cortisol (Arch et al., stressor as less threatening or harmful, by not
2014). Contrasting this, other researchers have over-identifying with stressful negative emotions
found that the positive and negative poles of self- either initially or after assessing one’s resources,
compassion were associated with lower reactivity can reduce or diminish stress reactivity and allow
as measured with markers of both sympathetic a faster return to prestress levels of functioning.
(salivary alpha amylase) and HPAC axis (inter- Additionally, acknowledging one’s struggle and
leukin-6 levels) responses following a stressful difficulties with a stressor as being a common
situation (Neff et al., 2018). Although it is possi- human experience can reduce any feelings of
ble that responding to stressors with self- shame that might prevent seeking support, infor-
compassion engages all three systems, more mation, or advice for addressing or even remov-
work is needed to verify this proposition and ing the stressor. The cognitive and emotional
examine which aspects of self-compassion might resources that are freed up from not ruminating
benefit which systems. about the stressor and reactivating its harmful
Classic psychological models define stress as effects (e.g., Smyth et al., 2013), can therefore be
a transaction between the individual and their mobilized to taking constructive action to prob-
environment. When the individual appraises the lem solve and eliminate or reduce the stressor.
demands of the environment as being harmful to Prior research indicates that overall, self-
their well-being, and taxing or overwhelming the compassionate people tend to use a healthier rep-
internal and external resources that they have ertoire of coping strategies to deal with stressors.
available, they experience stress (Lazarus & This evidence was summarized in a recent meta-
Folkman, 1984). Appraisal is also viewed as an analysis of 136 studies which found that self-
ongoing process that can lead to different evalua- compassion was associated with greater use of
tions of the demands of the situation and how adaptive coping strategies, and less use of mal-
they can be met depending on the resources that adaptive coping (Ewert et al., 2021). Specifically,
are available and mobilized to respond to the self-compassion was associated with greater use
demands. When viewed from this perspective, of emotional approach coping strategies, such as
self-compassion may help to reduce stress seeking emotional social support, positive
through several key processes tied to the interpre- reframing, and acceptance of stressors, as well as
tation of the stressor and one’s resources, as well greater use of problem-focused coping strategies,
as the response to the challenging event. Theory including active coping, planning, and seeking
and evidence suggest that coping strategies and instrumental social support. Such strategies are
emotion regulation are two such processes. well-known to be effective for reducing stress
(Carver & Connor-Smith, 2010; Carver et al.,
1989). In contrast, coping strategies such as self-
oping as a Process Linking Self-
C blame, denial, rumination, disengaging from and
Compassion to Lower Stress avoiding the stressor, and substance use to with-
draw from the stressor provide immediate relief
Consistent with appraisal-based models of stress, from stress, but at the cost of prolonging or wors-
coping is viewed as a process involving cognitive ening stress in the long run as the stressor
and behavioral responses that aim to manage or remains. Not surprisingly, self-compassion was
control the stressor or reduce the associated stress moderately and negatively associated with the
use of these maladaptive strategies in the studies such as cognitive reappraisal (reframing situa-
included in the meta-analysis (Ewert et al., 2021). tions to change their emotional impact) and sup-
In addition to the reasons noted earlier, self- pression (decreasing the experiences and
compassion may promote adaptive coping behaviors linked to an emotion) (Gross & John,
through lower perceptions of threat, and increased 2003). Like adaptive coping, emotion regulation
perceptions of control over the stressor. For is considered successful when the changes expe-
example, in one longitudinal study of Japanese rienced are lasting rather than short-term.
undergraduate students, baseline self-compassion Emotion regulation can also be viewed from a
predicted greater use of adaptive coping strate- more holistic perspective, as part of global self-
gies 1 month later, with reduced perceptions of regulatory system that includes physiological
threat and greater perceptions of controllability regulation of heart rate, for example, that can
accounting for this association (Chishima et al., have a direct impact on physical health (Butler,
2018). The links between self-compassion and 2011). From this perspective, success in regulat-
reduced threat appraisals and enhanced control ing emotions should also translate into positive
appraisals have also been noted in a study of physiological changes such as healthy respon-
female athletes (Mosewich et al., 2019). Viewing siveness of the parasympathetic nervous system
stressors as common human experiences, rather to quiesce stress.
than something that is unique to the individual or Current evidence supports the linkages of self-
a sign of failure can make the stressor seem less compassion to healthy emotion regulation as a
threatening. However, it is likely that this rela- process for understanding stress responses.
tionship is bidirectional. Reappraisal of a stressor Cross-sectional studies have noted strong link-
to be less harmful and threatening may also ages between self-compassion and cognitive
enhance feelings of control that are essential for reappraisal but not suppression (Sirois et al.,
taking constructive action toward dealing with 2019), and between low self-compassion and dif-
the stressor and using problem-focused and ficulties in emotion regulation (Finlay-Jones
approach-oriented strategies. et al., 2015). There is also some evidence that
self-compassion is linked to physiological mark-
ers of healthy emotion regulation, such as vagally
Self-Compassion, Emotion mediated heart rate variability (Svendsen et al.,
Regulation, and Stress 2016), even after controlling for related relevant
constructs such as mindfulness (Svendsen et al.,
Several researchers have suggested that emotion 2020). These findings make sense if we consider
regulation is a core process within self- how the synergistic actions of the three bimodal
compassion (Barnard & Curry, 2011; Finlay- components of self-compassion may operate.
Jones et al., 2015; Inwood & Ferrari, 2018). This Responding with self-kindness and common
is not surprising given the capacity of self- humanity provides opportunities to reappraise
compassion for enhancing positive mood states one’s difficulties from a less critical and more
and reducing negative mood states aligns with connected perspective that can reduce negative
classic definitions of emotion regulation. For emotions and enhance positive emotional states.
example, the process model of emotion regula- Mindfulness rather than over-identifying can at
tion defines emotion regulation as “the processes the same time foster stepping back and viewing
by which individuals influence which emotions one’s emotional experiences during difficulties
they have, when they have them, and how they from a more balanced perspective.
experience and express these emotions” (Gross, Although there are few direct tests of the role
1998, p. 275). Adaptive emotion regulation fur- of emotion regulation for explaining why self-
ther involves upregulating positive emotions and compassion may reduce stress, at least one study
downregulating negative emotions such as dis- provides clear evidence supporting this proposi-
tress, often through the use of specific strategies tion. In a study of practicing and trainee
318 F. M. Sirois
p sychologists, fewer emotion regulation difficul- and is not healthy is not enough to motivate
ties such as nonacceptance of emotional behavior change.
responses and lack of emotional clarity, mediated It is also important to highlight that self-
the link between self-compassion and stress compassion is not equivalent to self-care. Self-
(Finlay-Jones et al., 2015). Notably, these results compassion involves a set of compassionate
were found after controlling for neuroticism, a responses to suffering that arises from failure, dif-
personality trait well known to predict stress and ficulties, or perceived personal shortcomings that
negative emotional states. help to reduce the suffering, re-establish balance,
It is also worth noting that emotion regulation and motivate steps toward self- improvement
has some conceptual overlap with coping and (Neff, 2003; Neff et al., 2007). Self-care, in con-
there are likely complex pathways between self- trast, involves engaging in behaviors aimed at car-
compassion, emotion regulation, and coping. For ing for the self, either more generally, such as
example, certain forms of emotion-focused coping having a relaxing day at the spa, or specifically in
may help regulate emotions, and regulating nega- the context of health circumstances which require
tive emotions by being self-compassionate may that certain self-management behaviors are prac-
make it easier to implement more rational, prob- ticed to ensure that health is maintained. Sticking
lem-focused coping. However, emotion regulation to a low sugar diet in the context of diabetes or
also includes processes such as enhancing and managing stress in the context of depression or
maintaining positive emotions that are not part of anxiety, are common examples of self-care prac-
the coping process (Gross, 1998). Accordingly, tices. Although engaging in self-care behaviors
self-compassion may help to reduce stress and such as these are associated with higher levels of
promote more adaptive functioning via emotion self-compassion (e.g., Sirois & Hirsch, 2019),
regulation, in ways that are distinct from coping their linkage alone tells us little about the reasons
(see Chap. 24 for a more detailed discussion). why self-compassion may promote their practice.
A further consideration that is needed before
discussing why self-compassion may promote
Self-Compassion and Health better physical health through health behaviors is
Behaviors the dimensionality of health behaviors. Theory
and evidence have demonstrated that health
On the surface, it may appear that self-compassion behaviors form two separate and replicable
would promote engaging in healthier behaviors dimensions: (1) health-promoting and maintain-
simply because doing so reflects self-kindness or ing behaviors (e.g., physical activity, healthy eat-
self-care. However, this simplistic view neglects ing, and medical care seeking); and (2) health-risk
a full consideration of the psychological pro- behaviors (e.g., smoking, substance use, and
cesses involved in being self-compassionate, as excessive alcohol use) (Lippke et al., 2012;
well as the complexities involved in understand- Vickers et al., 1990). Given the outcomes of these
ing when, why, and whether people choose to behaviors can lead to better or worse health,
engage in certain health behaviors. Most people respectively, we might expect that self-
are aware that certain behaviors are healthier than compassion would be differentially related to
others, and that uptake of such behaviors has the health-promoting and health-risk behaviors.
potential to improve health and quality of life. Overall, current evidence supports this assump-
But this knowledge alone is not enough to moti- tion. For example, a meta-analysis of self-
vate people to stop unhealthy habits such as compassion and health behaviors found an
smoking or excessive alcohol use, or to adopt overall positive association with a range of
better eating habits and stay physically active. health-promoting behaviors, as well as with
Indeed, the tripling of worldwide obesity rates health-risk behaviors that had been recoded to
since 1975 (World Health Organization, 2021) reflect less engagement in healthy behaviors
attests to the idea that simply knowing what is (Phillips & Hine, 2019). Consistent with these
findings, another meta-analysis found that self- change efforts to the extent that feel they have
compassion (both dispositional and induced) was some control over the behavior. For example,
associated with greater engagement in physical perceptions of control figure prominently in
activity (Wong et al., 2021). Other reviews have explaining intentions and actual behaviors in the
examined the effectiveness of self-compassion Theory of Planned Behavior (TPB; Ajzen, 1991),
interventions for promoting health behavior one of the most widely used theories for under-
changes. One review found that self-compassion standing the self-regulation of health behaviors.
interventions were effective for eating-related Self-efficacy is another control-related concept
behaviors and weight loss (Rahimi-Ardabili that is often used as a proxy for perceived behav-
et al., 2018), whereas another review found that ioral control from the TPB to understand the
they were just as effective as more traditional regulation of health behaviors. Self-efficacy
approaches for fostering the self-regulation of reflects the extent to which an individual believes
health behavior (Biber & Ellis, 2019). they have the capacity and ability to execute the
Traditionally, models for understanding when actions required to achieve their goals (Bandura,
and why people do or do not engage in health 1977).
behaviors focus on social cognitive factors, such The influence of self-compassion on percep-
as attitudes, social norms, and perceptions of con- tions of and reactions to failures is one reason
trol. These social cognitive models, such as the why self-compassion may foster feelings of self-
Theory of Planned Behavior (Ajzen, 1991), high- efficacy about reaching health goals. Self-
light the central role of cognitions in behavior, compassionate people may notice and remember
often overlooking or downplaying the influence of not just their failures when trying to make
emotions and mood states in people’s health changes to their health behaviors, but also their
behavior choices. Increasingly though, researchers successes. The mindfulness component of self-
are acknowledging the importance of also consid- compassion can also promote taking a balanced
ering these hot or automatic processes that govern view of one’s health behavior efforts and prog-
behavior choices, which can provide additional ress so that failures do not overshadow successes.
insights and predictive power to the more cold or Taking a kind and accepting stance to difficulties
reflective processes involved in decision-making experienced when trying to change health behav-
(e.g., Gerrard et al., 2008). Emotion-regulation iors can promote viewing these lapses not as fail-
processes fall under these more automatic pro- ures, but as a natural part of any behavior change
cesses and have relevance for understanding why effort that anyone may experience. In short, self-
self-compassion can help promote engagement compassion can reduce self-defeating thinking in
with health-promoting behaviors, whilst also min- response to the inevitable lapses that occur when
imizing temptations or motivations to engage in people try to change their health behaviors.
health-risky behaviors. The following sections dis- From the perspective of Social Cognitive
cuss possible reasons why self-compassion is Theory, these shifts in perspective are crucial for
linked to better health behaviors, drawing on both building self-efficacy (Bandura, 1977). When
traditional and contemporary theories of self- people view their challenging experiences with a
regulation of health behaviors, and the evidence particular behavior as failures, it diminishes their
that supports these views. confidence in their ability to be successful. But
the reverse is also true. Focusing on the successes
experienced with a behavior can help to build
Self-Compassion, Self-Efficacy, confidence about one’s capacity to continue to be
and Health Behaviors successful with similar behaviors. This increased
self-efficacy can then help fuel persistence in the
A core concept within several social cognitive face of any minor lapses whilst trying to change
theories of health behavior change is that people behavior, something that is all too common in the
will engage and persist with their behavior context of health behaviors.
320 F. M. Sirois
Current evidence supports these explanations that people are at their greatest risk for putting off
of why self-compassion may promote self- or even abandoning their health goals, in part
efficacy. For example, a meta-analysis of 60 stud- because of their emotional reactions to these
ies found that self-compassion overall was lapses (e.g., Sirois & Giguère, 2018). Rather than
associated with higher self-efficacy, and that each motivating persistence, feelings of guilt, self-
of the three positive subscales were positively criticism, and other negative emotions arising
linked to self-efficacy, and each of the three nega- from lapses can impair self-regulation by shifting
tive subscales were negatively linked to self- attention away from longer-term health goals and
efficacy (Liao et al., 2021). placing it on the immediate goal of regulating
Although there has been less research testing current negative mood states (Sirois & Pychyl,
whether self-efficacy explains the link between 2013; Wagner & Heatherton, 2015). As a result,
self-compassion and health behaviors, two stud- people may use avoidant coping strategies and
ies provide supportive evidence for this proposi- other self-defeating, but immediately gratifying,
tion. In one study of emerging adults, higher behaviors, such as overindulging in food, or
levels of self-compassion were associated with binge-watching their favorite shows rather than
stronger intentions to engage in health-promoting exercising, as a way to regulate these negative
behaviors such as staying physically active, eat- emotions (Baumeister et al., 2007).
ing healthy, and managing stress within the next Successful navigation of these lapses and
6 months (Sirois, 2015). Consistent with the temptations requires healthy emotion regulation
TPB, higher levels of health-specific self-efficacy skills to reduce the negative emotional responses
explained this link. In another study, overweight to such challenges and enhance positive states
and obese adults trying to lose weight by restrict- that can fuel motivation and persistence to con-
ing their diet were followed for 2 weeks using tinue (e.g., Sin et al., 2015). This is where theory
Ecological Momentary Assessment with twice and evidence suggest that self-compassion may
daily sampling (Thøgersen-Ntoumani et al., be particularly beneficial for promoting the prac-
2021). Self-compassionate responses to dietary tice of healthy behaviors. Accepting lapses as a
lapses and temptations were associated both with normal part of health behavior change that any-
stronger intentions to continue dieting, and one can experience can reduce negative self-
greater self-efficacy for dieting, with lower feel- defeating thoughts and emotions and taking a
ings of guilt explaining these associations. These balanced view of the lapse in the context progress
findings support the idea that the healthy emotion made rather than ruminating about it can further
regulation linked to being self-compassionate reduce negative emotional responses and increase
can contribute to feelings of self-efficacy, and in positive feelings about overall progress. Research
turn health behaviors, as proposed by the triadic on how people respond to exercise setbacks sup-
model of self-compassion and health (Fig. 18.1). ports these ideas. In one study, self-compassion
was associated with lower levels of negative
affect, and greater goal re-engagement following
motional Regulation as a Self-
E the recall an exercise lapse, even after controlling
Regulation Resource for Health for self-esteem (Semenchuk et al., 2018).
Behaviors From a self-regulation perspective, the healthy
balance between high levels of positive emotions
Making healthy behavior changes can be chal- and low levels of negative emotions that charac-
lenging for most people. The path to successfully terize self-compassionate responses to setbacks
achieving health goals typically follows a trajec- can be viewed as resources that promote effective
tory of peaks, when progress is made, and self-regulation of health behaviors. According
troughs, when lapses and temptations may tem- the Temporal Self-Regulation Resource Model
porarily derail progress. It is at these challenging (TASRR; Sirois, 2015, 2016; Sirois & Hirsch,
points on the path to changing health behaviors 2015), the extent to which individual differences
are characterized by high levels of positive affect associated with more frequent practice of a set of
and future orientation, and low levels of negative health behaviors such as eating healthy, staying
affective states, will predict the effectiveness of physically active, and managing stress, with a
self-regulation. In essence, positive affect and meta-analysis of these effects showing a small
future orientation (i.e., a tendency to consider but significant association. Additional analyses
future time frames when making decisions) serve with eight samples testing the indirect effects
as resources to draw upon when facing self- through positive and negative affect revealed
regulation threats (Baird et al., 2021; Fredrickson, results consistent with the TASRR model. Across
1998), whereas negative affect is a liability for each sample, the association between self-
effective self-regulation (see Wagner & compassion and more frequent health-promoting
Heatherton, 2015 for a review). Health behaviors behaviors was explained in part by higher posi-
are often considered the prototypical self- tive affect and lower negative affect. Although
regulation task (Baumeister et al., 1994), because the above findings rely upon cross-sectional data
they require regulating and monitoring emotions which preclude drawing conclusions about cau-
to maintain a focus on long-term goals rather sality, they are consistent with theory, which
than allowing emotions to drive choices for assumes the temporal precedence of dispositional
immediate gratification (Tice & Bratslavsky, self-compassion as contributing to health behav-
2000). Individual differences that are character- iors rather than the reverse. Nonetheless, longitu-
ized by healthy emotion regulation skills and dinal research testing these links over time would
affective balance are therefore likely to promote provide more conclusive evidence.
the practice of health-promoting behaviors. Self-
compassion can be viewed as one such individual
difference. Self-Compassion, Emotion
Current research provides some support for Regulation, and Sleep Quality
this emotion regulation account of how self-
compassion promotes engaging in healthy behav- In addition to ameliorating stress and supporting
iors. In one study of mothers who had young effective self-regulation of health behaviors,
children, those with higher levels of self- emotion regulation figures prominently as a pro-
compassion experienced lower levels of guilt cess to explain why self-compassion can contrib-
about taking time for themselves to engage in ute to better sleep quality. Emotion regulation
health-promoting behaviors, and this lower guilt processes that are supported by taking a self-
explained their more frequent practice of health compassionate response to daily difficulties may
behaviors (Miller & Strachan, 2020). Similar be particularly useful for helping individuals to
results with respect to negative emotions were wind down after a difficult day rather than rumi-
found in a study of university students. Lower nating about things that did not go as well as
levels of negative affect, but not higher levels of expected. Positive presleep cognitions are known
positive affect, explained the association between to impact sleep quality (Wood et al., 2009), and
self-compassion and stronger intentions to may be fostered by making adaptive cognitive
engage in health-promoting behaviors after reappraisals of difficult events. Consistent with
accounting for current body mass index (BMI) this idea, a study of university students found that
and current practice of health behaviors (Sirois, self-compassion was associated with better sleep
2015). quality, and this link was explained by less use of
More compelling evidence for the idea that a harmful cognitive emotional regulation strate-
healthy affective balance links self-compassion gies, such as self-blame (Semenchuk et al., 2021).
to health behaviors comes from a meta-analysis Other research has directly tested the role of
of 15 samples that included over 3200 partici- adaptive cognitive reappraisals for reducing neg-
pants (Sirois et al., 2015a). In all 15 samples, dis- ative affect and improving sleep-related out-
positional self-compassion was significantly comes. In one study, self-compassion was
322 F. M. Sirois
associated with engaging in less bedtime procras- respect to health behaviors, but also for stress and
tination, a sleep behavior known to contribute to sleep quality.
poor sleep quality (Kroese et al., 2014), and this Despite the promise of this research, there
association was explained by greater use of emo- remains several gaps that future research on self-
tion regulation in the form of cognitive reap- compassion would be wise to address to elucidate
praisal, which in turn contributed to lower levels the links between self-compassion and health.
of negative emotions (Sirois et al., 2019). The Triadic Pathway model highlights the syner-
gistic nature of the three health pathways and the
processes linking self-compassion to each. Yet
Conclusions and Future Directions research to date has not considered these three
pathways simultaneously to understand their pos-
From the research reviewed in this chapter, it is sible dynamic and reciprocally reinforcing link-
clear that self-compassion has important implica- ages or how the different components of
tions for physical health. Both dispositional self- self-compassion may be involved. Often stress
compassion and self-compassion interventions and/or health behaviors are examined as path-
are linked to reduced physical symptoms and bet- ways linking self-compassion to health (e.g.,
ter overall physical health. Dunne et al., 2016; Homan & Sirois, 2017), but
The current chapter introduced a Triadic rarely is sleep considered as a key pathway.
Pathway model of self-compassion and physical Research examining one or more of the proposed
health as a provisional framework to conceptu- processes and how they contribute to the three
ally organize the current research on the possible health pathways is rare, despite the fact that emo-
routes and self-processes linking self-compassion tion regulation is often considered a central fea-
to health. It is hoped that this model can guide ture of self-compassion and has clear relevance
future “second wave” research into the reasons for understanding stress, sleep quality, and health
why self-compassion may be beneficial for phys- behaviors. As the field of self-compassion and
ical health and provide a foundation for generat- health continues to advance, it will be important
ing new theoretical insights. Lower stress, better that investigations consider the simultaneous
sleep quality, and engaging in a repertoire of contributions of the self-regulation processes
healthier behaviors, such as staying physically proposed by the Triadic Pathway model and use
active and eating a healthy diet, are three key- robust experimental and longitudinal research
related pathways through which self-compassion designs to provide further clarity regarding how
is proposed to exert its effects on health. One key and why self-compassion can benefit physical
message from the theory and evidence reviewed health.
is that the value of self-compassion for promot-
ing the practice of healthy behaviors may be due
to its effectiveness in helping people bridge the References
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Self-Compassion and Chronic
Medical Conditions 19
Amy Finlay-Jones, Anna Boggiss,
and Anna Serlachius
Introduction health difficulties (Daré et al., 2019; Katon et al.,

2007; Tegethoff et al., 2015). For example, a
Chronic medical conditions (CMCs) are health recent study conducted in the United States found
problems that are likely to require treatment, a 51% greater risk of mental health conditions
including hospital stays, medication, or outpa- among young people with CMCs compared to
tient supports, for longer than 12 months those without (Adams et al., 2019). These rela-
(Hardelid et al., 2014). Examples of CMCs tionships may be bidirectional, and mental and
include cancer, diabetes, autoimmune disorders, physical health symptoms can compound one
asthma, and myalgic encephalomyelitis/chronic another, leading to a vicious cycle of chronic
fatigue syndrome; collectively, these conditions comorbidity (Katon et al., 2007; Moussavi et al.,
affect between 40 and 65% of adults (Chapel 2007). Accordingly, there is a need to understand
et al., 2017; Harrison et al., 2017; Hvidberg et al., modifiable factors that are associated with mental
2020), with a substantial proportion experiencing well-being and resilience among individuals liv-
multimorbidity (Newman et al., 2020). The ing with CMCs. The current chapter explores
impact of CMCs is pervasive and multidimen- self-compassion as a modifiable, transdiagnostic
sional. Individuals living with CMCs often expe- resilience factor that is associated with better
rience limitations in their physical functioning physical and mental health outcomes among indi-
and report disruptions to family and peer rela- viduals living with CMCs. We provide specific
tionships, school and employment, and activities examples from the literature on chronic pain, dia-
of daily living. In addition, they frequently expe- betes, and cancer, and discuss future directions
rience ongoing burden as a result of treatment for self-compassion and CMC research.
and physical symptoms such as pain and fatigue
(Lambert & Keogh, 2015). Unsurprisingly, indi-
viduals with CMCs may experience difficulties Self-Compassion as a Psychological
with adjustment and vulnerability to mental Resource in CMCs
There are several theoretical frameworks that

A. Finlay-Jones (*) describe the process of adjustment for individu-
Telethon Kids Institute, Nedlands, WA, Australia
e-mail: [email protected] als with CMCs, and these models vary in the
extent to which they emphasize the role of bio-
A. Boggiss · A. Serlachius
Department of Psychological Medicine, University of logical, psychological, and social factors in
Auckland, Auckland, New Zealand determining an individual’s well-being. While

https://doi.org/10.1007/978-3-031-22348-8_19
330 A. Finlay-Jones et al.
the biomedical model highlights disease-related young adults with a range of CMCs. Together,
processes as the primary determinant of adjust- these findings suggest that self-compassion is a
ment, psychological and biopsychosocial models valuable transdiagnostic intervention target for
emphasize the key role of psychological func- promoting better adjustment and mental health
tioning and coping resources in influencing among individuals with CMCs (Finlay-Jones
adjustment outcomes (Walker et al., 2004). et al., 2020).
Examples of these latter models include Lansing One of the ways in which self-compassion
and Berg’s (2014) self-regulation model, and may serve a protective function for individuals
Dall’Oglio et al’s (2021) integrated self-care with CMCs is by reducing the experience of
model, which highlight how psychological shame and self-stigma. Individuals living with
resources interact with biological and environ- CMCs often report high levels of shame, self-
mental factors to influence self-regulation and criticism, self-blame, and stigma (Casati et al.,
self-care, which in turn promote better adjust- 2000). This may be heightened when an individ-
ment and well-being. Through the lens of psy- ual’s physical appearance is altered because of
chological and biopsychosocial models, their CMC, such as in the case of chronic skin
self-compassion can be viewed as an important conditions (Clarke et al., 2020) or when stigma
psychological resource that can support individu- exists around other aspects of the disease. For
als to cope with the various challenges associated example, individuals with inflammatory bowel
with living with a CMC. Self-compassion disease report perceived stigma around their con-
involves responding to oneself in a supportive dition as a “dirty disease” that is socially unac-
manner during times of difficulty, by taking a ceptable (Dibley et al., 2018), while people with
mindful perspective on the difficult experience, diabetes have described stigma regarding inject-
remembering that one is not alone, and treating ing insulin due to the association between needle
oneself with kindness and understanding (Neff, use and illicit drug use (Schabert et al., 2013).
2003). Prior work has underscored the role of Shame and self-stigma may also be exacerbated
self-compassion in promoting adaptive coping when individuals experience decreases in func-
and emotion regulation (Finlay-Jones, 2017; tioning or increased dependence on others, which
Inwood & Ferrari, 2018) in the context of mental may lead to feelings of uselessness or being a
health difficulties, indicating that self-compassion burden on others (Ambridge et al., 2020). In turn,
may act in a similar way among individuals with experiences of stigma, shame, and self-blame are
CMCs (Prentice et al., 2021). associated with poorer psychological outcomes
Empirical evidence indicates that self- among people living with CMCs (Bennett et al.,
compassion is consistently related to better 2005; Clarke et al., 2020; Phelan et al., 2013;
adjustment and psychological health in individu- Trindade et al., 2018, 2019), and may also impact
als with a range of different CMCs. For example, on help-seeking, treatment engagement, and
self-compassion is associated with more resil- health behavior change (Casati et al., 2000;
ience, greater quality of life and coping efficacy, Joachim & Acorn, 2000; Valdiserri, 2002).
and less depression and anxiety among individu- Hughes et al.’s (2021) systematic review
als with epilepsy (Baker et al., 2019; Clegg et al., found that across studies of people with CMCs,
2019) and multiple sclerosis (Gedik and Idiman, the association between self-compassion and
2020; Nery-Hurwit et al., 2018). A recent sys- poor mental health (i.e., anxiety and depression)
tematic review found that across CMCs, self- was mediated by shame, as well as depressive
compassion shares moderate-large inverse brooding and worry. Further, studies have
associations with depression and anxiety (Hughes revealed that among individuals with HIV, self-
et al., 2021). While most research has been con- compassion buffers the adverse impact of self-
ducted with adults, Prentice et al. (2021) found stigma on life satisfaction (Yang & Mak, 2017)
self-compassion was associated with both well- and is inversely associated with shame (Brion
being and distress in a sample of adolescents and et al., 2014), while self-compassion also attenu-
19 Self-Compassion and Chronic Medical Conditions 331
ates the impact of self-directed disgust on ing the risk of physical deterioration and vulner-
symptoms of depression in people living with ability to mental health problems.
chronic skin conditions (Clarke et al., 2020). Self-compassion appears to play a meaningful
Connected to, but distinct from self-criticism and role in disrupting the fear-avoidance model of
shame, a second pathway by which self- chronic pain, via reductions in pain-related fear
compassion may promote more adaptive out- (Edwards et al., 2019), pain catastrophizing
comes for people living with CMC is by (Wren et al., 2012), avoidance (Costa & Pinto-
promoting more positive health behaviors, such Gouveia, 2013), and other maladaptive cognitive
as treatment adherence and reducing health-risk emotion regulation strategies (Purdie & Morley,
behaviors, such as smoking, illicit drug use, and 2015). Other research demonstrates that self-
unprotected sex (Dawson Rose et al., 2014; Sirois compassion is meaningfully associated with
& Hirsch, 2019; Sirois & Rowse, 2016). For important pain-related clinical and functional
example, self-compassion was found to moderate outcomes. For example, one study found that
the link between shame and health-risk behaviors people with obesity and chronic pain who were
in people with HIV, such that those who were more self-compassionate reported lower levels of
higher in self-compassion were more likely to pain-related disability (Wren et al., 2012) while
disclose their HIV status to others and adhere to other studies found self-compassion to be associ-
healthy self-management practices (Brion et al., ated with greater engagement in daily activities
2014). Chapter 18 in this Handbook describes the (Costa & Pinto-Gouveia, 2011). Conversely,
associations between self-compassion and vari- individuals with low self-compassion – particu-
ous health-promoting behaviors in greater detail. larly those who feel alone in their pain - report
higher levels of pain severity (Chang et al., 2019).
In addition to reducing avoidance, self-
Self-Compassion and Chronic Pain compassion is associated with factors that are
recognized to protect individuals from the delete-
Chronic pain provides one example of how self- rious effects of chronic pain. For example, self-
compassion might help to promote better out- compassion is associated with greater pain
comes for individuals living with CMCs. Chronic acceptance (Costa & Pinto-Gouveia, 2011, 2013)
pain is one of the most common CMCs and one and use of adaptive strategies to cope with pain
of the leading causes of disability worldwide (Barnes et al., 2018). Unsurprisingly, across sam-
(Vos et al., 2012). In addition to functional ples of individuals with chronic pain, self-
impairment, individuals living with chronic pain compassion is associated with better mental
often experience difficult emotional and affective health outcomes, including symptoms of depres-
experiences, such as fear of pain, and of activities sion, anxiety, and stress (Carvalho et al., 2018;
that may cause pain (Bunzli et al., 2015) and Costa & Pinto-Gouveia, 2011, 2013).
shame regarding their condition (J. A. Smith & Additionally, self-compassion may alleviate the
Osborn, 2007), which may exacerbate their pain impact of cognitive fusion, or the tendency to
symptoms and compound disability (Crombez believe the literal content of one’s thoughts.
et al., 2012). In the fear-avoidance model of Cognitive fusion is a known risk factor for pain-
chronic pain, cognitive factors and experiential related disability and bears similarities with the
avoidance act as key mechanisms in the onset and overidentification facet of Neff’s (2003) model of
maintenance of chronic pain. Interpretation of self-compassion. Conversely, the mindfulness
pain is a core component of the model. When facet of Neff’s model provides an adaptive alter-
individuals respond to pain by catastrophizing native mode of relating to one’s difficult thoughts.
about it, they are more likely to engage in hyper- For example, with cognitive fusion or overidenti-
vigilance or experiential avoidance. In turn, fication, the thought “this pain is never going to
hypervigilance and avoidance lead to reduced go away” may provoke a strong fear reaction,
engagement in daily activities, over time increas- whereas, with mindfulness, the stance that “I am
having the thought that this pain is never going to ness and self-compassion for the ABCT group,
go away (but that is not necessarily true)” may with moderately large to large effects (Montero-
help to decouple the thought from the affective Marin et al., 2020). While changes in functional
response. Indeed, it has been found that while impairment were not mediated by either mindful-
cognitive fusion mediates the relationship ness or self-compassion, analyses of self-
between pain severity and depressive symptoms, compassion subscales showed that changes in the
this relationship is moderated by self-compassion, common humanity facet of self-compassion
such that those with high self-compassion are mediated improvements in anxiety and depres-
less likely to experience adverse outcomes sion. These findings indicate that by being able to
(Carvalho et al., 2018). Interestingly, while there connect their individual struggles with that of the
are substantial numbers of studies attesting to the shared human experience, individuals with fibro-
role of mindfulness in protecting against pain- myalgia participating in the ABCT program were
related fear and avoidance, a longitudinal study less likely to experience symptoms of anxiety
found that baseline self-compassion, but not and depression.
mindfulness, predicted depressive symptoms
over time, above and beyond baseline impair-
ment, and depressive symptoms (Carvalho et al., Self-Compassion and Diabetes
2019). This study indicates that self-compassion
may play an important role in preventing depres- Further examples of how self-compassion bene-
sion among individuals experiencing pain-related fits those living with CMCs can be found in the
functional impairment. diabetes literature. Diabetes mellitus is a cluster
Psychological interventions for those who of metabolic disorders of which the most com-
experience chronic pain aim to support patients mon types are type 1 and type 2 diabetes, with
to change their cognitive, affective, and behav- type 2 diabetes accounting for approximately
ioral responses to the physical sensation of pain. 90% of cases worldwide (Chatterjee et al., 2017).
To date, two studies have trialed self-compassion- More than 451 million adults are estimated to live
based approaches as a means of promoting more with diabetes worldwide, which is expected to
adaptive responding in the face of pain, with increase to 693 million by 2045 (Cho et al.,
demonstrated benefit. Montero-Marin et al. 2018). The economic costs of diabetes are con-
(2017) compared Attachment-Based Compassion siderable, with type 2 diabetes estimated to cost
Therapy (ABCT) with a relaxation training con- the global economy US$825 billion (Seuring
dition to determine the effect on functional et al., 2015). As well as the economic and public
impairment and mental health in people with health impact of diabetes, the psychological
fibromyalgia. The ABCT intervention was deliv- impact of living with diabetes is substantial and
ered over 8 weeks (one two-hour session per is estimated to double the odds of developing
week), with three booster sessions. The focus of mental health problems such as depression
ABCT is to support participants to be kinder to (Anderson et al., 2001; Young-Hyman et al.,
themselves and others, through exercises focused 2016).
on mindfulness, self-compassion, and early Diabetes requires daily, onerous self-care
attachment experiences. Functional outcomes, behaviors. Achieving optimal glycemic control in
depression, and anxiety in the ABCT group were diabetes and preventing hyperglycemia (high
significantly better than those in the relaxation blood sugar levels) is paramount, as tighter gly-
group following the intervention, and these dif- cemic control in diabetes is associated with
ferences were maintained over three months with slower progression of diabetes-related complica-
a large effect size. Follow-up studies found that tions and reduced mortality (Diabetes Control
the ABCT training had greater cost utility than and Complications Trial Research Group, 1993;
the relaxation comparator (D’Amico et al., 2020), Holman et al., 2008; Stratton et al., 2000;
and also reported treatment effects on mindful- Zoungas et al., 2012). Self-management of type 2
diabetes is multifaceted and includes modifying excessive focus on numbers and achieving
lifestyle behaviors, such as diet and physical “good” glycemic control, as well as the stigma-
activity, as well as adherence to medication, reg- tizing nature of diabetes (Liu et al., 2017), self-
ular monitoring of blood glucose levels, and foot compassion offers an empathetic approach to
care. Arguably type 1 diabetes is characterized by dealing with the never-ending burden of striving
an even more invasive treatment regimen, con- to achieve optimal diabetes management. Self-
sisting of administering insulin (via multiple compassion seems an especially good fit with
daily injections or pump therapy), 4–8 daily type 1 diabetes, which is often diagnosed in
blood tests (via finger pricks or using continuous childhood with peak onset in adolescence
glucose monitoring devices), and the ongoing (Tuomilehto, 2013). Adolescence is in itself a
need for close monitoring of food intake and the period of significant physical, cognitive, and
dose of insulin required to cover food that is con- emotional change and upheaval, with an increased
sumed. People living with type 1 and type 2 dia- risk for depression, poor self-esteem, and body
betes must also attend regular GP or diabetes image (Hazen et al., 2008; Thapar et al., 2012).
outpatients’ appointments to assess their glyce- Teenagers living with diabetes must navigate this
mic control (HbA1c) and screen for diabetes- challenging developmental period while also liv-
related complications. ing with a demanding chronic illness.
The self-discipline needed to optimize glyce-
mic control and prevent hyperglycemia or hypo- Despite the good conceptual fit and potential
glycemia (low blood sugar levels) can be utility in managing diabetes, the evidence base
immensely challenging and stressful for people for self-compassion is limited. A handful of
living with diabetes. Due to the vast challenges observational studies have examined the associa-
associated with managing diabetes, it is not sur- tion between self-compassion and mental and
prising that diabetes is associated with adverse health outcomes in diabetes, using either the
mental health outcomes including depression, Self-Compassion Scale (SCS) (Neff, 2003) or the
anxiety, and impaired quality of life (Ducat et al., Self-Compassion Scale–Short Form (Raes et al.,
2014; Semenkovich et al., 2015; Smith et al., 2011). One of the first studies to examine the
2013). The prevalance of depression and other association between self-compassion and diabe-
psychiatric disorders are significantly higher in tes outcomes was a cross-sectional study con-
people living with diabetes, with adults living ducted in New Zealand with sample of 110 adults
with diabetes being three to four times more with type 1 or type 2 diabetes (Friis et al., 2015).
likely to be diagnosed with depression or anxiety Friis et al. observed that higher self-compassion
(Ali et al., 2006; Barnard et al., 2006; Nouwen was correlated with lower levels of diabetes dis-
et al., 2010). In youth with type 1 diabetes, the tress and depression and that self-compassion
prevalence of psychiatric disorders including moderated the relationship between diabetes dis-
depression, anxiety, and eating disorders are esti- tress and glycemic control. In another cross-
mated to be as high as 30–50% (Hislop et al., sectional study of 310 adults with type 1 or type
2008; Jones et al., 2000; Kovacs et al., 1997). The 2 diabetes conducted in Australia, self-
high rates of psychiatric disorders are especially compassion was associated with improved self-
alarming due to the association between mental care behaviors, lower glycemic control, and
illness and sub-optimal glycemic control and higher well-being (Ferrari et al., 2017). Similar
increased risk of life-threatening diabetes-related findings were observed in a cross-sectional study
complications (de Groot et al., 2001; van Dooren of 176 adults in the UK with type 2 diabetes,
et al., 2013; Van Tilburg et al., 2001). where higher self-compassion was associated
with more optimal glycemic control (Morrison
Self-Compassion and Physical and Mental et al., 2019). These findings were further sup-
Health Outcomes in Diabetes Due to the chal- ported by a larger (n = 1907) cross-sectional
lenges associated with the treatment regimen, the study of adults in Australia with type 1 or type 2
diabetes (Ventura et al., 2019), where higher self- Diabetes-Specific Measures

compassion was positively associated with more of Self-Compassion
optimal glycemic control, self-management
behaviors, and negatively associated with diabe- General measures of self-compassion such as the
tes distress and depression. To our knowledge, SCS may not adequately measure or capture the
only one study has explored self-compassion and numerous, daily diabetes-specific challenges and
physical health outcomes in youth with diabetes. how people living with diabetes cope with feel-
A recent cross-sectional study conducted in New ings of self-criticism when these challenges arise.
Zealand with 113 young adults aged 17–25 years To try to capture diabetes-specific self-
with type 1 diabetes (Loseby et al., 2022) compassion, Tanenbaum et al. (2018) developed
explored associations between self-compassion, and validated the Diabetes-Specific Self-
self-care behaviors, and glycemic control. Higher Compassion Scale (SCS-D) for adults living with
self-compassion was associated with more opti- diabetes and a version for parents of children
mal self-care behaviors and demonstrated a trend with diabetes (SCS-Dp) (Tanenbaum et al.,
toward more optimal glycemic control. 2020), who often shoulder the burden of diabetes
In comparison to the studies noted above management. The original 26-item SCS was
which all used the SCS as a unitary scale, a lon- adapted and items which could be reworded were
gitudinal study of 120 adults in the US with type modified to capture diabetes-specific situations
2 diabetes (Kane et al., 2018) examined the pre- and experiences. The new 19-item SCS-D dem-
dictive ability of the positive and negative onstrated acceptable reliability and validity in a
domains of the SCS and their association with sample of 542 adults with type 1 diabetes, with
diabetes distress three months later. It was only higher diabetes-specific self-compassion associ-
the negative domain of the SCS (items assessing ated with lower diabetes distress, higher diabetes
negative self-responding) that was independently empowerment, and lower glycemic control. The
associated with diabetes distress at the three- subsequent parent version (SCS-Dp) was further
month follow-up. These findings add to the ongo- reworded to capture how parents respond and
ing debate (see Chap. 1) of the role of positive treat themselves in the context of their child’s
versus negative self-responding and the validity diabetes-specific challenges. In a sample of 198
of assessing the scale as a whole as well as which parents (Tanenbaum et al., 2020), higher parental
aspects are more important to target in psycho- self-compassion was negatively associated with
logical interventions (Kane et al., 2018). youth diabetes distress and diabetes empower-
When considering the observational research ment, but not with youth glycemic control.
examining self-compassion and its relationship
to diabetes outcomes, there are several potential
mechanisms that may play a role. Studies in Self-Compassion Interventions
healthy participants demonstrate that higher self- in Diabetes
compassion may decrease stress and reduce cor-
tisol levels (Rockliff et al., 2008), may improve Despite the limited but promising observational
health behaviors and reduce inflammatory research, self-compassion interventions devel-
responses (Homan & Sirois, 2017), and in adults oped for diabetes patients are even more scarce,
and youth with diabetes may buffer against dia- possibly a reflection of the intensive training
betes distress (Friis et al., 2016) and improve required to administer standardized interventions
self-care behaviors and lower stress leading to such as Mindful Self- Compassion (MSC; Neff &
more optimal HbA1c (Loseby et al., 2022). Germer, 2013). To our knowledge, there are only
However, further longitudinal and experimental three published interventions, two conducted in
studies are required to explore potential mecha- New Zealand (Boggiss et al., 2020a, b; Friis et al.,
nisms between self-compassion and diabetes 2016) and a pre-post intervention study conducted
outcomes. in Iran (Karami et al., 2018). The first intervention
was conducted by Friis et al. (2016), who trialed ogy literature. Cancer is one of the most signifi-
MSC in a cohort of adults with type 1 and type 2 cant health problems in the world. In 2018, it was
diabetes. In this wait-list controlled trial, 63 par- estimated 43.8 million people were living with
ticipants completed the standardized 8-week cancer, 18.1 million cases diagnosed, and 9.6
MSC intervention and were followed up for three million cancer deaths worldwide (Bray et al.,
months. Findings demonstrated significant and 2018). The most commonly diagnosed cancers
clinically meaningful within-group improvements worldwide are lung (1.61 million), breast (1.38
in depression, diabetes distress, and glycemic million), and colorectal cancers (1.23 million),
control in the MSC group from baseline to three- with lung, stomach, and liver cancers accounting
months follow-up with no changes observed in for the most deaths. As the second leading cause
the control group. A more recent feasibility study of death globally, cancer brings an increasing and
(Boggiss et al., 2020b) trialed an adapted 2-session rising public health and economic burden, with
version of the 8-session teen-specific version of the continuing growth and aging of the world’s
MSC (Mindful Self-compassion for Teens) for population (Bray et al., 2018).
adolescents with type 1 diabetes and disordered Unsurprisingly, cancer is associated with sig-
eating behavior to assess feasibility and accept- nificant physical, financial, and emotional strains
ability of the 2- session intervention. Nineteen to the individuals and their families and commu-
adolescents aged between 12 and 16 years nities. A cancer diagnosis brings significant dis-
attended the program (with ten participants com- tress due to uncertainty of diagnosis, survival
pleting both sessions) and reported an increased odds, demanding exams and treatments, con-
sense of common humanity, mindfulness, and fronting complex decisions, changing relation-
coping strategies. Despite qualitative data report- ship dynamics, and financial burden (Gorman,
ing high acceptability, feasibility was limited by 1998). In addition, treatments often include sur-
the reported difficulties of attending the face-to- gery, chemotherapy, hormonal therapy, and radi-
face sessions. In a follow-up qualitative study, the ation treatments, alone or in combination, and
majority of adolescents with type 1 diabetes have significant and complex side effects, such as
described that they would prefer to learn self- fatigue, insomnia, nausea/ vomiting, limited
compassion digitally, using a chatbot, as opposed physical functioning, problems with memory and
to face-to-face or other digital options, such as a attention, and often appearance altering side
website or app (Boggiss et al., 2021). As such, a effects, such as scars, hair loss, skin discolor-
digital adaptation of this trial is currently under- ation, and loss or removal of body parts (Coates
way aiming to deliver MSC for teens with type 1 et al., 1983; Mustian et al., 2012). As a result,
diabetes using a chatbot, adapting the content to clinical distress is reported by approximately 35
be delivered in 5-to-10-minute conversational les- to 45% of people diagnosed with cancer (Carlson
sons. Lastly, a pre-post intervention conducted by et al., 2004; Mitchell et al., 2011; Zabora et al.,
Karami et al. (2018) (n = 20) assessed self- 2001) and a significant number of cancer patients
compassion training delivered in eight sessions develop clinically significant levels of anxiety
for adults with type 2 diabetes in Iran compared to and depression (Pirl & Roth, 1999; Stark et al.,
a control group (type of control not specified). 2002). Further, the comorbidities of anxiety and
However, the small sample size and limited data depression can negatively impact cancer progres-
reporting mean that conclusions about efficacy sion, symptomology, and pain (Spiegel & Giese-
cannot be drawn. Davis, 2003), negatively affect adherence to
medical treatment and screening (Lerman et al.,
1994; Pirl & Roth, 1999), quality of life (Spiegel
Self-Compassion and Cancer & Giese-Davis, 2003), and ultimately survival
rates (Pinquart & Duberstein, 2010).
A final example of self-compassion applied in the While many cancer survivors return to normal
context of CMCs can be derived from the oncol- functioning, some physical and psychological
problems last even after treatment is finished. illustrate how individual differences in protective
Long-term consequences frequently impact the factors can influence not only psychological
quality of life and everyday functioning of many adjustment but also cancer progression.
cancer survivors and can include weakness, Self-compassion has recently shown to be an
numbness, or pain, persisting fatigue, cognitive important protective factor in promoting better
or sexual difficulties, continuing anxiety and adjustment in cancer patients generally. Studies
depression, and functional difficulties with of mixed samples of cancer patients have shown
returning to work and physical and social activi- higher levels self-compassion to associate with
ties (Stein et al., 2008). In addition, fear of cancer better psychological function, shown in fewer
recurrence has been shown to persist five or more symptoms of anxiety, depression, stress
years after initial diagnosis (Koch et al., 2013), (Gillanders et al., 2015; Pinto-Gouveia et al.,
with 42–70% of survivors reporting clinically 2014), fatigue (Zhu et al., 2019), and higher qual-
significant levels of fear of recurrence (Thewes ity of life (Gillanders et al., 2015; Pinto-Gouveia
et al., 2012). et al., 2014). In a longitudinal study of cancer
Several individual factors have been shown to patients, the level of positive self-compassion at
predict short- and long-term adjustment and dis- diagnosis was the most consistent predictor of
tress following a cancer diagnosis, such as cop- symptoms of depression, anxiety, and fatigue,
ing strategies (Carver et al., 1999), social support over the period of their cancer treatment (Zhu
(Carver et al., 2005; Morris & Shakespeare- et al., 2019). Similarly, higher levels of self-
Finch, 2011), illness cognitions (Morris & compassion have been shown to strongly relate to
Shakespeare-Finch, 2011), personality traits, depressive symptoms and affect, with the indi-
such as optimism (Carver et al., 2005), psycho- vidual facets of higher levels of isolation and
logical resilience (Harms et al., 2019; Mohlin reduced levels of mindfulness most significantly
et al., 2020), perceived self-efficacy (Boehmer associated (van der Donk et al., 2020). Together,
et al., 2007), attachment styles (Arambasic et al., these findings suggest that for cancer patients
2019; Porter et al., 2012; Rodin et al., 2007), and generally, being kind and understanding toward
medical factors, such as the stage of disease or themselves, reminding themselves of common
choice of treatment (Glanz & Lerman, 1992; humanity, and holding an accepting and mindful
Moyer & Salovey, 1996). Significantly, social awareness of their challenges appear to be more
support has been shown to be a strong predictor beneficial than being self-critical of changes in
of adjustment, with evidence of associations with physical appearance, psychosocial difficulties or
higher post-traumatic growth (Morris & life limitations imposed by cancer, feeling differ-
Shakespeare-Finch, 2011) and better subjective ent or isolated, or focusing on negative experi-
well-being (McDonough et al., 2014). For exam- ences in the long run.
ple, in a study of women with breast cancer, When investigating these effects across differ-
women who were socially isolated before diag- ent forms of cancer, results are consistent. In lung
nosis had a 66% increased risk of mortality cancer patients, higher levels of self-compassion
(Kroenke et al., 2006). In addition, coping strate- have been demonstrated as an important predic-
gies such as acceptance and the use of humor tor of mental adjustment to cancer diagnosis
have shown to predict lower levels of distress (Batista et al., 2015), with higher levels of self-
(Carver et al., 1999), whereas coping strategies of compassion significantly related to higher social
denial, disengagement (Carver et al., 1999), and support and fewer symptoms of depression, anxi-
avoidance have shown to predict poorer adjust- ety (Batista et al., 2015), distress (Arambasic
ment (Stanton et al., 2013). Regarding cognition, et al., 2019), shame (Siwik et al., 2019), and
threatening appraisals of cancer and cognitive fatigue over time (Hsieh et al., 2019). Similarly,
fusion have been shown to be strong predictors of in breast cancer, survivor’s lower levels of self-
distress and lowered quality of life after cancer compassion were significantly related to higher
(Gillanders et al., 2015). Together, these studies levels of distress (Arambasic et al., 2019; Boyle
et al., 2017; Przezdziecki & Sherman, 2016) and Furthermore, self-compassion also offers a
higher perceived negative impact of cancer promising approach to the body image distress
(Arambasic et al., 2019). Self-compassion has also that frequently arises following a cancer diagno-
been shown to reduce negative cognitions such as sis (Fingeret et al., 2014) and impacts quality of
threat-related rumination and worry in breast can- life, identity, sense of self, sexuality, and further
cer survivors (Brown et al., 2020). In prostate can- depression and anxiety (Przezdziecki & Sherman,
cer patients, results indicated that higher levels of 2016). For example, in studies in breast cancer
self-compassion moderate the distress related to samples, higher levels of self-compassion have
the emasculating aspects of their prostate cancer shown associations with lower levels of depres-
experience (Lennon et al., 2018). sion, anxiety, stress, body image distress
A limited amount of evidence also suggests (Przezdziecki & Sherman, 2016; Todorov et al.,
self-compassion can improve interpersonal func- 2019), and higher levels of body appreciation
tioning (Schellekens et al., 2017). In a study con- (Przezdziecki & Sherman, 2016), and hope
ducted with couples facing lung cancer, higher (Todorov et al., 2019). More specifically, in a
levels of self-compassion were associated with study of breast cancer survivors who underwent
better communication with their partner about surgery, self-compassion was found to mediate
their emotional experience of their cancer diag- the relationship between body image disturbance
nosis. Secondly, the association between self- and distress, suggesting self-compassion may
compassion and psychological distress was serve as a protective factor (Przezdziecki et al.,
shown to depend on their partner’s level of self- 2013). Similarly, self-compassion has also been
compassion. Thus, suggesting that if one partner shown to moderate the relationship between body
displays less self-compassion, the other may image disturbance and psychological distress, in
compensate by showing more self-compassion, those survivors who underwent mastectomy and
alleviating the distress on both people. Together, breast reconstruction (Sherman et al., 2018).
showing the associations with self-compassion Self-compassion may also have the protective
and better psychological functioning in cancer ability on psychological distress and clinical out-
patients is not only limited to individual coping comes, through the mechanisms of threat-related
but may also be able to impact functioning in rumination and worry. When people face a cancer
romantic relationships. diagnosis or any type of adversity, people com-
In addition, a limited number of studies have monly respond by ruminating about the past or
shown higher levels of self-compassion to associ- worrying about the future (S. L. Brown et al.,
ate with better clinical outcomes and self-care 2020), activating our threat system and increas-
behaviors in cancer patients. In a study of breast ing psychological distress (Gilbert, 2017). In a
cancer patients, self-compassion was found to study conducted with breast cancer patients
moderate the relationship between stress and (Brown et al., 2020), findings demonstrated
self-care behaviors, such as engaging in physical worry and depressive brooding (a form of rumi-
exercise (Abdollahi et al., 2020). Self-compassion nation) as meditators between the relationship of
has also been shown to associate with better sleep self-compassion subscales of mindfulness and
quality and fewer cancer-related psychological self-kindness, and anxiety. In addition, depres-
and physical symptoms in a mixed sample of sive rumination was shown to mediate the rela-
cancer patients (Wan et al., 2016). Also of note, tionship between mindfulness and self-kindness,
ongoing research is investigating the relationship and depression. These findings are supported by
between inflammation, postcancer symptoms, the results of a qualitative study that explored
and self-compassion (Cohen et al., 2017), follow- changes in self-compassion in cancer patients
ing evidence suggesting self-compassion may be after completing a mindfulness intervention.
a protective factor against inflammatory disease Along with reports of improved emotion regula-
and stress-induced inflammation in healthy par- tion, a key finding was that participants reported
ticipants (Breines et al., 2014). less engagement in thoughts and indicted
decreases in rumination (L’Estrange et al., 2016). tion to the MSC program, a brief online self-
However, more research is needed in determining compassion writing intervention “My Changed
these causal mechanisms and in diverse cancer Body” (MyCB) has also been shown to be accept-
samples. able (Przezdziecki et al., 2016) and effective for
breast cancer patients (Mifsud et al., 2021;
Self-Compassion Interventions in Przezdziecki & Sherman, 2016; Sherman et al.,
Cancer Recently, self-compassion interventions 2018). In comparison with control conditions,
have been conducted in cancer, both in young improvements have been demonstrated in nega-
adult and adult samples. In young adult cancer tive affect, self-compassion (Przezdziecki &
survivors, a combination of the 8-week MSC and Sherman, 2016), body image-related distress,
“Making Friends with Yourself” (MFY) pro- and body appreciation (Sherman et al., 2018).
grams has been trialed using videoconferencing. Altogether, showing promise for the use of self-
The study found the program to be feasible and compassion interventions to improve well-being
acceptable, and revealed significant improve- and body-image distress for cancer patients and
ments, with moderate to large effect sizes, for survivors.
mindfulness, self-compassion, anxiety, depres-
sion, body image, social isolation, and post-
traumatic growth, from pre- to postintervention Summary and Conclusion
(Campo et al., 2017). A qualitative analysis was
then conducted analyzing the transcripts from theTaken as a whole, the existing research on self-
8-week program, revealing the program addressed compassion in CMCs suggests self-compassion
their key concerns of peer isolation, body image supports adjustment and well-being in the face of
concerns, and health-related anxiety through the challenges inherent in living with a
increasing self-reliance for emotional support, CMC. There are several mechanisms through
common humanity, gratitude, self-kindness, which self-compassion may exert positive effects,
acceptance, and self-care behaviors (Lathren including through reducing shame and self-
et al., 2018). stigma, improving self-care behaviors, and poten-
tially, through modulating physiological markers
In adults, a limited number of randomized of disease. It follows that self-compassion inter-
controlled trials (RCTs) and feasibility and ventions may be beneficial for individuals with
acceptability studies have been conducted. An chronic conditions, although a recent meta-
RCT in a sample of colorectal cancer patients analysis found that overall, the quality of the
investigated the effectiveness of the 8-week MSC available literature in this area was low (Mistretta
program. Participants showed improvements in & Davis, 2022). Further, it has been acknowl-
self-compassion; however, no significant effect edged that transdiagnostic approaches are useful
on anxiety, depression, or cancer-related symp- as they target common processes across CMCs
tomatology was seen, when compared to a wait- and therefore have the potential to be used by a
list control group (Ho et al., 2018). In a more larger proportion of the population, as well as
recent, feasibility and acceptability study, the those with multimorbidity (Finlay-Jones et al.,
MSC program was shown to be acceptable and 2020; Prentice et al., 2021). Despite this, there are
feasible among 32 cancer patients. Sixty-three limited studies of the effectiveness of self-
percent of participants perceived an improvement compassion-based interventions among samples
in their mental well-being throughout the pro- with a range of different chronic conditions.
gram and although under-powered, small-to- Available literature documenting study protocols
medium effects were observed in fear of cancer (Finlay-Jones et al., 2020) and pilot studies
recurrence, depressive symptoms, stress, loneli- (Brown et al., 2019) suggests that such evidence
ness, body image satisfaction, mindfulness, and may be available in the future. Given the range of
self-compassion (Brooker et al., 2020). In addi- different self-compassion training approaches
available, we also echo Kılıç et al.’s (2021) rec- there is the opportunity to examine whether sup-
ommendation that future work examines which porting caregivers of individuals with CMCs to
methods are most effective for promoting self- practice self-compassion may simultaneously
compassion among people with CMCs. support the cultivation of self-compassion in
In addition to understanding the role of self- those for whom they provide care. This poten-
compassion across different chronic illness experi- tially has the dual benefit of potentially support-
ences, further insight into the benefits of ing well-being in caregivers, who are an at-risk
self-compassion for specific groups is needed. group for psychological distress (Cousineau
However, the literature exploring the associations et al., 2019), as well as supporting more sustained
between self-compassion and adaptive outcomes intervention effects in people living with CMCs.
in individual conditions is small, and additional
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Self-Compassion in Trauma
Treatment 20
Christine Brähler
Introduction evidence suggests that interventions are safe and

acceptable, the evidence for clear-cut benefits in
Self-compassion refers to the capacity to respond clinical populations remains limited, as meta-
mindfully to difficult experiences, be kind to our- analyses usually combine clinical and nonclinical
selves in the midst of suffering, and see ourselves populations (Ferrari et al., 2019; Kirby et al.,
as connected to humankind when we experience 2017b).
distress (Neff, 2003a, b). Shame, on the other In this chapter, I aim to expand the early ratio-
hand, can be defined as seeing oneself as unwor- nale for integrating self-compassion into psycho-
thy of love and attention and as uniquely isolated logical treatment for psychiatric conditions by
from the rest of humankind. Self-compassion drawing on the latest clinical research and clini-
thus appears to represent an obvious antidote to cal experience and by highlighting the common
shame. Shame is a much-neglected social emo- pitfalls and how to navigate around them.
tion, whose role in psychopathology is being Specifically, I will focus on the relevance of self-
increasingly recognized. Shame has been found compassion for the psychological treatment of
to contribute to, trigger, maintain, and exacerbate complex PTSD. Frequently, those who meet
a wide range of psychiatric conditions such as diagnostic criteria for complex PTSD lack in
depression (Kim et al., 2011), eating disorders self-compassion, have high fears of compassion,
(Kelly & Tasca, 2016), psychosis (Carden et al., high shame, and a history of attachment traumas
2020), obsessive-compulsive disorder and other traumas (Maercker et al., 2013a, b). I
(Weingarden et al., 2016), complex Post- will address the relevance of self-compassion for
Traumatic Stress Disorder (PTSD; see this chap- treating complex PTSD within a phase-based
ter), and borderline personality disorder (Brown approach (Herman, 2015). Herman, a pioneer of
et al., 2009). The lack of self-compassion com- trauma research and therapy, summarizes the
bined with the high prevalence of shame in most work of trauma recovery as involving “overcom-
individuals with psychiatric conditions has led ing barriers to shame and secrecy, making intol-
clinicians and researchers to hypothesize that erable feelings bearable through connection with
interventions promoting self-compassion hold others, grieving the past, and coming to a new
great promise for clinical populations. Whilst the perspective with a more compassionate view of
oneself in the present.” (Herman, 2015, p. 276),
C. Brähler (*) thus placing self-compassion at the heart of
University of Glasgow, Glasgow, Scotland trauma recovery.

https://doi.org/10.1007/978-3-031-22348-8_20
348 C. Brähler
rauma Exposure and Complex

T sociative subtype encompassing additional crite-
PTSD ria of depersonalization (i.e., feeling as though
one is detached from oneself or observing one-
Trauma exposure is common. In a global survey self from the outside) and/or derealization (i.e.,
of approximately 51,000 people across low-, the feeling that one’s experiences are surreal or
middle-, and high-income countries, seventy per- distorted) (American Psychiatric Association,
cent of adults were found to have experienced at 2013).
least one traumatic event over their lifetime
(Kessler et al., 2017). For trauma exposure to
lead to PTSD or to other mental disorders Self-Compassion and PTSD
depends on a variety of inner and outer risk and
resiliency factors. Exposure to a traumatic event Authors of a systematic review of 35 studies on
per se hence does not say anything about the PTSD and self-compassion confirmed the results
mental health of an individual. However, child- from earlier studies, which found self-compassion
hood and adult trauma exposure is known to be a to be negatively related to PTSD symptomatol-
nonspecific etiological factor for most mental ogy in general and to the avoidance cluster of
health problems. Prior work has found that men- symptoms in particular (Winders et al., 2020).
tal health problems increase in a dose-response The studies, however, were largely based on stu-
relationship with exposure to adverse childhood dent or general population samples, thus limiting
experiences (see Zarse et al., 2019, for a review). their transferability to clinical populations.
In the eleventh revision of the International Karatzias et al. (2017) examined the link between
Classification of Diseases (ICD-11), the symp- self-compassion and complex PTSD in a largely
tom profile of PTSD comprises six symptoms female sample referred to trauma therapy ser-
distributed across three symptom clusters: (1) re- vices. Interestingly, self-compassion was found
experiencing the traumatic event in the here-and- to be negatively associated with the disturbance
now; (2) avoidance of stimuli that remind one of in self-organization factor, but not with a general
the traumatic event; and (3) a sense of threat PTSD factor (Karatzias et al., 2017). More spe-
(First et al., 2015). Unlike simple PTSD which cifically, low self-compassion was linked to neg-
focuses on the impact of a single traumatic event, ative self-concept, relationship difficulties, and
complex PTSD refers to the impact of cumulative affect dysregulation—particularly hypoactiva-
traumatic events occurring across childhood and tion strategies. Hypoactivation of distress
adulthood (van der Kolk et al., 1993). These trau- involves attempts to downregulate, numb, and
matic events are often interpersonal as opposed turn the distress inwards, which are in keeping
to impersonal (car accident, natural disaster), with shame, defeat, dissociation, and feelings of
often occur in relationships to attachment figures, depression, whereas hyperactivating strategies
and thus often occur repeatedly (Hyland et al., involve increasing arousal, expressing distress,
2017). Complex PTSD is defined as consisting of and potentially becoming aggressive. Such an
the existing PTSD criteria plus a set of symptoms internalization of abusive treatment by others is a
referred to as disturbances in self-organization, common consequence of chronic interpersonal
which summarize the pervasive dysregulating trauma, especially when it occurs early in life and
effects of chronic victimization on affect regula- in caregiving contexts (van der Kolk et al., 2005).
tion involving shame, fear, guilt, anger, the sense In contrast, increasing self-compassion among
of self, and relational functioning (Maercker individuals with PTSD is hypothesized to help
et al., 2013a). Dissociation is another common them to improve their affect regulation, self-
adaptation to chronic victimization, and the fifth concept, and relational functioning by reducing
edition of the Diagnostic and Statistical Manual their feelings of shame, guilt, failure, and defeat
for Mental Disorders (DSM-V), includes a dis- (Lee et al., 2001).
20 Self-Compassion in Trauma Treatment 349
Self-Compassion, Shame, and PTSD 2018). In contrast, self-compassion might help

veterans to better adjust once back home by
Self-compassion may be an effective antidote to reducing their shame, as higher self-compassion
the shame experienced by those with PTSD, has been linked to lower PTSD symptoms, gen-
where feelings of kindness, common humanity, eral psychopathology, and better functioning
and mindfulness can come to replace feelings of among returning veterans, irrespective of trauma
self-blame, isolation, and emotional avoidance. exposure (Dahm et al., 2015; Hiraoka et al.,
Although shame is known to exacerbate many 2015).
types of psychological disorders, including Shame is often a result of childhood trauma,
PTSD, it is still frequently overlooked in treat- which is a risk factor for the later development of
ment, which has historically prioritized anxiety, PTSD and other pathologies. Childhood mal-
fear, and anger (Taylor, 2015). Shame is a univer- treatment has been linked to higher shame and
sal emotion (Sznycer et al., 2018) characterized lower self-compassion and worse PTSD symp-
by a state of hypoarousal and submission that toms (Andrews et al., 2000), via emotion dys-
evolved to avert attack by members from one’s regulation (Barlow et al., 2017; Scoglio et al.,
own group (Keltner & Harker, 1998). To escape 2018; Vettese et al., 2011). Children may inter-
the attack, shame activates submissive or aggres- nalize their caregivers’ contemptuous and hostile
sive defenses. If those are ineffective and the intentions by developing deeply shaming core
individual cannot find safety or support with beliefs such as “I am bad/evil/disgusting/unwor-
another person or group, then primary conscious- thy,” which resolve some of the cognitive disso-
ness shuts down leading to dissociation (Schore, nance (i.e., the discomfort associated with
2015). Shame can have a paralyzing effect and holding opposing beliefs, ideas or values; Briere,
thus being shamed can be considered traumatic if 1992). Not surprisingly, higher doses of early
it happens early in development and if done by a trauma are associated with lower levels of self-
caregiver (Matos & Pinto-Gouveia, 2010). compassion (Játiva & Cerezo, 2014; Tanaka
Submissive strategies involve pleasing powerful et al., 2011). For example, highly critical or oth-
others by adapting and giving up one’s own will, erwise dysfunctional family environments and
internalizing their opinions about oneself, cor- emotional abuse have been linked to low self-
recting, or punishing oneself, suppressing anger compassion and insecure attachment (Neff &
and self-protective impulses in the body, losing McGehee, 2010; Tanaka et al., 2011). In turn, low
any boundaries with powerful others, and becom- levels of self-compassion have been associated
ing complacent. Aggressive strategies involve with depression and anxiety (Joeng et al., 2017),
some form of counterattack such as blaming oth- self-harming behavior (Jiang et al., 2016), anxi-
ers overtly or covertly by talking negatively about ety (Berryhill et al., 2018), and PTSD symptoms
people behind their backs or by using physical (Bistricky et al., 2017).
aggression.
Shame may maintain and exacerbate PTSD by
increasing the severity and duration of illness Betrayal Traumas and Shame
(Brewin & Holmes, 2003), over and above the
impact of exposure to trauma (DePrince et al., In cases of interpersonal violence at the hands of
2011a, b). For example, intrusive memories of a close one, distress among survivors is often
traumatic experiences were found to be accom- fueled by a sense of betrayal (Freyd, 1996). The
panied more often by feelings of shame than by closer and the more trusting the relationship, the
feelings of fear, horror, or helplessness (Holmes worse the sense of betrayal. High betrayal trau-
et al., 2005). Other recent research indicates that mas have been associated with greater shame and
shame may mediate the relationship between dissociation (DePrince et al., 2011b; Platt &
PTSD symptom severity and suicidal ideation Freyd, 2015) and with more severe PTSD symp-
among veterans with PTSD (Cunningham et al., toms than low betrayal traumas such as natural
350 C. Brähler
disasters or abuse by someone not close to the Zeller et al., 2015) and via relational routes such
victim (DePrince & Freyd, 2002). Victims of as by helping the person to use social supports
interpersonal violence may blame themselves for (Maheux & Price, 2016).
not defending themselves, for trusting the person
in the first place, for not detecting the threat
sooner, or, in the case of repeated violence, for Self-Compassion in the Treatment
not being able to separate or distance themselves of Complex PTSD
from the perpetrator. Partner violence in adult-
hood, incest, or other abuse by caregivers in Although the correlational research to date
childhood are amongst the high betrayal traumas clearly suggests that self-compassion may pro-
and more frequently suffered by women than by tect against the toxic effects of shame in PTSD, a
men (Freyd, 1996). systematic review concluded that there is only
When a person is subjected to abuse by a care- tentative evidence that “interventions based, in
giver or close one during childhood, the depen- part or in whole, on a self-compassion model
dency on that person creates such a high level of potentially reduce PTSD symptoms” (Winders
threat in the child that the experience might be et al., 2020, p. 300) and they conclude that “self-
partly or completely dissociated (Liotti, 2004). compassion may be agent of change in PTSD
Many survivors of such high betrayal trauma who symptom reduction and also in trauma-related
begin to remember the trauma more clearly (trau- guilt and shame” (Winders et al., 2020, p. 321).
matic memories are often fragmented or due to Whilst some of these interventions integrated
dissociative amnesia cannot be recalled) struggle self-compassion into a standard evidence-based
to break the silence of this shameful secret as they treatment for simple PTSD such as cognitive
fear not being believed, not being supported, or on behavior therapy (CBT), other interventions
the contrary to be betrayed and punished again included ultra-brief bibliotherapy interventions,
and to lose any important attachment relation- which were unintegrated into any other evidence-
ships. They may avoid seeking treatment for fear based treatment for PTSD. These findings might
of being misunderstood, blamed, invalidated, let be explained by: (1) self-compassion being
down, and retraumatized by mental health provid- offered as a stand-alone intervention instead of
ers. The lack of inner safety, trust in others and in being integrated into an evidence-based treat-
solidarity as well as the lack of self-protective ment for complex PTSD; (2) by interventions
anger or fierce self-compassion, maintains PTSD being too brief (Galili-Weinstock et al., 2019);
and keeps them suffering in silence and isolation. (3) by self-compassion being introduced without
Taken together, trauma survivors who experi- providing the person with a relational template
ence shame during or after the traumatic event for compassion, e.g., receiving compassion from
have worse outcomes as evidenced by higher peers in groups therapy or from the therapist in
symptom load, longer duration of illness, greater individual therapist; (4) by self-compassion not
suicidality in war veterans, higher retraumatiza- being offered within a safe compassionate thera-
tion rates in betrayal trauma, and less engage- peutic relationship where working through com-
ment with mental health services (Saraiya & mon fears and obstacles to compassion is
Lopez-Castro, 2016). PTSD sufferers who expe- possible; or (5) by research focusing on symp-
rienced childhood maltreatment by caregivers are tomatic outcomes instead of capturing the mech-
more prone to feel shame and to have low self- anism of change (i.e., self-compassion).
compassion (Matos et al., 2017). Shame in its dif- Regarding the latter point, increasing self-
ferent guises clearly constitutes a valid target for compassion would be expected to bring about a
treatment for many PTSD clients. Self- change in the relationship to the symptoms and
compassion has the potential to buffer against the to the person experiencing it instead of reducing
impact of the trauma via cognitive appraisal and the symptoms per se. This in turn may help to
emotion regulation routes (Barlow et al., 2017; reduce the functional impact of PTSD symptoms.
Measures of life satisfaction, quality of life or explicitly cultivated self-compassion. These find-
other indicators of psychological resilience could ings tell us that a kinder relationship to oneself is
help to determine the broader impacts of such a common mechanism of change that can have a
interventions on adaptive functioning, while lon- significant positive impact on symptoms without
ger follow-up periods may be helpful in deter- including explicit interventions. Instead, self-
mining whether changes in self-compassion drive compassion seems to be at play implicitly through
reductions in PTSD symptoms over time. other therapist, client, and relational variables.
These findings also support the idea that compas-
sion and self-compassion can be integrated into
Self-Compassion for Complex any acceptance-based approach to psychother-
Mental Health Problems apy. This has been done with complex mental
health issues such as psychosis (Braehler et al.,
There are two common misconceptions about 2013a,b) and eating disorders (Kelly et al., 2017)
self-compassion in clinical practice. Firstly, it is through Compassion-Focused Therapy (CFT;
commonly viewed solely as a technique that can Gilbert, 2010; see Chap. 23). CFT is the only
be successfully trained by the client with guided clinical compassion-based approach which has
meditations. Whilst this is the case for healthy integrated explicit compassion practices into
populations (McEwan & Gilbert, 2016), it pro- CBT. Core CBT interventions are given a com-
motes an overly mechanistic view of clinical psy- passionate mind focus and modules are added to
chotherapy with the therapist being a mere mental standard psychological treatment, which consists
health technician prescribing automated inter- of standard disorder-specific CBT protocols.
ventions to fix the problem. Secondly, it is repre- Being familiar with standard CBT interventions
sented as a stand-alone psychotherapy for is thus necessary to implement CFT. Evidence-
individuals with psychiatric disorders. This way based phase-based treatments for complex PTSD
of overstating the scope of self-compassion in the are Skills Training in Affective and Interpersonal
clinical domain often results from the powerless- Regulation (STAIR; Cloitre et al., 2002) and
ness clinicians feel when faced with complex Dialectical Behavior Therapy-Post-Traumatic
clinical issues and the wish for a simple and reli- Stress Disorder (DBT-PTSD; Bohus et al., 2019).
able solution. Clinicians therefore need to learn A compassion-based module is being integrated
to hold the uncertainty and the complexity lightly into DBT-PTSD to target shame more explicitly.
without being overwhelmed and without running Whilst healthy groups can benefit from prac-
the risk to resort to a one-method-cures-all atti- ticing with guided exercises on their own, clinical
tude that oversimplifies complex mental health groups encounter many more fears and barriers
issues and runs the risk of harming clients. and shame (Kirby et al., 2019). They therefore
Self-compassion is a radical new way of meet- need modeling from the therapist as well as guid-
ing suffering. It is therefore primarily an attitude ance to overcome obstacles in a way that is
of care and goodwill toward difficult emotions attuned and suited to their needs and limitations
and experiences. Techniques and interventions before they can give it to themselves. For this to
have been developed to help cultivate this atti- be genuine and authentic, a therapist needs to
tude. In a therapeutic setting, our goal is to help have integrated these various qualities to embody
the client develop a compassionate way of relat- them. A therapist also needs to know ways to
ing to herself and to the inner experiences that return to a place of good will and open-
she finds painful or unlikable. Several studies heartedness and clarity toward the client when-
have shown that improved self-compassion in the ever he or she has lost it, got triggered or
client is associated with reduced symptoms fol- distracted and to transform empathy distress into
lowing a whole range of different diagnoses and compassion – not just to prevent burnout but also
therapies (Galili-Weinstock et al., 2017; Hoffart malpractice. A therapist also requires an existing
et al., 2015; Schanche et al., 2011), none of which model of an acceptance-based psychotherapy
352 C. Brähler
suited for the client’s issues in which to integrate of love and connection as an adult can activate
self-compassion and compassion across three experiences of shame and disconnection one was
relational levels: (1) for therapist from therapist; exposed to as a child. Germer and Neff (2019;
(2) from therapist to client; and (3) for client Neff & Germer, 2018) encapsulate this experi-
from client. ence by saying: “When we give ourselves uncon-
ditional love, we uncover the conditions under
which we have not been loved.” We can extend
Understanding Fears and Barriers this by adding “or under which we were mal-
to Compassion treated or otherwise traumatized.”
Such emotional conditioning is largely uncon-
Asking a person who is more familiar with being scious and only manifests in an attachment con-
in abusive than nonabusive relationships to “treat text such as during a close relationship or
herself like a dear friend,” as is done in some self- eventually in the therapeutic relationship. Once
compassion practices, may simply be impossible these patterns become manifest, they typically
to do, as she has no template to draw upon. It is reveal meta-cognitive beliefs about negative con-
like asking someone to imagine the taste of choc- sequences or feelings that may occur if the per-
olate who has never tasted chocolate. Being son receives or gives kindness or compassion to
asked to hold yourself in a loving embrace might self or others (Gilbert et al., 2014c). These so
bring up confusing and distressing feelings if you called “fears of compassion,” tap into people’s
have never been held unconditionally, or were fears about what reactions they may have to giv-
held but also abused or neglected by the same ing or receiving compassion for others, from oth-
person, or you lost them suddenly. The repair of ers, and from themselves (Gilbert et al., 2011).
the attachment system of this person must start “People will take advantage of me if I am too
by drawing up a new template for healthy caring compassionate or forgiving” suggests the need to
relationships with oneself and with others that stay harsh to protect oneself. “I worry that people
the client would like to work toward. Slowly are only kind toward me when they want some-
developing a secure attachment to the therapist or thing,” refers to experiences of earlier experi-
to other trusted sentient beings in her life may be ences of manipulation. Others involve a fear of
a first longer-term goal. dependency on others, a sense of unworthiness of
kindness, a fear of being overwhelmed by diffi-
cult emotions, and a preference for self-
Our Attachment Past Determines Our punishment over self-forgiveness (Gilbert et al.,
Compassion Present 2011). Among people with clinical depression,
fears of compassion are associated with greater
Why are some people mistrusting or afraid of attachment insecurity (Gilbert et al., 2014a, c).
kindness and care? Evidence suggests that barri- Fears and resistance to compassion are associ-
ers and facilitators for self-compassion are ated with greater anxiety and depression in the
closely linked to early attachment experiences general population (Gilbert et al., 2012) and in
(Bowlby, 1982; see Chap. 5). When early experi- clinical cohorts (Gilbert et al., 2014c). People
ences of needing or receiving care are associated who have early memories of shame and who lack
with emotions such as shame, anger, loneliness, early experiences of warmth and safeness may be
fear, panic, despair, vulnerability, powerlessness, more liable to fear receiving compassion (from
or disgust, an individual is much more likely to self or others) and also more likely to experience
feel an aversion or fear toward these care experi- anxiety, depression, and paranoia (Matos et al.,
ences, even as adults. In turn, the capacity to 2017). One study found that together, fears of
experience affiliative emotions such as love, and compassion accounted for 53% of variance in
compassion in a safe and nurturing way can thus depressive symptoms and were strongly
be severely compromised. In effect, experiences associated with self-criticism, which in turn is a
risk factor for depression (Gilbert et al., 2014a). insecurity as not to “overdose” and trigger an
Unsurprisingly, greater fear of compassion is adverse “allergic” reaction to the “medicine.”
associated with increased PTSD symptomatol- Clinicians would not ordinarily give oxytocin
ogy (Winders et al., 2020). A meta-analysis found spray, so the adverse effects may be less strong,
fears of self-compassion and of receiving com- yet we need to take into account that this study
passion to be linked to shame, self-criticism, and was conducted with healthy participants. What
depression. These associations were strongest in about individuals who suffer from psychological
clinical versus healthy populations (Kirby et al., distress and whose attachment systems are thus
2019). This highlights the need to take into on high alert?
account these fears in clinical populations instead Ebert et al. (2018) measured plasma oxytocin,
of generalizing findings from healthy fears of compassion, and parental warmth in 57
populations. clients with Borderline Personality Disorder
(BPD) and compared those to healthy controls.
BPD patients had lower levels of plasma oxyto-
Trust First, Compassion Second cin compared to healthy controls. Within the
BPD group, greater fears of compassion from
The anecdotal evidence of the importance of self, from others, and for others were correlated
attachment and safeness for self-compassion was with lower oxytocin. In keeping with the hypoth-
first backed up by somewhat accidental research esis that oxytocin is related to salient memories
findings by Rockliff and colleagues (Rockliff of affiliation, patients with BDP who recalled
et al., 2011). In a double-blind placebo-controlled less emotional warmth from their parents had
trial, participants from the general public received lower levels of oxytocin. No such relationships
either oxytocin nasal spray or placebo before were found amongst the healthy group. BPD is
being guided in a compassion-focused imagery. associated with traumatic invalidation and sham-
Oxytocin is a neuropeptide involved in affiliative ing from attachment figures in childhood. This
behavior (Bartz et al., 2011). The authors detected study supports the hypothesis that early adverse
significant individual differences in the response attachment experiences change the endocrine
to the compassion-focused imagery, which were substrate of the attachment system, thus likely
the most pronounced under oxytocin. As leading to different responses to training in self-
expected, about half the participants experienced compassion designed for healthy populations and
the compassionate friend imagery as leading to a thus pointing to the need for adaptations.
safe/content/relaxing feeling in both oxytocin Heart rate variability (HRV) is thought to be a
and placebo groups. Those with higher self- physiological measure of the functioning of the
criticism, lower social safeness (trust), and with parasympathetic nervous system and in particular
attachment insecurity however experienced more of the ability to self-soothe (Kirby et al., 2017a).
resistance to receiving compassionate feelings Low HRV is considered indicative of poorer self-
when they received the oxytocin spray and felt soothing ability whereas high HRV is indicative
less safe/content than before starting the exercise. of a better soothing capacity. Rockliff et al.
They reported feeling angry, frustrated, sad, (2008) explored both HRV and cortisol in
scared, and lonely. In keeping with other oxyto- response to compassionate friend imagery rela-
cin research (Bartz et al., 2010), oxytocin spray is tive to control imagery. One group showed an
thought to directly activate socially salient mem- activation of the soothing system indicated by an
ories of affiliation, which explains the negative increase in HRV and decrease in cortisol. Another
emotions and aversion to care in those with group, however, showed a decrease in HRV and
attachment insecurity. This points to the impor- similar cortisol levels following the compassion
tance of titrating the dose of any compassion imagery, indicating an increase in the physiologi-
intervention in individuals with high self- cal threat response. The main distinguishing
criticism, low social safeness, and attachment variable between the two groups was the degree
354 C. Brähler
of social safeness (or sense of trust in others). to label their emotions and to talk about their
Nonsignificant trends showed that the threat feelings, making it more difficult to notice and
group was more self-critical, colder toward them- feel their pain (Gilbert et al., 2012). Fear of self-
selves, more anxiously attached, and had more compassion and high psychological inflexibility
psychiatric symptoms. have been shown to interact to predict PTSD
Trust in others appears to be a key prerequisite symptom severity in students with trauma expo-
for being able to benefit from compassion imag- sure (Boykin et al., 2018; Hiraoka et al., 2015).
ery. What if you prime people to think of some- Clients with the highest levels of shame and self-
one they trust? Baldwin et al. (2020) found that criticism experience the lowest level of self-
this experimental manipulation was associated compassion and the greatest fears of receiving
with an increase in HRV following compassion compassion from others including from oneself,
imagery in 68 students with attachment insecu- which correlates with insecure attachment
rity thus suggesting that helping to build trust (Gilbert et al., 2014c), low mentalizing ability
first made it easier for the person to receive com- (Boykin et al., 2018), and worse outcomes (Kelly
passion from a being in their imagination. The & Carter, 2013; Miron et al., 2016; Vettese et al.,
researchers found a decrease in HRV (threat 2011). Therefore, therapists need to assess and
response) in those same participants when they consider not just fears of compassion but also
asked them to do the compassion imagery with- their clients’ capacity to mentalize and to differ-
out the prime (Baldwin et al., 2020; Galili- entiate their emotions when planning any
Weinstock et al., 2017; Kelly & Tasca, 2016) compassion-based interventions. Directive inter-
Taken together, the neurophysiological and endo- ventions based on CBT and DBT that helped cli-
crinological studies show that clients with attach- ents differentiate negative emotions associated
ment insecurity or disorganization may not only with self-criticism were associated with a greater
have a different HPA axis functioning but also a increase in self-compassion over the course of
different oxytocinergic system. Beliefs such as therapy compared to nondirective interventions
“Others cannot be trusted. Kindness from others (Galili-Weinstock et al., 2019). In the later sec-
is not genuine. Giving kindness to others means I tion on differentiation, I give some guidance on
would let them off the hook.” (Gilbert et al., how to adjust interventions for individuals with
2011) might easily be triggered by compassion low mentalizing ability.
exercises and create adverse emotional reactions.
To prepare clients emotionally and physiologi-
cally, therapists first need to establish trust in the An Attachment-Based
therapeutic relationship and within the client. Reformulation of Self-Compassion
External safety is of course necessary before any in Trauma Treatment
therapeutic work can begin.
Self-compassion has the potential to buffer
against the impact of traumatic stress through the
Consider the Capacity to Mentalize process of cognitive appraisal and emotion regu-
lation (Barlow et al., 2017; Játiva & Cerezo,
Another obstacle to receiving compassion from 2014; Zeller et al., 2015) and by helping individ-
others can be related to mentalizing difficulties. uals to make better use of social support (Maheux
Mentalizing difficulties include a compromised & Price, 2016). Much like attachment security,
ability to infer and reflect on the mental states of self-compassion offers an inner safe haven,
oneself and others and to take different perspec- where individuals can seek refuge and recover
tives (Fonagy et al., 2002), similar to psychologi- when distressed, and a secure base, from which
cal inflexibility (Miron et al., 2016). Gilbert they can explore the world and connect to others
found that individuals with greater fears of com- to feel energized again (Bowlby, 1988).
passion were more self-critical, but also struggled Capacities for emotion regulation and mentaliz-
ing/psychological flexibility develop in early acknowledging and reinforcing experiences

attachment contexts and are critical for later emo- where the client has effectively responded to her
tional and interpersonal functioning (Fonagy own needs. In some cases, it may be easier for
et al., 2002). Self-compassion involves both emo- clients to infer their needs based on their expecta-
tional regulation (self-kindness) and mentalizing tion of what another person might need in a simi-
(mindfulness and common humanity). Research lar situation. An important part of this exploration
demonstrates that attachment styles are, however, may also be workshopping potential ways that
fluid across the lifespan, and that a secure attach- the client can meet her own needs in a situation
ment style can be developed later in life through without always relying on others.
corrective experiences with another attachment In contrast, dismissive-avoidant attachment
figure, such as a teacher, therapist, a romantic tendencies tend to manifest as exclusive self-
partner, or a spiritual being—an “earned secure” reliance, as caregivers were unreliable in times of
style (Roisman et al., 2002). It could be argued need. In this case, the prospect of seeking or
that self-compassion is the result of such correc- receiving help from others may trigger fears of
tive experiences, which have been shown to buf- abandonment or being let down or disappointed.
fer against the impact of dysfunctional family Given that the client’s self-reliance has long felt
experiences (Berryhill et al., 2018; Homan, 2016; critical to their survival, relying on others can
Jiang et al., 2017). also evoke feelings of powerlessness or shame.
Therapists can start to engage such clients by
acknowledging the strength that the client has
Safely Navigating Unchartered shown through their ability to survive without
Attachment Trauma Territory others’ help, while also validating that this can-
not have been an easy task. It is important, how-
If clients fear the care they long for, then how can ever, that validation of these experiences comes
we safely integrate self-compassion into therapy? from a place of curiosity and compassion, rather
Ask yourself: “How can I, as a therapist, safely than sympathy or pity. Respecting and honoring
access the care system in this person without the client’s need for autonomy is critical. As
unnecessarily activating the threat system?” Self- described in Braehler and Neff (2020), focused
report questionnaires might help to assess con- self-disclosures can also be helpful in de-shaming
scious fears (Gilbert et al., 2011), although most the client with dismissive-avoidant attachment
are unconscious unless activated in an attachment tendencies. For example, in acknowledging and
context. Knowing a client’s attachment style and validating the steps a client has taken to seek help
mentalizing capacity can also provide helpful by coming to therapy, the therapist may wish to
guidance for how to attune your role and the type disclose a time when they also struggled to con-
of interventions you use. fide or trust in others for support.
Fearful-avoidant attachment tendencies in
adults result from a sense of being unable to trust
Adapt to the Attachment Style neither themselves nor others to care for them at
times of distress, creating confusion, dissocia-
Clients with anxious-preoccupied attachment tion, and intense despair. Such expectations are
tendencies might present as needing the therapist strongly associated with sexual, physical, or
or others for support, guidance, reassurance, and emotional abuse and neglect by caregivers during
comfort. This is often because the client does not childhood (Van Ijzendoorn et al., 1999). The
trust their ability to self-soothe. Thinking about attachment figure was a source of fear, account-
their own needs may bring up feelings of confu- ing for the intensely ambivalent and confusing
sion, despair, or fear. In this scenario, the thera- behavior in relationships. Seeking help is likely
pist can play a role in supporting the client to to be a struggle for clients with this attachment
recognize and express her own needs, while conditioning, as they touch on the fear of being
356 C. Brähler
abused again. Significant courage and motivation while the care and attachment system is typically
to help oneself is needed to overcome this fear. associated with “pleasant” feelings such as con-
Expressions of care from the therapist are likely nectedness and warmth, when it has been
to be met with intense fear and reactivation of “offline” for some time, reactivation can feel
early relational trauma, such as by flashbacks, quite unpleasant. This can be likened to running
dissociation, or numbing. Rage or anger might be one’s hands under warm water after being out in
another response to create distance again from the snow. Although the warmth is needed (and
the therapist who is seeking to come closer. will become pleasant over time), the initial expe-
Clients with such distressing early experiences rience of warmth can be a painful one. However,
require the utmost stability, attunement, flexibil- this explanation should not be viewed as carte
ity, patience, long-term commitment, and good blanche to trigger negative emotions. Instead,
will from the therapist. Any rigid expectations the therapist should always titrate the dose of
with regard to how the client should respond, their own compassionate presence with the cli-
behave, or how therapy should unfold may be ent - as well as that of any practices – to avoid
met with increased dysregulation and could such adverse effects as far as possible. Warmth,
potentially result in the client dropping out of kindness, and wisdom are qualities we would
therapy prematurely. hope to find in all therapists. What is important is
that any warmth does not emerge from a script of
how one should be as a therapist but emerges
Principles for Selecting Interventions from resonance with the client and good will,
which helps therapists to provide sensitive,
Following an assessment and formulation, attuned, and thus flexible care. Flexible means
including experiences of safeness, warmth and also toning down one’s expression of kindness if
care, the therapist might want to formulate some it is “too much of a good thing” for the client. By
hypotheses about where roadblocks may occur. titrating exposure to the care system in a sensi-
Despite the best analysis and preparation, many tive and flexible manner, therapists can help their
attachment traumas remain hidden until they are clients stay within the window of tolerance and
activated during therapy. The following three keep this window open, rather than causing the
principles based on my clinical experience may client to shut down.
help to prevent unnecessary activation of the
threat system and help overcome fears of com- Direction: Accessing Compassion Where It
passion safely. Flows Freely Just as fears of compassion can
manifest as fears of receiving from others, giving
Desensitization: Warming Up to others, and receiving from self, so too can the
Slowly Accessing the care and attachment sys- flow of compassion be directed from self to other,
tem (for example, by receiving care and compas- from other to self, or from self to self. It is likely
sion with the therapist) can be extremely that not all directions flow as freely for each cli-
threatening for the client with attachment ent. Accordingly, therapists can support the cli-
trauma. Accordingly, the therapist needs to ents to become accustomed to accessing the care
“warm up slowly” by working with the client to and attachment system where it flows most
find a safe way of bringing the care system freely. Allowing the client to choose how far
“online”. This includes first working with the away or how close to them they want to experi-
protective parts and exploring their fears instead ence care can help to establish feelings of safety
of pushing them to the side and forcing your way and trust in the process. Ask yourself: “In which
to the vulnerable parts without their consent thus direction can the client feel trust, kindness,
destabilizing the client. Therapists might want to compassion, or happiness most easily without
acknowledge and normalize the paradox that feeling threatened?”
Differentiation: Who Needs What from Whom if this is an unfamiliar concept. For example, in
and How? Self-compassion practices frequently the context of insecurity, encouragement is a
involve differentiating various “parts” or selves, common need; in the context of abuse, protec-
such as the inner self-critic and the inner compas- tion; when one has experienced neglect, they may
sionate voice. For clients who are easily able to need a sense of providing; if they experience
identify and differentiate these parts, such exer- grief, they may need comfort; in the context of
cises can provide a useful demonstration of how fear, they may need calming; and in the context
one can utilize one’s internal resources to respond of shame, they may need validation and a sense
to internal difficulties. However, clients with com- of belonging.
plex PTSD may be more likely to overidentify
with one part of themselves at the expense of being
able to acknowledge or hold other parts or selves. elf-Compassion Within Phase-Based
S
For example, they may feel overidentified with a Therapy for Complex PTSD
younger, more vulnerable self at the expense of
honoring and validating their stronger, adult self. I now highlight a few processes during any phase-
Over the course of therapy, clients may based treatment of complex PTSD (Herman,
become more aware of, and able to integrate 1992) where self-compassion comes into play in
these different parts. For example, they may iden- its different guises. Self-compassion for the ther-
tify both protector parts, and vulnerable, exiled apist strengthens compassionate presence, which,
parts that are connected to specific autobiograph- in turn, strengthens the therapeutic relationship,
ical memories. In doing so, the client may experi- and lastly allows for sensitive direct interventions
ence the capacity to offer care from their with the client.
compassionate self to another part and to inte-
grate traumatic memories with present-day reali- Troubleshooting for Triggered Parts in the
ties. However, this parts-based approach is only Therapist It is normal to experience empathic
recommended where clients are reasonably sta- distress when sitting with clients with significant
ble, have good mentalizing ability, and have trauma. We may feel a whole range of distressing
capacity to access their compassionate self. When emotions in response to the wide range of dis-
working with individuals with low mentalizing tressing images, feelings, and thoughts the client
abilities, it is recommended that you make any is carrying with her. The first and most significant
intervention concrete, visible (interpersonal), and step is to recognize the activation of your own
focused on the here-and-now instead of making it threat system, to stay grounded in your body, and
abstract, invisible (intrapersonal), and focusing it to offer love and understanding to your parts that
on distress in the there-and-then (Bateman & have been triggered in order to return to a suffi-
Fonagy, 2006). Undifferentiated practices keep ciently open, relaxed, and caring state. If you
the level of differentiation of the quality of care have taken self-compassion training, you can
and of the object of care low as well as concrete, insert informal practices in your clinical day to
visible, and based in the here-and-now. Touch or practice silently whilst sitting with a client or in
practical behaviors are examples of undifferenti- your break in response to any of those explor-
ated care, and nurturing the body through diet, atory questions:
exercise, touch, massage or pets, plants, nature or
simply breathing provides opportunities for here- • How am I feeling right now? Is there distress
and-now, concrete, and visible care experiences. in me? How am I relating to my (empathic)
Differentiation may also be applied to the distress? What do I need to alleviate this dis-
quality of care. What is needed? Providing the tress somewhat for now? What gets in the way
client with examples of some common needs in of giving that to myself?
relation to specific experiences may help to • Why am I doing what I am doing right now?
expand their vocabulary of needs-based language What part is in the driver’s seat? Powerless,
358 C. Brähler
overwhelmed, traumatized, despairing, numb- understanding amongst therapists is that com-

ing, intellectualizing, angry, afraid of emo- passion means only to be nurturing, calming,
tions, shaming, punitive, or striving to rescue, and soothing (yin qualities) instead of also
succeed, control, lecture, or please? Offer love including assertiveness, protection, and
and understanding to the part that is trying to encouragement (yang qualities). Compassion
protect you or that feels vulnerable and has means being sensitive to suffering and alleviat-
been activated. ing it with a quality of care that is appropriate
to the suffering.
Therapists thereby take full responsibility for For those who have experienced betrayal
regulating any of their triggered parts. Therapists traumas, it is fundamental to validate the anger
can be transparent about their emotions such as and the pain connected to the betrayal.
feeling compassion for a part of the client if it Validating the injustice of the experience
serves the therapeutic process, but they need to should continue for as long as the person needs
be careful not to burden the client with their own validation. Many survivors may be accustomed
unresolved issues. For example, co-regulating to having their experiences invalidated and
yourself by guiding a practice with the client who may even engage in self-invalidation.
only serves to calm the therapist down would be Accordingly, the role of the therapist is to
unethical as the therapist would be putting part of model healthy self-protective anger so that the
the responsibility for him or herself onto the cli- client is able to recognize the full weight of
ent. This would be violating the therapist’s duty their experience. Over time, as clients start to
of care. We need to ensure that practices serve the believe that what was done to them is wrong,
client and that we are here to support and guide, unjust, and in most cases, illegal, they develop
not the other way around. If you notice being the capacity to validate their own anger. This is
triggered regularly, then personal therapy, mind- the first step of Yang self-compassion as
fulness, and self-compassion training are strongly described in the Yang Self-compassion break
advised for the therapist as well as considering (Braehler & Neff, 2020). However, this is not
referring the client to a more experienced thera- necessarily a linear process. Often, shame will
pist. A study found that therapists who were more re-emerge, leading the survivor to feel guilt
self-critical were more likely to be critical and regarding their anger. This in turn can activate
hostile to their clients leading to worse outcomes a submissive defeat state, triggering depressive
(Henry et al., 1990). mood (Catarino et al., 2014). Accordingly, it is
vital that the therapist can remain patient and
Empowerment Through Fierce Self-present with the client’s experience. Creating
Compassion An important step in recovery space to gently explore and acknowledge the
from high betrayal traumas is when the person fear of anger that survivors may carry provides
begins to experience healthy anger (fierce self- a firm foundation for clients to gradually expe-
compassion). Righteous outrage about the rience, express, and validate their own anger.
injustices helps the survivor to move out of dis- The therapist’s own relationship with anger
sociation, shame, and self-attacking into plays an important role in this process. If thera-
groundedness, self-confidence, calm strength, pists have not yet integrated healthy anger in
and readiness to protect herself, which is pro- their own personality, their own habitual reac-
foundly empowering. Feeling appropriate tions to anger in the client may trigger their own
anger about the physical or emotional cruelties fear or shame, which might drive the wish to
inflicted on one’s body and mind also allows stop the anger for fear of aggression or the wish
the person to begin to grieve. A common mis- to tell the person off for being angry. If a thera-
pist cannot tolerate a patient’s anger well, then prematurely by inviting the client to empathize
the therapist is likely to shame the client for with the perpetrators instead of remaining the
being angry or to react with anger or even go client’s loyal and wise advocate who validates
into a freeze response themselves. Consequently, the victim’s perspective fully first. Clients are
the patient is likely to feel invalidated or shamed, usually deeply afraid of their own anger and
thus potentially dropping out of therapy or rage, as expressing these feelings at the time of
returning to submissive relational patterns. the trauma would have meant more cruelty and
Personal inner work is necessary on the side of even death. The therapist needs to empathize
the therapists to empathize with the anger or with the victim and these fears yet see that this
rage the client might be feeling and to tolerate it is a healthy and important step on the healing
easily to avoid harming the client with pseudo journey.
yin compassion offered in the service of sup- Given the abundance of “forgiveness prac-
pression of anger, shaming and ultimately tices” available, therapist may think that for-
retraumatization. giveness is a skill to be practiced and a task to be
Once clients have stopped dissociating as accomplished instead of a process that unfolds
much from their suffering, they begin to see the naturally within the client as a by-product of the
measure of cruelty that has been inflicted on other therapeutic work over a long period of
them. Whilst this is an important step to integrat- time. Once dissociation stops and all feelings
ing traumatic memories, it understandably can have been felt and integrated, a bigger perspec-
give rise to rage and revenge fantasies against the tive of oneself and of life and on one’s painful
perpetrators and any bystanders who allowed this past and hopefully positive future naturally
to happen. Rage and revenge fantasies are an emerges. This increased wisdom and equanim-
attempt to reduce the feeling of powerlessness ity usually gives rise to a more balanced out-
experienced at the time of the traumatic events look, including at the perpetrators. Actively
and experience now at not being able to change guiding the client to get into the heads of the
the past. Through validation and staying present perpetrator from a place of goodwill when their
with these feelings and fantasies, they can be intentions were ill will, could be considered
transformed into healthy self-protective anger manipulative and retraumatizing. Furthermore,
and assertiveness and eventually give way for clients may bypass the outrage about the atroci-
grief to naturally arise once there is enough of a ties they have experienced by escaping into fan-
secure base within the client. tasies of being able to forgive and absolve the
Therapists working with complex PTSD cli- perpetrator (Herman, 1992, p. 189). Therapists
ents are likely to suffer empathy fatigue as they who are unaware of the importance of integrat-
absorb the many intense emotions the client ing outrage and anger may breathe a sigh of
experiences. Self-compassion training outside relief at hearing this and may inadvertently feed
the office can help therapists build the resilience this fantasy of grand forgiveness by introducing
necessary to regulate their own empathic dis- forgiveness practices. All extreme fantasies of
tress and shift to a compassionate stance that the client either annihilating or of loving the
allows them to be exactly where the client is, not perpetrator can be viewed as attempts to deal
where the therapist wants them to be. If thera- with the underlying powerlessness and hurt and
pists are not conscious of their own aversion to prevent the person from mourning the losses.
anger or revenge fantasies, then they may tend Therapists thus need to let go of any agendas
to want to bypass anger in the client instead of and meet the clients where they are at. Therapists
working directly with it and helping the client have a duty of care, thus they need to be open to
transform rage into assertiveness. The therapist all emotions and take personal responsibility for
may push the client to consider the forgiveness their own well-being by regulating the vicarious
360 C. Brähler
distress they might be feeling themselves instead and develop the capacity to practice fierce self-
of by closing down or manipulating the experi- compassion with regard to past experiences, they
ence of the client. may feel more confident asserting themselves.
Being reminded of the “steps” to follow when
Offering Solidarity We can apply the three com- injustice is experienced (or re-experienced) can
ponents of yang self-compassion to the therapeu- be a supportive informal practice for when these
tic relationship. Firstly, the client should feel safe moments arise. The Yang Self-Compassion Break
to vent her rage and anger with the therapist and (Box 20.1), taken from Braehler and Neff (2020)
be met with radical understanding and accep- was developed to validate the truth of trauma sur-
tance (mindfulness). Secondly, to help move vivors’ experience, to nurture self-protection, and
from fantasies of rage and revenge to a more to evoke courage and wisdom. While the practice
grounded and ultimately powerful feeling of is infused with fierce self-compassion, through a
“righteous indignation” (Herman, 1992, p. 189), strong, calm, and assertive stance, it is not
the trauma victim needs to feel actual support aggressive.
from others, i.e., to directly experience solidarity
instead of standing alone and having to resort to
grandiose ideas of power though love or hatred Grief and Mourning
(common humanity). This involves being
believed by others and having authorities and After shame and guilt have abated and righteous
others join forces to bring the perpetrator to jus- anger has been transformed into assertiveness and
tice. The feeling of safety in numbers allows the self-protection, it is common for trauma survivors
victim to voice her outrage, too. The therapist to move into an experience of grief and mourning.
needs to convey clearly that they believe the cli- Grief may relate to both the atrocities endured and
ent and offer themselves as advocates who share feelings of loss connected to the impact of these
the outrage about the injustice and support the experiences in quality of life. Mourning is there-
client in accessing a wider sense of solidarity and fore a central part of trauma recovery. By provid-
strength in numbers. Group therapy with other ing a yin compassionate presence to bear witness
trauma survivors or other peer groups might help to the client’s pain, therapists can support clients
at this stage, if the person feels ready. Thirdly, the to gradually grieve whilst feeling held. As clients
question arises what the wisest action would be become more accustomed to receiving compas-
in this moment that would promote the well- sion from the therapist, fears of compassion may
being in the client in the longer-term. The thera- gradually diminish.
pist should trust the wisdom of the client to know Over time, the client may also start to internal-
and if the client struggles to work toward finding ize both the yin and yang aspects of compassion,
functional ways to protect and assert themselves. so that they are able to hold the assertive and the
These may vary depending on the situation. It is vulnerable parts of themselves simultaneously. A
important to guide the client to connect with her typical barrier to mourning and crying is the
inner wisdom instead of staying stuck in rage or belief that it is a weakness, which makes clients
submission. All these three steps of yang com- vulnerable to further attacks. Again, the therapist
passion require courage, strength, and a degree of never pursues an agenda to make the client feel
fearlessness of the therapists. anything as this would be trying to control or
manipulate when in fact the trauma client needs
Informal Practice for Trauma Survivors: Yang to be empowered. Instead, the therapist holds the
Self-Compassion Break for Protection As cli- client in their hearts and thus creates a loving
ents learn to manage feelings of shame and guilt space in which the client can go at his or her own
pace. Once enough trust and compassion is pres- taining what they have learnt in therapy. While the
ent within the client, grief naturally arises. practice can be applied between sessions, it is
important that the client knows how to connect
with their bodily experiences without dissociating
Box 20.1: Yang Self-Compassion Break for
and to access their soothing system in a safe way.
Protection (from Braehler & Neff, 2020)
1. Mindfulness of Suffering
Box 20.2: Yin Self-Compassion Break for
(a) Validating the pain or hurt or injus-
Grief
tice you are experiencing.
“This is my truth. I believe what I 1. Mindfulness: To Notice, Name, and
experienced. I trust myself Validate the Distress
despite what others might be Feel the grief in your body for now. Let
saying to invalidate me!” yourself know that you get why you feel
(b) Courage. this now. For example: “It is tragic that this
“I dare speak my truth starting with happened to me. It is so painful to have
myself.” missed out on happiness, joy and ease. It is
2. Common Humanity and Solidarity so understandable that I would feel like this
(a) Empowering yourself to reach out at this point.”
to and to trust in others to share 2. Common Humanity: To Help You
your truth. Feel Connected Instead of Isolated
(b) Feeling connected in suffering to Think of at least one person you know
others who experience similar suf- who has experienced similar pain. You do
fering and to feel solidarity in pro- not even have to know them personally. For
tecting yourself against future example: “Even though it feels like I am all
hurts. alone, I also feel some connection to my
3. Fierce Self-Kindness two friends from group therapy. They are
(a) What do I truly need to protect people who really understand what it is like
myself or to support myself or to to have experienced these unspeakable
stand up for myself? things.”
(b) What is the wisest thing for me to 3. Soothing Touch: To Bring the Care
do in this situation in the short-term Physiology Online
and in the longer-term? To say no? If it is comfortable, place the hand on a
To draw my boundaries? To speak part of the body where touch feels comfort-
my truth? To walk away? To gather ing or touches a warm blanket or warm
support to stand our ground and mug of tea or stroke a pet.
keep making our voices being 4. Self-Kindness: To Offer Yourself
heard? Inner Guidance and Comfort
Ask yourself: what comforting words or
gestures do you need to receive right now?
From whom would they feel safest to
Informal Practice for Trauma Survivors: Yin receive? For example: “I am here for you,
Self-Compassion Break for Grief When clients my dear. Luckily the hurt is over. May you be
experience grief and are in mourning, The Yin extra gentle and kind with yourself as you go
Self-Compassion Break for Grief (Braehler & through this grief remembering that it will
Neff, 2020; see Box 20.2) can be a supportive pass, too. I will take good care of you and
practice. This practice can support clients to allow you to feel whatever you are feeling.”
soothe themselves and feel more confident main-
362 C. Brähler
The Final Phase: Learning to Thrive ness is unlikely to accommodate the many vari-
ables influencing treatment outcome.
The final phase of working with trauma moves Compassion- based work is attachment-based
beyond merely surviving and toward learning to work and taps directly into early experiences of
thrive. This involves becoming acquainted – and attention, care, love, and appreciation, or lack
comfortable with – feeling states and experi- thereof. As with all trauma-based works, it
ences that may be very foreign to the client, requires clinicians to be sensitive, flexible, dili-
such as happiness and play. Because they have gent, and willing to become a safe haven and
spent most of their life in survival mode, most secure base for their clients until they learn to
clients with complex PTSD experience chronic become a safe haven and secure base for them-
tension and hyperarousal, sleep and digestive selves. This chapter provides comprehensive
problems, restlessness, and hypervigilance. Just guidance on how therapists can work with their
as early experiences can give rise to fears of own and their clients’ emotional and relational
compassion, these experiences may also make experiences in a compassionate way in the treat-
the client vulnerable to fears about experiencing ment of complex PTSD. I trust that the pro-
joy and happiness (Şar et al., 2019). For instance, cesses and principles presented in this chapter
a client who had early experiences of punish- can easily be transferred to the integration of
ment or shame when they were happy or at play self-compassion into the psychological concep-
will learn quickly to suppress happiness and tualization and treatment of other complex men-
may be actively avoidant or dismissive of expe- tal health disorders.
riences akin to play or relaxation. Similar to
fears of compassion, fears of happiness are
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Two decades of research on childhood trauma
Self-Compassion and Non-suicidal
Self-Injury 21
Penelope Hasking
What Is NSSI? men. However, meta-analytic studies suggest that

there is little difference in rates of self-injury
Non-suicidal self-injury (NSSI) is a growing across sexes in community samples (Bresin &
health concern for many clinicians, parents, Schoenleber, 2015). Early studies in the area
teachers, and the general public. Defined as the tended to include clinical samples, where females
deliberate damage to body tissue without suicidal are over-represented, studies of people with bor-
intent, and for purposes not socially or culturally derline personality disorder, for which NSSI is
sanctioned, NSSI often includes behaviours such one diagnostic criterion, or limited forms of self-
as cutting or burning the skin, self-battery, and injury (e.g. cutting) which may be more com-
severe scratching (International Society for the monly reported by females. When these
Study of Self-Injury [ISSS], 2020). Typically first methodological factors are taken into account,
emerging among young people aged 12–14 years we see that girls and women may be more likely
(Plener et al., 2015), onset of NSSI in early adult- to try self-injury, but there is little sex difference
hood is also common (Kiekens et al., 2018). In in who continues to engage in the behaviour
community samples, approximately 18% of ado- (Swannell et al., 2014). In clinical samples, girls
lescents, 13% of young adults, and 5% of adults and women are more likely to report a history of
over 25 years of age report a history of self-injury self-injury than boys and men, but this could be
(Swannell et al., 2014). However, university stu- due to sex differences in help-seeking, over-
dents appear more likely to engage in self-injury representation of individuals diagnosed with bor-
than their same-aged peers (20%), and 15% of derline personality disorder (more often
students first engage in NSSI during the first diagnosed among women), or a tendency for
2 years of university (Kiekens et al., 2019). In girls/women to be more comfortable reporting
clinical samples, rates of NSSI are higher, with NSSI.
up to 50% reporting a history of self-injury Individuals can engage in NSSI for a multi-
(Glenn & Klonsky, 2013; Groschwitz et al., 2015; tude of reasons; however, the most commonly
Kaess et al., 2013). reported reason to self-injure is to reduce or avoid
For some time, it was believed that girls and intense or unwanted emotion (Taylor et al., 2018).
women self-injure at higher rates than boys and Not surprisingly then, NSSI is associated with a
number of psychological concerns (e.g. low self-
P. Hasking (*) esteem, stress), and a range of emotional disor-
School of Population Health, Curtin University, ders, including depressive and anxiety disorders,
Kent St, Bentley, WA, Australia panic disorder, and post-traumatic stress disorder

https://doi.org/10.1007/978-3-031-22348-8_21
370 P. Hasking
(Bentley et al., 2015). Although explicitly not one may engage in self-injury. Selby and Joiner
engaged with conscious suicidal intent, NSSI is (2009) propose that a repeated focus on negative
the single most reliable predictor of subsequent affective experience, through rumination, ampli-
suicidal thoughts and behaviours (Franklin et al., fies the negative affect, which in turn encourages
2017; Ribeiro et al., 2016). Even among individ- greater rumination. In this way, emotion and cog-
uals with no diagnosis of mental illness, individ- nition interact to produce an emotional cascade,
uals reporting a history of NSSI are 5.3 times resulting in escalating negative emotional experi-
more likely to report a subsequent suicide attempt ences. They propose that less potent coping strat-
(Kiekens et al., 2018). Of note, NSSI first appears egies are insufficient to break this cascade, but
approximately 3 years before a suicide attempt, that NSSI can effectively divert attention away
providing a critical window for intervention. from the cascade by directing attention to the
self-injury.
Another model to incorporate an interaction
Theoretical Accounts of NSSI between emotion and cognition is the Cognitive
Emotional Model of self-injury (Hasking et al.,
Given the central role of emotion regulation in 2016). In this model, Hasking et al. (2016) high-
the initiation and maintenance of NSSI, it is not light a specific role for outcome expectancies and
surprising that most theoretical accounts of NSSI self-efficacy in the initiation, maintenance, and
focus on the experience and regulation of emo- recovery from self-injury. They argue that even
tion. One of the earliest accounts, the Experiential without having directly experienced self-injury,
Avoidance Model (Chapman et al., 2006) pro- an individual holds beliefs about what may hap-
poses that individuals vary in the extent to which pen if they did engage in the behaviour (outcome
they wish to avoid unpleasant or unwanted emo- expectancies). In line with operant principles, if
tions. Individuals at the higher end of this spec- an individual expects favourable outcomes from
trum are more likely to use NSSI as a means of self-injury (e.g. emotional relief), they are more
avoiding emotions, particularly when coupled likely to self-injure than if they hold unfavour-
with experiencing more intense emotions (anger, able outcomes (e.g. physical pain). These out-
shame, sadness, frustration), difficulty regulating come expectancies interact with a person’s belief
emotion, and poor distress tolerance. NSSI pro- in their ability to deliberately hurt themselves, or
vides temporary relief from the negative emo- belief in their ability to resist an urge to self-
tional experience and is thus negatively injure (self-efficacy). Individuals bring these
reinforced, and repeated when future negative beliefs to any given situation, and when encoun-
emotional experiences are felt. tering an emotionally volatile situation act in
Nock’s (2009) integrated model of NSSI accordance with these beliefs, and in line with
incorporates distal risk factors (genetic predispo- their existing coping and emotion regulation
sition, childhood abuse, family criticism) which strategies.
are proposed to lead to intrapersonal and inter- The most recent theoretical account of NSSI
personal vulnerabilities (e.g. poor distress toler- deviates away from a focus on the experience and
ance, poor communication skills) that increase regulation of emotion to outline the potential
risk of NSSI in a stressful situation. Nock (2009) benefits and barriers to self-injury. In the Benefits
proposes that there are a number of reasons an and Barriers model, Hooley and Franklin (2017)
individual may self-injure rather than engage in note that self-injury serves a purpose for those
other coping strategies, including learning of the who engage in the behaviour and thus has several
behaviour from others, self-punishment, or to benefits. These include emotion regulation, grati-
communicate distress to others. The Emotional fying the desire for self-punishment, bonding
Cascade Model (Selby & Joiner, 2009) was one with peers, and communicating distress or
of the first to highlight the interaction between strength. Yet there are a number of barriers that
emotion and cognition in explaining why some- prevent most people engaging in self-injury,
21 Self-Compassion and Non-suicidal Self-Injury 371
including having not previously come across the and NSSI. Among adolescents and young adults,
behaviour and thus not being aware it exists, a self-criticism mediates the relationship between
reluctance to experience physical pain, a positive parent expressed emotion (i.e. the extent to which
view of the self, and adherence to social norms families are critical hostile, or overinvolved) and
that view NSSI in a negative light. NSSI (Ammerman & Brown, 2018), as well as
All theoretical accounts have a significant between parental self-criticism and NSSI
amount of empirical work to support their propo- (Gromtasky et al., 2017). Self-criticism also
sitions. Of note, individuals who self-injure con- mediates the relationship between childhood
sistently report greater levels of experiential emotional abuse and NSSI (Glassman et al.,
avoidance and use of avoidant coping strategies 2007). Further, the relationships between nega-
(Hasking et al., 2008), greater levels of negative tive childhood experiences, the absence of posi-
affect and rumination (Hasking et al., 2019; tive experiences, and NSSI are mediated by
Richmond et al., 2017), poor distress tolerance self-criticism (Xavier et al., 2016c). Relatedly,
(Anestis et al., 2013; Slabbert et al., 2018), and a Swannell and her colleagues (2012) also found
lack of alternate emotion regulation strategies the relationship between child maltreatment and
(Tatnell et al., 2018; Voon et al., 2014). Individuals NSSI was mediated by self-blame.
who self-injure report stronger expectations that Several longitudinal studies support self-
NSSI will alleviate negative affect and weaker criticism as a temporal predictor of later NSSI
expectations of physical pain than individuals (Perkins et al., 2020; Smith et al., 2020; Zelkowitz
with no history of NSSI (Dawkins et al., 2019), & Cole, 2019). Yet the relationship between self-
findings which have been supported in experi- criticism and NSSI may be bidirectional. Among
mental work (Dawkins et al., 2021a, b). Further, first-year university students, NSSI at baseline
self-efficacy to resist self-injury reliably differen- predicted self-criticism 1 year later, but the
tiates individuals with no history of NSSI, from reverse was not observed (Daly & Willoughby,
those who have a history of NSSI, but have not 2019). In longitudinal work, Xavier et al. (2017)
engaged in the behaviour in the last 12 months, noted that NSSI at baseline predicted subsequent
from those who continue to engage in the behav- self-hatred, which in turn was related to NSSI
iour (Dawkins et al., 2021a, b). 6 months later. Similarly, among a sample of ado-
lescents from Hong Kong, You et al. (2017)
observed parental control to be related to later
Self-Criticism and NSSI NSSI, which in turn was associated with self-
criticism, but not NSSI, 6 months later. In the
One of the most common findings in the self- same sample, You et al. (2015) observed self-
injury literature is that individuals who self-injure criticism to interact with features of borderline
are more self-critical than individuals who do not personality disorder and negative emotions to
(Cohen et al., 2015; Itzhaky et al., 2015). Many predict later NSSI. Self-criticism also interacted
suggest that the relationship between self- with baseline NSSI to predict NSSI at two later
criticism and NSSI may stem from a history of time points, each 6 months apart.
childhood maltreatment or abuse. Individuals While affect regulation is the most commonly
who experience a critical, hostile, or abusive reported reason for NSSI, most studies find self-
childhood environment are more likely to inter- punishment to be the second most common rea-
nalise this criticism and self-injure in an effort to son, and this is linked to self-criticism (Hooley
punish the self (Glassman et al., 2007; Hooley et al., 2018; Nock, 2009). The self-punitive
et al., 2018). Supporting this, perceived parental model proposes that some people are highly sen-
criticism is associated with self-criticism among sitive to failure and that real or perceived failures
individuals who self-injure (Baetens et al., 2015). can impact self-worth. Consistent with this, per-
Of note, self-criticism appears to mediate the fectionism, parental criticism, shame, and self-
relationship between a number of family factors criticism are strongly associated with NSSI,
372 P. Hasking
especially among women (Flett et al., 2012; Jeong, 2021). The authors highlighted the impor-
Gong et al., 2019). Self-criticism also impacts tance of considering both underactivation of self-
emotional responses to pain (Fox et al., 2017). compassion and overexposure to risk factors
Participants who are highly self-critical report when attempting to understand the pathways that
less pain during experimental pain induction, lead to NSSI.
suggesting that highly critical people may use the Among adolescents, self-compassion medi-
pain of self-injury as a form of self-punishment ates the relationship between a reduced sense of
(Fox et al., 2019). As such, self-criticism may not closeness to mothers, fathers, and peers and NSSI
only remove a barrier to self-injury but may (Jiang et al., 2017b). Adolescents with a history
enhance the benefits. Consistent with this, cogni- of self-injury report greater self-judgement, iso-
tive interventions designed to improve self-worth lation, and over-identification than adolescents
are associated with both a decrease in pain toler- with no such history. Of interest, adolescents who
ance and willingness to endure pain among indi- had thought about self-injury but not engaged in
viduals who self-injure (Hooley & St Germain, the behaviour reported more self-kindness and
2014). A journaling intervention, in which par- common humanity than youth who acted on these
ticipants were asked to write for 5 min each day thoughts, suggesting that fostering self-kindness
about something that made them feel good about may be preventative and may disrupt the link
themselves, was associated with reductions in between injurious thoughts and behaviour (Jiang
self-criticism; there was a reduction in NSSI dur- et al., 2017a, b). Self-compassion scores are also
ing the treatment period (4 weeks), but this negatively associated with using self-injury for
change was not maintained over time (Hooley self-punishment suggesting that fostering self-
et al., 2018). These results might suggest that fos- compassion may negate the need to punish one-
tering a more enduring sense of self-compassion self by self-injuring (Tuna & Genҫöz, 2021).
could mitigate against NSSI. Fear or resistance associated with self-compas-
sion also appears to play a role in moderating the
link between rejection sensitivity and NSSI, such
Self-Compassion and NSSI that those with high rejection sensitivity are more
likely to experience NSSI when they have greater
In contrast to self-criticism, self-compassion fears of self-compassion (Jiang et al., 2021).
involves relating to oneself with kindness, taking Although self-compassion mediates the rela-
a mindful, balanced perspective on difficult expe- tionship between negative affect and NSSI
riences, and remembering that one is not alone in (Hasking et al., 2019), this relationship may also
times of failure or struggle (Neff, 2003). be bidirectional, with lowered self-compassion
Consistent with findings regarding the associa- associated with symptoms of depression and
tion between NSSI and elevated self-criticism, daily hassles, which in turn are associated with
individuals who self-injure also report reduced NSSI (Xavier et al., 2016a). Self-compassion
self-compassion. A systematic review of studies may also act as a buffer in the relationship
examining the association between self-between peer victimisation and NSSI (Jiang
compassion and NSSI or suicidal ideation noted et al., 2016) and mediate associations between
that all 16 included studies found a relationship gratitude, hope, and reduced NSSI (Jiang et al.,
between self-compassion and lower levels of 2020). Among university students, self-
self-injury, with several suggesting that self- compassion attenuates the relationships between
compassion may weaken the relationship depressive symptoms, anxiety symptoms, and
between negative life events and NSSI (Cleare NSSI. Specifically, self-kindness and common
et al., 2019). More recently, a meta-analysis of 18 humanity were the two salient moderators of both
studies reported substantial heterogeneity across the depression–NSSI and anxiety–NSSI relation-
studies, and a small effect size for the relationships (Kaniuka et al., 2020). Similar results have
ship between self-compassion and NSSI (Suh & been observed among adolescents in Portugal,
with high levels of self-compassion attenuating social judgement, and being more open and vul-
the relationship between symptoms of depression nerable with others. Finally, mindfulness was
and NSSI (Xavier et al., 2016a, b, c). Self- also evident in the posts. This included individu-
kindness and mindfulness were particularly als becoming more accepting of their self-injury
salient in reducing the strength of this relation- as well as being able to recognise distress as tem-
ship, while the negative scales of isolation, and porary. This appeared to foster a sense of hope
over-identification increased the impact of for the future, even among individuals who were
depressive symptoms (Xavier et al., 2016a, b, c). still engaging in self-injury. These facets of self-
In longitudinal work, Wu et al. (2019) observed compassion were seen as central to NSSI
self-compassion to moderate the relationship recovery.
between behavioural impulsivity and NSSI
among Chinese adolescents; a negative relation-
ship between self-compassion and NSSI was NSSI Recovery
observed for students reporting high impulsivity,
suggesting self-compassion may counter the risk In recent years, there has been a shift from explor-
conferred by high levels of impulsivity. ing factors associated with the initiation and
In one of the early first-hand accounts of the maintenance of NSSI to identify factors associ-
role of self-compassion in NSSI, Sutherland et al. ated with recovery. In this research, “recovery” is
(2014) analysed comments that people made often conceptualised as not having engaged in
about their self-injury online (e.g. in discussion self-injury for over 12 months. However, when
forums). The authors identified that individuals talking to people with lived experience of self-
made comments that reflected self-kindness, injury, the idea of recovery is much more nuanced
common humanity, and mindfulness in efforts to (Lewis et al., 2019). People experience ongoing
understand and provide meaning to their self- thoughts and urge to self-injure long after ceasing
injury. Individuals described understanding why to engage in the behaviour, and these may never
they self-injured, acknowledging that it was a fully dissipate, although the strength will reduce
response to particularly difficult times, not a sign over time (Kelada et al., 2018). For this reason, it
of psychopathology or that something was is not surprising that individuals experience set-
“wrong” with them. This self-kindness allowed backs throughout the recovery process. A key
participants to stop blaming and criticising them- part of NSSI recovery is finding alternate emo-
selves and promoted self-care through acts such tion regulation strategies. However, other strate-
as engaging in hobbies, practising mindfulness, gies may not be as immediately effective, and it
exercising, and relaxing. This self-kindness ulti- takes trial and error, and concerted effort, to prac-
mately led to individuals re-affirming a sense of tice alternate coping strategies. Along with this,
self and seeing themselves as more than their an individual will develop self-efficacy to engage
self-injury. other coping strategies and increased self-efficacy
Common humanity was evident in posts that to resist ongoing thoughts or urges to self-injure
reflected receiving compassion and understand- (Lewis & Hasking, 2020).
ing from others, understanding the impact of self- NSSI can also come with physical scars that
injury on others, and coming to terms with may be visible to others. Because of this, NSSI
disclosures of self-injury (Sutherland et al., recovery requires that the individual is able to
2014). For most people, self-injury is a hidden accept any NSSI scars or make decisions about
behaviour. The significant stigma associated with whether they choose not to conceal them (Lewis
self-injury means individuals are reluctant to dis- & Mehrabkhani, 2016). In line with this, NSSI
close their experiences for fear of judgement recovery may involve a number of disclosures
from others (Staniland et al., 2020). When post- about NSSI. This could be voluntary disclosure
ing online, individuals talked about coming to to another individual, or it could be that another
accept care from others, to avoid internalising person notices NSSI scars. Either way, an
374 P. Hasking
individual who has self-injured needs to be able without judgement may counter self-criticism.
to consider the consequences of disclosure, and They also recommend compassionate imagery
consider, to whom, when, and how any such dis- (e.g. a loved one wrapping them in a blanket) to
closures may take place (Lewis & Hasking, help reduce urges to self-injure. A self-report
2020). Given NSSI is associated with significant diary in which individuals record self-critical
stigma (Staniland et al., 2020), this process can thoughts, and then construct reassuring thoughts
be extremely difficult, and an individual may that counter these, is offered as one strategy that
struggle with talking about or disclosing their may promote self-compassion and reduce self-
self-injury (Rosenrot & Lewis, 2020). Given the injury. Finally, compassionate behaviours are not
risk of enacted stigma, disclosure may risk rela- only alternative behaviours to self-injury but
tionships with others, or result in a stigmatising involve fostering self-efficacy and positive rela-
or unhelpful response that can have a detrimental tionships with others.
effect on the individual with lived experience of Despite clear evidence that self-compassion
self-injury. may play a role in reducing NSSI, it is interesting
The relationship between self-compassion and that there are no published studies of compassion-
NSSI disclosure has not been directly studied. focused therapy for NSSI. Individual writing
However, prior work has demonstrated that self- exercises have been trialled. Similar to Hooley’s
compassion facilitates distress disclosure (2018) writing task described above, undergradu-
(Dupasquier et al., 2019) and help-seeking ate students tasked with writing a brief essay
(Hermanto et al., 2017; Hermanto & Zuroff, about their best value (5 min) reported elevated
2016), thereby suggesting that those with greater self-compassion relative to students who wrote a
self-compassion may be more likely to disclose brief essay about their lowest ranked value and
their NSSI. why it might be important to someone else
In summary, NSSI recovery is not simply (Gregory et al., 2017). Students with a history of
about stopping the behaviour. Rather, it involves NSSI who completed the values-affirmation task
accepting that ongoing thoughts and urges to also rated their pain, in a cold pressor task, as
self-injure, and setbacks are a normal part of the more intense than students in the control condi-
recovery process, that developing new ways of tion, and could tolerate pain for a shorter period
coping will take time and effort, accepted or of time (Gregory et al., 2017). This is significant
attributed meaning to scars and considering given theories that those who engage in self-
approaches to disclosure. In this way, an individ- injury believe that they “deserve” pain and are
ual can move towards self-acceptance and self- therefore willing to endure it for longer (Glenn
compassion. Further, individuals can build et al., 2014, Hamza et al., 2014, Hooley et al.,
resilience and find meaning in their history of 2010).
self-injury (Lewis & Hasking, 2020). The writing tasks outlined above demonstrate
some promise in reducing NSSI, but to date there
has not been a committed effort to exploring the
Self-Compassion Interventions potential benefits of compassion-focused therapy
or other self-compassion-based interventions.
Given the role of self-compassion in NSSI recov- Given the central role of affect regulation, and the
ery, there have been surprisingly few efforts to salience of self-criticism and shame in the onset
trial self-compassion interventions for NSSI. In and maintenance of self-injury, this seems like a
2011, van Vliet and Kalnins proposed that lost opportunity. The combination of acceptance,
compassion-focused therapy may have applica- mindfulness, and self-soothing taught through
bility in counselling clients who self-injure. They compassion-focused therapy (Gilbert, 2009) and
proposed that mindfulness practice may come to mindful self-compassion training (Neff &
replace self-injury as a means of self-soothing Germer, 2013) seems ideally matched to the
and that acceptance of emotional experiences holistic concept of NSSI recovery, which goes
beyond cessation of the behaviour to foster self- meta-analysis. Clinical Psychology Review, 38, 55–64.
https://doi.org/10.1016/j.cpr.2015.02.009
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Self-Compassion
in Psychotherapy: Clinical 22
Integration, Evidence Base,
and Mechanisms of Change
Christopher Germer
Introduction lying self-compassion in psychotherapy. A few

empirically supported models of therapy are
Imagine that you are a psychotherapist and have explicitly compassion-based, such as compassion-
a client who suffers from anxiety or depression. focused therapy (CFT; Gilbert, 2009), emotion-
During therapy, your client becomes deeply com- focused therapy (EFT; Greenberg, 2006), and
passionate toward herself. That means that when internal family systems (IFS; Schwartz, 1995).
things go wrong in her life, your client can recog- This chapter is primarily informed by CFT, the
nize and validate for herself how she feels rather most distinctly compassion-based treatment
than getting lost in rumination (mindfulness); she model, and by Mindful Self-Compassion pro-
feels connected to other people in the midst of gram (MSC; Germer & Neff, 2019; Neff &
her troubles rather than feeling alone (common Germer, 2018), a structured, empirically sup-
humanity); and her internal conversation is ported training for the general public designed
mostly reassuring and supportive rather than self- specifically to cultivate self-compassion.
critical (self-kindness). With these mental habits, The chapter begins by locating self-
there is a good chance that her anxiety or depres- compassion in the context of psychotherapy, past
sion would have already subsided and she does and present. Next, we outline the evidence for
not need as much therapy anymore, although the self-compassion as a transdiagnostic and trans-
challenges of life will inevitably remain. theoretical mechanism of action in therapy. The
As this book amply demonstrates, self- majority of this chapter describes three levels by
compassion is a key ingredient in mental health which self-compassion can be integrated into
and psychological well-being. The beneficial psychotherapy—compassionate presence, com-
impact of self-compassion is perhaps even more passionate relationship, and compassionate
evident in psychotherapy where people bring interventions—along with supporting research.
their most challenging life experiences. The pur- When all three levels are part of treatment, it can
pose of this chapter is to offer a panoramic view be considered fully self-compassion based.
of how to integrate self-compassion into any Finally, we explore emotion regulation as the
form of treatment and also to outline the evidence basic mechanism by which self-compassion
base and putative mechanisms of change under- works in psychotherapy, along with underlying
neurophysiological and psychological processes,
C. Germer (*) especially the cultivation of secure attachment
Harvard Medical School, Cambridge Health Alliance, and the alleviation of shame.
Cambridge, MA, USA

https://doi.org/10.1007/978-3-031-22348-8_22
380 C. Germer
Historical Context A modern definition of compassion is:

… a multidimensional process comprised of four
Self-compassion has been part of psychotherapy key components: (1) an awareness of suffering
for over a century under the umbrella of “self- (cognitive/empathic awareness), (2) sympathetic
acceptance.” Psychotherapy giants such as concern related to being emotionally moved by
suffering (affective component), (3) a wish to see
William James, Sigmund Freud, and B. F. Skinner the relief of that suffering (intention), and (4) a
all considered acceptance of oneself and others to responsiveness or readiness to help relieve that suf-
be psychologically beneficial (Williams & Lynn, fering (motivational) (Jinpa (2010) in Jazaieri
2010). Carl Rogers (1951) and other humanistic et al., 2013).
therapists elevated self-acceptance to the status
of a core change process in psychotherapy. In this definition of compassion, awareness and
Interestingly, both Freud (1957) and Rogers concern refer to cognitive and affective empathy,
(1951) considered self-acceptance to be a precur- and the wish and readiness to alleviate suffering
sor to positive therapeutic change and acceptance are special attributes of compassion—the added
of others, and this perspective became a focus of component of goodwill in the face of suffering.
empirical investigation well into the 1980s. In the Since the premise of psychotherapy is the allevia-
1990s, clinical research shifted away from accep- tion of psychological distress, we can assume
tance of the “self” to acceptance of “moment-to- that the wish and readiness to alleviate suffering,
moment experience” with the introduction of or compassion, have always been implied in our
Buddhist-inspired mindfulness and acceptance- clinical understanding empathy.
based treatments such as dialectical behavior Empathy is a key ingredient in effective ther-
therapy (DBT; Linehan, 1993), acceptance and apy relationships (Elliott et al., 2011; Norcross &
commitment therapy (ACT; Hayes et al., 2011), Lambert, 2018). Our understanding of empathy
and mindfulness-based cognitive therapy has continued to evolve since Carl Rogers, espe-
(MBCT; Segal & Teasdale, 2018). Recently, the cially with the advent of social neuroscience in
pendulum has begun to swing back to include the 1990s. Empathy now encompasses not only
acceptance of both moment-to-moment experi- experiencing the world of another as one’s own,
ence (mindfulness) and the experiencer (self- but also having perspective on the emotional
compassion)—the “self.” state of another person and the ability to regulate
one’s own empathic distress in order to maintain
a compassionate state of mind (Eisenberg &
Empathy and Compassion Eggum, 2009). With the addition of perspective
and emotion regulation to sustain a positive atti-
For most of the history of psychotherapy, the tude, the modern definition of empathy moves
term “compassion” has been relatively absent closer to our understanding of compassion.
from the research literature. However, we can
assume that compassion has not been absent from
psychotherapy, but rather implied in the defini- Discovering Self-Compassion
tion of empathy. Empathy refers to experiencing
the world of another person as one’s own. Carl Most people are more compassionate toward oth-
Rogers (1951) wrote the following about empa- ers than themselves (Knox et al., 2016; Pommier
thy in client-centered therapy: et al., 2020). This disparity comes at a price,
It is the counselor’s function to assume…the inter- however, especially in the clinical arena. Twenty
nal frame of reference of the client, to perceive the years ago, in 2000, Paul Gilbert had a revolution-
world as the client sees it, to perceive the client ary insight while treating depressed clients with
himself as he is seen by himself, to lay aside all cognitive-behavioral therapy (CBT). He realized
perceptions from the external frame of reference
while doing so…(p. 29). that his clients could become adept at identifying
cognitive distortions and replacing them with
22 Self-Compassion in Psychotherapy: Clinical Integration, Evidence Base, and Mechanisms of Change 381
more balanced thoughts, but their symptoms of with” challenging moment-to-moment experi-
depression did not diminish as long as they spoke ences rather than directly changing them
to themselves in a harsh and demanding tone. (Dimidjian et al., 2016; UliaSzek et al., 2020).
What his clients needed, Gilbert concluded, was This approach has since embraced compassion-
to “warm up the conversation” (personal commu- oriented treatment and coalesced into a new par-
nication). This understanding led to the develop- adigm—mindfulness-, acceptance-, and
ment of CFT, a therapy model based on compassion-based psychotherapy (Germer &
evolutionary psychology, attachment theory, and Siegel, 2012; Germer et al., 2013). Within this
Tibetan Buddhist compassion practice, that is new paradigm, some therapists focus more on
currently researched and practiced by clinicians mindfulness, others on acceptance, and still oth-
throughout the world (Gilbert, 2010a, b). ers on compassion as the primary mechanism of
Three years later, Kristin Neff (2003), a devel- change in treatment. For example, mindfulness-
opmental psychologist, operationalized the con- based clinicians (e.g., Segal et al., 2012; Shapiro
struct of self-compassion and published the & Carlson, 2009; Siegel, 2009) tend to empha-
self-report scale, the Self-Compassion Scale size the role of attention and awareness in how
(SCS), that is used in most research on self- we create, experience, and alleviate emotional
compassion. Since then, the number of studies on suffering. Acceptance-based clinicians (e.g.,
self-compassion has grown exponentially. Most Hayes et al., 2011; Roemer et al., 2008) focus
self-compassion research is still correlational, more on non-avoidance and acceptance of
but studies with laboratory mood manipulations moment-to-moment experience, along with
and outcome studies on self-compassion training values-based living, and they are less likely to
are increasing as self-compassion training and prescribe meditation than mindfulness-based cli-
compassion-based therapy becomes widely dis- nicians. Compassion-based therapies, such as
seminated. Self-compassion may be considered a CFT, EFT, and IFS, focus primarily on emotion
psychological construct (e.g., Neff’s three com- regulation through care and connection. However,
ponent model), a trait or state (Neff, 2003; Neff elements of mindfulness, acceptance, and com-
et al., 2020, respectively), a practice (e.g., medi- passion can be found in all therapies contained
tation), or a psychological process (mechanism within this paradigm.
of change). It is possible, for example, to measure Compassion can be directed toward oneself or
self-compassion as an underlying process in ther- others and also received from others. However,
apy without the treatment containing any identifi- these directions are not entirely distinct. For
able self-compassion practices (Galili-Weinstock example, research shows that cultivating self-
et al., 2018; Kelly & Tasca, 2016). However, the compassion often increases other-compassion
construct of self-compassion, especially Neff’s (Neff & Germer, 2013), and increasing other-
three component model, guides our understand- compassion enhances self-compassion (Breines
ing of self-compassion as a trait, state, practice, & Chen, 2013). Although a therapy model like
or process. CFT enhances the flow of compassion in all
directions, the primary focus of compassion-
based therapy is on helping the client to develop
A New Paradigm self-compassion. Nonetheless, compassion is
embedded in all aspects of compassion-based
Within the CBT tradition, a “third wave” of ther- therapy—self-compassion by the client, compas-
apies (after behavioral and cognitive approaches) sion for the client, and compassion by and for the
began emerging in the 1990s that focus on “being therapist.
382 C. Germer
Transdiagnostic ments increased self-compassion and improved

and Transtheoretical Change various outcomes (Kılıç et al., 2020).
Process Self-compassion training programs designed
for the general public have also been effective in
Self-compassion has been proposed as a mecha- reducing various kinds of psychological distress
nism of change in mindfulness- and acceptance- (Finlay-Jones, 2017). MSC reduced anxiety and
based treatment (Baer, 2010). Increasing evidence depression among adults in the community (Neff
shows that self-compassion improves mental & Germer, 2013) as well as depressive symptoms
health in diverse clinical populations, suggesting among diabetes patients (Friis et al., 2016).
that it is a transdiagnostic mechanism of change. Compassion cultivation training (CCT; Goldin &
Empirical evidence also indicates that self- Jazaieri, 2017) decreased worry and emotional
compassion increases in clients in different kinds suppression (Jazaieri et al., 2014), cognitively
of therapy, suggesting that self-compassion is based compassion training (CBCT; Ash et al.,
also a transtheoretical change process. 2019), reduced cancer stress (Gonzalez-
Hernandez et al., 2018), and online Mindfulness
Based Compassionate Living (MBCL; Van den
Transdiagnostic Process Brink & Koster, 2015) lowered self-criticism and
raised self-compassion (Halamová et al., 2020).
There is a growing body of research demonstrat- An online version of Compassionate Mind
ing the potential of compassion-based psycho- Training (CMT), a structured program based on
therapy across a range of clinical disorders, CFT principles and practices, decreased self-
including anxiety (Haj Sadeghi et al., 2018), criticism in a non-clinical sample (Halamová
depression (Kirby, 2017), trauma (Au et al., et al., 2020) and reduced analgesic use among
2017), social anxiety disorder (Gharraee et al., people suffering from chronic pain (Dhokia et al.,
2018), eating disorders (Kelly et al., 2017), 2020).
(Braehler et al., 2013), dementia (Craig et al., In general, trait self-compassion (measured by
2018), addictions (Kelly et al., 2010), and per- the SCS) is associated with mental health in clini-
sonality disorders (Feliu-Soler et al., 2017; Lucre cal and non-clinical populations. High-trait self-
& Corten, 2013). CFT was the main treatment compassion is associated with decreased
model studied and the data are encouraging, psychopathology in adults (MacBeth & Gumley,
although many studies were pilot or feasibility 2012) and adolescents (Marsh et al., 2018), and
studies and more randomized controlled trials are reduced suicidality (Kelliher Rabon et al., 2018;
needed (Craig et al., 2020). Xavier et al., 2016). Self-compassionate people
A number of meta-analyses support self- tend to ruminate less (Fresnics et al., 2019); they
compassion as a transdiagnostic mechanism of recover from negative moods more easily
change. In a meta-analysis of compassion-based (Diedrich et al., 2017) and are less vulnerable to
interventions for a variety of different diagnoses, shame (Ewert et al., 2018; Zhang et al., 2018).
treatment significantly relieved psychological Self-compassion is associated with a more posi-
distress and increased self-compassion, even tive body image and fewer eating disorders
when the studies used active control groups (Braun et al., 2016; Webb et al., 2016). Higher
(Kirby et al., 2017b). A meta-analysis specifi- levels of self-compassion are also associated with
cally for self-compassion-based interventions lessened symptomology among individuals with
found strong effect sizes for eating behavior and schizophrenia (Eicher et al., 2013) and obsessive-
rumination and moderate effect sizes for stress, compulsive disorder (Wetterneck et al., 2013).
anxiety, depression, and self-criticism (Ferrari Self-compassion levels tend to be lower among
et al., 2019). Interestingly, a meta-analysis of people with bipolar disorder (Døssing et al.,
compassion-related therapies for chronic physi- 2015), depression (Krieger et al., 2013), general-
cal health conditions also found that the treat- ized anxiety disorder (Hoge et al., 2013), social
anxiety disorder (Werner et al., 2012), substance Cognitive-behavioral therapy also enhances
use disorder (Phelps et al., 2018), and persecu- self-compassion. For example, Hoffart et al.
tory delusions (Collett et al., 2016). In a system- (2015) looked at within-person change in CBT
atic review of studies on self-compassion and for post-traumatic stress disorder (PTSD) and
trauma, Winders et al. (2020) found that self- found that changes in self-compassion predicted
compassion was consistently associated with PTSD symptoms, while the opposite was not
reduced PTSD symptomatology. In sum, based true. Wadsworth et al. (2018) treated patients
on outcome research with clinical and non- with CBT and DBT and reported that improve-
clinical populations, and on correlational research ments in anxiety and depression were related to
on self-compassion and mental health, self- changes in self-compassion.
compassion appears to be an underlying change Unsurprisingly, within the paradigm of mind-
process that alleviates distress and enhances fulness-, acceptance-, and compassion-based
well-being. therapies, self-compassion is also related to posi-
tive outcomes. Participation in Mindfulness-
based Stress Reduction (MBSR; Kabat-Zinn,
Transtheoretical Process 2013) and MBCT (Birnie et al., 2010; Goodman
et al., 2014; Raab et al., 2015; Taylor et al., 2014)
Although there are currently over a thousand dif- increase self-compassion even though self-
ferent kinds of psychotherapies, they may be compassion is usually taught implicitly in those
broadly categorized into four paradigms: psycho- programs. In mediation analysis—a statistical
dynamic, cognitive-behavioral, humanistic, and method used to determine underlying causal
third-wave therapies. These traditions differ theo- mechanisms between two variables (MacKinnon
retically, yet preliminary research evidence sug- & Lueken, 2008)—self-compassion mediated
gests that they all increase self-compassion, many of the positive effects in MBSR (Keng
which implies that self-compassion is a trans- et al., 2012; Shapiro et al., 2005) and MBCT
theoretical mechanism of action. (Greenberg et al., 2018; Kuyken et al., 2010). Van
Schanche et al. (2011) found that both psycho- Dam et al. (2011) found that self-compassion
dynamic and cognitive therapy for Cluster C per- predicts mental health even more strongly than
sonality disorders (avoidant, dependent, mindfulness in a large community sample,
obsessive-compulsive) increased self-compassion, accounting for ten times more unique variance in
and self-compassion predicted decreases in psy- symptom severity (anxiety, depression) and qual-
chiatric symptoms, interpersonal problems, and ity of life, although mindfulness remains difficult
personality pathology. Galili- Weinstock et al. to measure by self-report scales (Park et al.,
(2018) also treated clients with psychodynamic 2013). Hildebrandt et al. (2017) found that mind-
psychotherapy and found that self-compassion fulness training and affect training with an
levels predicted session-by-session improvement explicit emphasis on self-compassion led to a
as well as overall therapy outcome. greater increase in self-compassion than mindful-
EFT is a type of humanistic psychotherapy ness training alone.
and a program adapted for the general public ACT is an acceptance-based therapy model
(with elements from CFT and MSC) increased that teaches clients to be kind to themselves in
self-compassion and reduced self-criticism various ways without necessarily mentioning
(Halamová & Kanovský, 2019). Neff et al. (2007) self-compassion (Neff & Tirch, 2013). An ACT
conducted a study with the two-chair technique training that specifically targeted self-compassion
from EFT and also found that it increased self- increased self-compassion while reducing psy-
compassion and decreased self-criticism along chological distress and anxiety, and a key process
with fewer experiences of depression, rumina- in ACT, cognitive flexibility, mediated changes in
tion, thought suppression, and anxiety. self-compassion (Yadavaia et al., 2014).
384 C. Germer
Since self-compassion seems to be implicitly corresponding mechanisms of action. The levels

influencing outcomes in therapy, it makes sense are as follows: (1) compassionate presence—
to target self-compassion directly in treatment. In how therapists relate to their experience of them-
a meta-analysis of all three “third wave” thera- selves and the client, mostly non-verbally, (2)
pies—mindfulness-, acceptance- and compassionate alliance—how therapists engage
compassion-based therapy—that supposedly tar- with their clients, verbally and non-verbally, and
geted self-compassion, Wilson et al. (2019) found (3) compassionate interventions—how clients
that these therapies all enhanced self-compassion relate to themselves, especially during home
and reduced anxiety and depression, but change practice. In the research literature, these catego-
scores were not significantly different from those ries correspond to therapeutic presence, thera-
of active control groups. The authors concluded peutic alliance, and therapeutic interventions,
that targeting self-compassion may not make a respectively. The qualifier, “therapeutic,” has
treatment more powerful than an active control been substituted by “compassionate” in this dis-
group. Challenging this conclusion, Kirby and cussion to make the implicit quality of compas-
Gilbert (2019) noted that the studies included in sion more explicit at each level.
the Wilson et al. meta-analysis were actually not
all compassion-based treatments. For example,
Wilson’s meta-analysis included manualized Level 1: Compassionate Presence
MBCT training that contains no explicit self-
compassion training. In their own meta-analysis Presence is about being with our moment-to-
(Kirby et al., 2017a, b), compassion-based inter- moment experience in a clear, open, and direct
ventions reduced psychological distress and way, often without thoughts or words (Brach,
increased self-compassion even when compared 2012; Morgan et al., 2013). The term “presence”
to active control groups. is closely related to “mindfulness” (Bourgault &
Overall, research showing that self-Dionne, 2019; Epstein, 1999). Mindfulness refers
compassion is linked to positive treatment out- to spacious, non-judgmental awareness of what is
comes in different kinds of therapies indicates occurring in the present moment (Germer, 2013;
that self-compassion is a transtheoretical mecha- Kabat-Zinn, 2003). Current evidence shows a
nism of action in psychotherapy. Interestingly, positive relationship between a therapist’s mind-
ordinary, non-clinical activities also increase fulness (usually measured with trait mindfulness
self-compassion, such as practicing yoga (Crews scales) and the therapy alliance (Leonard et al.,
et al., 2016), owning a dog (Bergen-Cico et al., 2018; Razzaque et al., 2015; Ryan et al., 2012),
2018), and spending time in nature (Kotera & but the relationship between therapist mindful-
Fido, 2020). It appears that anything we do for ness and treatment outcome is less reliable
ourselves that promotes a sense of well-being is (Escuriex & Labbé, 2011; Grepmair et al., 2007;
likely to increase our self-compassion. Perich et al., 2013; Stanley et al., 2006).
Mindfulness and self-compassion may be
considered two wings of a bird—we need both to
Three Levels of Integration into stay present. Mindfulness appears to regulate
Psychotherapy emotions primarily through attention regulation
(Bishop et al., 2004; Malinowski, 2013) whereas
Since self-compassion is strongly related to men- self-compassion regulates emotions through care
tal health and appears to increase during success- and connection (Finlay-Jones, 2017; Gilbert,
ful psychotherapy, clinicians are beginning to 2009). Self-compassion is the attitude of mind-
ask, “Can I help my clients become more self- fulness in the midst of suffering. Mindfulness is
compassionate while continuing to practice psy- likely to diminish when we suffer, for example,
chotherapy in my own way?” This is possible by when we experience fear and our perceptual field
considering three levels of integration and their contracts (Bezdek et al., 2015; Zadra & Clore,
2011). Self-compassion—a warm and kind atti- we need to be open and receptive to our own
tude toward the suffering “self”—can support experience, especially the impact our clients are
mindfulness and the practice of mindfulness having on us, mentally, physically, and emotion-
meditation (Evans et al., 2018; Rowe et al., ally. “Am I feeling afraid?” “Inspired?”
2016). Clinicians who wish to enhance their pres- “Annoyed?” If we are capable of holding the “cli-
ence in psychotherapy are therefore encouraged ent within” in compassionate awareness, we are
to have a personal practice of both mindfulness more likely to relate compassionately to the cli-
and self-compassion. Personal practice has been ent sitting in front of us. Research has shown that
emphasized when teaching mindfulness (Shohin self-compassion usually, but not always, enhances
& Van Gordon, 2015) and self-compassion compassion for others (Bayır-Toper et al., 2020;
(Germer & Neff, 2019) and also when practicing Neff & Germer, 2013; Neff et al., 2020).
psychotherapy (Bennett-Levy & Finlay-Jones, Bourgault and Dionne (2019) found that self-
2018; Gale et al., 2017; Kolts et al., 2018). compassion is clearly linked to therapeutic pres-
Research has shown that MBSR, the gold ence. The authors speculate that self-compassion
standard of mindfulness training, raises levels of works by enhancing presence in three ways: with
mindfulness which can lead to functional and oneself by reducing self-criticism and fostering
structural changes in the brain (Gotink et al., self-kindness (Neff & Vonk, 2009), with the cli-
2016; Hölzel et al., 2011a, b; Young et al., 2018). ent by enhancing consideration of others (Neff &
Self-compassion training, such as MSC, also Pommier, 2013), and in the therapy relationship
raises mindfulness (Neff & Germer, 2013) and by increasing awareness of common humanity
mindfulness training increases self-compassion and lowering reactivity to relational difficulties
(Golden et al., 2020; Keng et al., 2012; Kuyken (Leary et al., 2007).
et al., 2010). Self-compassion can also be learned There are many legitimate reasons why a cli-
by participating in compassion-based training. nician might not be present during a therapy ses-
Yela et al. (2020) found, for example, that MSC sion. For example, listening to a client’s traumatic
increased self-compassion in clinical psychology experience might trigger a similar experience in
trainees (but only when the trainees were com- the therapist and hijack the therapist’s attention.
mitted to the training). Furthermore, research Or it might be too distressing to hear what a client
shows that individual meditation practices can is saying so the therapist stops listening. Such
raise self-compassion, such as loving-kindness lapses are not a problem as long as therapists can
meditation (Engel et al., 2019; Weibel et al., find their way back to compassionate presence.
2017) or visualizing a compassionate image Research suggests that loving-kindness and com-
(Allen et al., 2015; Naismith et al., 2018). passion meditation can help to enhance empathy
Mindfulness and self-compassion meditation and restore therapeutic presence (Bibeau et al.,
are usually practiced in isolation, but presence in 2016; Mascaro et al., 2013).
psychotherapy is distinctly interpersonal.
According to Geller (2017), therapeutic presence Working with Empathic
means that the therapist is: Distress Psychotherapy can be a challenging
…first (a) open and receptive to clients’ experi- profession because clinicians listen to painful
ence, attuning to their verbal and nonverbal expres- experiences of others all day long. Since human
sions. You then (b) attune inwardly to your beings are hardwired to feel the emotions of oth-
resonance with clients’ in-the-moment experience, ers as their own (see below), therapists inevitably
which serves as a guide to (c) extend and promote
contact (p. 19). experience empathic distress. How do therapists
cope with empathic distress and still manage to
Openness to the experience of the client comes maintain compassionate presence?
before attuning inwardly because our primary
obligation is to the well-being of the client. Compassion seems to mitigate the negative
However, to be open and receptive to our clients, impact of empathic distress. Tania Singer and
386 C. Germer
colleagues (Klimecki et al., 2014; Singer & 2009). We have specialized neurons dedicated to
Klimecki, 2014) identified non-overlapping neu- this process—mirror neurons (Kilner & Lemon,
ral networks for empathic distress and for com- 2013; Rizzolatti et al., 1996). Mirror neurons are
passion. Empathic distress activated areas activated when we perform an action and when
associated with empathy and negative affect we observe another person performing the same
(anterior insula and the anterior middle cingulate action, thereby allowing us to directly experience
cortex, respectively) and compassion-activated in our own bodies what others are experiencing.
brain areas associated with positive affect and Similar circuits in the brain are also stimulated
affiliation (medial orbitofrontal cortex and the when people observe an emotion in others or
ventral striatum, respectively). In other words, experience the same emotion themselves (Decety
the pain of others is less stressful when it is & Lamm, 2006; Keysers et al., 2010). For exam-
wrapped in compassion. ple, witnessing another person in pain activates
Self-compassion is a way of bringing compas- similar brain structures in the observer (Marsh,
sion back into the therapy room. Research shows 2018; Saarela et al., 2007). This process has been
that self-compassion training protects healthcare variously called “brain-to-brain coupling”
professionals against caregiver fatigue (Neff (Hasson et al., 2012), “neural resonance”
et al., 2020) and that self-compassion buffers (Krautheim et al., 2019), and “interpersonal syn-
caregiver fatigue and burnout among student chrony” (Cacioppo et al., 2014).
counselors (Beaumont et al., 2016). One explana- Interpersonal synchrony is a robust, multidis-
tion is that self-compassion activates a physio- ciplinary field of research which explores how
logical state of safety and deactivates the threat two or more people synchronize their neural, per-
state associated with empathic distress (Svendsen ceptual, affective, physiological, verbal, and
et al., 2020). Increasing self-compassion also behavioral responses (Koole & Tschacher, 2016;
enhances compassion for others (Neff et al., Wheatley et al., 2012). There are many methods
2020). A practical method for activating self- of measuring interpersonal synchrony, including
compassion in therapy is the Giving and brain imaging (Lecchi et al., 2019) heart rate
Receiving Compassion meditation from the MSC (Feldman et al., 2011), breathing (McFarland,
training (Germer & Neff, 2019). When a thera- 2001), pupil size (Kret & De Dreu, 2017), hor-
pist notices she is anxious or distracted, she can mone levels (Edelstein et al., 2017), as well as
bring her attention to the sensation of breathing, vocal pitch (Imel et al., 2014), skin conductance
allowing each inhalation to be for herself and (Palmieri et al., 2018), and body movements
each exhalation for her client. Anecdotal evi- (Gupta et al., 2019; Ramseyer & Tschacher,
dence suggests that paying attention in this way 2011). Sophisticated technologies are used to
during therapy enhances compassionate measure brain synchrony, for example, dual EEG
presence. (Lecchi et al., 2019) and functional near-infrared
spectroscopy (Zhang et al., 2020).
Mechanisms of Compassionate Presence What Koole and Tschacher (2016) argue that inter-
underlying mechanisms could help to explain personal synchrony is important for emotion
how compassionate presence alone, without even regulation. In research with children, interper-
talking, might have a positive impact on a client? sonal synchrony has been shown to enhance a
To explore this question, we turn to the neurobi- child’s ability to downregulate emotional distress
ology of empathy, mirror neurons, and interper- (Feldman, 2015). Parent–child synchrony gener-
sonal synchrony. ates a sense of familiarity in the child, which
enhances the child’s ability to internalize the par-
Human beings are hardwired for empathy—to ent and use the parent’s image to manage distress
feel in our own bodies what others are feeling in even when the parent is absent (Symons &
theirs (Bernhardt & Singer, 2012; Decety, 2011; Johnson, 1997). Interpersonal synchrony also
Nummenmaa et al., 2008; Singer & Lamm, increases compassion, presumably due to
enhanced familiarity (Valdesolo & DeSteno, relationship refers specifically to the bond
2011). between client and therapist and is not identical
In psychotherapy, interpersonal synchrony is to the alliance. However, it is difficult to accom-
likely to function in a similar manner: synchrony plish any tasks or goals, especially challenging
helps a client and therapist to feel emotionally ones, without a strong bond between the client
connected, it facilitates the therapist’s compas- and therapist. Research shows that the therapeu-
sion, encourages the client to internalize the ther- tic alliance is a robust predicter of therapy out-
apist, and promotes emotion regulation in the come across many different kinds of therapy
client. For example, if a therapist maintains com- (Horvath et al., 2011).
passionate presence while a client describes a Overall, research on psychotherapy outcome
traumatic experience, the therapist’s compassion indicates that 75–80% of people who participate
will be felt by the client through emotional attun- in psychotherapy receive some benefit (Lambert
ement, compassion will co-mingle with the trau- & Ogles, 2004). Averaging across thousands of
matic memory, and the memory will be recalled outcome studies, Norcross and Lambert (2019)
slightly differently going forward. Over time, determined that approximately 30% of therapy
exposure to a therapist with compassionate pres- outcomes are attributable to “common factors,”
ence, and with whom the client identifies, and is most notably the therapy relationship and client
likely to change how a client thinks and feels and therapist factors. Treatment techniques only
about herself. Therefore, if therapists want their account for 15% of improvement and the placebo
clients to become more self-compassionate, the effect is another 15% (the largest percentage of
first step is for the therapist to cultivate compas- therapy outcome, 40%, is due to factors outside
sionate presence. therapy such as social support or getting a new
job). Among the factors related to therapy itself,
30% of therapy outcome is attributable to the
Level 2: Compassionate Alliance patient, 15% to the therapy relationship, 10% to
the therapist, and the treatment method accounts
The next level of integration of self-compassion for about 10% of outcome (Norcross & Lambert,
in psychotherapy is the compassionate alliance, 2019). However, the therapeutic alliance and
variously called the therapeutic alliance, thera- treatment methods cannot be clearly delineated.
peutic relationship, working relationship, or ther- For example, Barber et al. (2006) found that
apeutic bond. Whereas compassionate presence when there was a strong therapeutic alliance,
is mostly about how therapists relate non-verbally adherence to a treatment manual did not affect
to their experience of the client and themselves in outcome whereas a weak alliance required a
the therapy relationship, the compassionate alli- moderate level of adherence for the best outcome.
ance involves another layer—verbal interaction. In other words, “treatment methods are relational
Sigmund Freud (1927, in Horvath & Luborsky, acts” (Safran & Muran, 2000).
1993) was the first to recognize that a positive Meta-analyses of psychotherapy outcome
relationship is necessary to do the difficult work highlight the importance of compassion in the
of therapy. Almost 50 years later, Bordin (1975, therapy alliance. Bohart et al. (2002) determined
1994) proposed the therapeutic alliance as a in their meta-analysis that empathy accounts for
common factor in effective therapy. The alliance more outcome variance than treatment interven-
has 3 factors: agreement on the goals of therapy tions. Other researchers found that empathy and
(e.g., alleviation of anxiety or shame), consensus positive regard (e.g., affirmation, respect,
on the tasks that they will engage in to reach warmth, support, validation, prizing) are impor-
those goals (e.g., dialogue, home practice), and a tant aspects of the therapy relationship (Elliott
strong, positive bond between the client and ther- et al., 2019; Farber et al., 2019) and that thera-
apist (e.g., rapport and mutual regard). In this pists who score higher on interpersonal skills like
widely accepted view of the alliance, the therapy empathy and warmth have better treatment
388 C. Germer
o utcomes (Anderson et al., 2009). Lambert and The Compassionate Therapeutic

Ogles (2004) concluded in their meta-analysis Relationship In the following discussion, we
that successful therapists tended to be warmer, focus specifically on the therapeutic relationship,
more empathic, understanding, and supportive of or bond, in the therapeutic alliance. There are
their clients, and are less likely to blame, ignore, three factors (three Rs) that constitute a compas-
neglect, or reject the clients. sionate therapeutic relationship—radical accep-
Unfortunately, although research indicates tance, resonance, and resource-building. Radical
that therapists can learn empathy skills in the acceptance is the overall attitude of the treatment
classroom, those skills do not necessarily gener- process, resonance is the primary mode of
alize to the therapy office (Lambert & Ogles, engagement, and resource-building is the desired
1997). Could compassion training enhance outcome of the therapy relationship. The three Rs
warmth and empathy in psychotherapy? Bibeau are based on the “inquiry” method used in mind-
et al. (2016) reviewed the literature on meditation fulness training (Brandsma, 2017; Wolf & Serpa,
as a means of cultivating empathy among psy- 2015) which was specifically adapted for self-
chotherapists. Three decades of research on compassion training in the MSC program
mindfulness meditation have been encouraging, (Germer & Neff, 2019).
but not conclusive, about whether mindfulness
meditation increases empathy (Boellinghaus R1: Radical Acceptance. Radical acceptance is
et al., 2013; Raab, 2014; Shapiro et al., 1998) or the attitude or intention of a compassionate
treatment effectiveness (Grepmair et al., 2007; therapeutic relationship. Marsha Linehan
Ivanovic et al., 2015; Ryan et al., 2012). In mind- (1993) first coined the term “radical accep-
fulness meditation, the attitude of warmth is tance” as the attitude that therapists need to
mostly implicit, however. Therefore, the question adopt toward their clients with borderline per-
arises whether explicitly training a warm attitude sonality disorder (BPD) in order to keep them
through loving-kindness or compassion medita- engaged and working in therapy. Radical
tion might have a more reliable impact on empa- acceptance is also the attitude that BPD clients
thy in therapy and treatment outcome. are encouraged to adopt toward their own
Boellinghaus et al. (2014) explored this question emotional challenges to reduce their suffering.
and found that mindfulness meditation tended to “Radical acceptance is the fully open experi-
increase self-compassion but not necessarily ence of what is, entering into reality just as it
compassion for others, whereas loving-kindness is, at this moment. …acceptance without the
meditation was more likely to achieve both these haze of what one wants and does not want it to
outcomes. In another literature review, Bibeau be” (Robins et al., 2004, pp. 39–40). Radical
et al. (2016) determined that loving-kindness and acceptance does not mean accepting harmful
compassion meditation have a positive impact on behavior or being complacent in the face of
numerous variables related to empathy, such as injustice; rather, it refers to abandoning the
altruism, positive regard, prosocial behavior, fight against our inner experience as it arises
affective empathy, and empathic accuracy. Later in the present moment.
qualitative research showed that compassion
meditation impacted both therapist empathy and Radical acceptance is a tall order. On a con-
the therapeutic relationship (Bibeau et al., 2020). tinuum on acceptance—curiosity, tolerance,
At the present time, however, we still do not have allowing, and friendship (Germer, 2009,
enough empirical evidence to determine whether pp. 27–28)—radical acceptance refers to friend-
compassion training (for oneself or others) ship with difficult emotions. Radical acceptance
increases empathy or compassion in psychother- goes beyond just tolerating difficult emotions.
apy or improves treatment outcomes. For example, consider how much better it feels
when your anger is embraced rather than just experience, the analyst’s care and love for the
endured, when your vulnerability is welcomed other makes a significant contribution to the
rather than merely tolerated, and when your transformative process” (p. 6). In compassion-
trauma is honored rather than simply acknowl- based psychotherapy, resonance is enabled by
edged. Radical acceptance by clients means the therapist’s own compassionate presence,
doing that for themselves. For therapists, radical but it has the added element of being actively
acceptance is an invitation to hold the client and engaged, usually verbally, with a client.
the client’s pain in a compassionate embrace,
especially when it hurts, without rushing to fix it. Interpersonal synchrony is an interesting way
There is a dialectic between radical accep- of measuring resonance and exploring how it
tance and change (Linehan, 1993). The goal of works in the therapeutic relationship (Altmann
compassion-based therapy is to alleviate suffer- et al., 2020; Koole & Tschacher, 2016). For
ing, but the main question is “how” therapists example, synchrony in vocal pitch between cli-
alleviate suffering—do we resist and avoid what ents and therapists was found to be associated
is happening in the present moment, which usu- with therapist empathy (Imel et al., 2014) and
ally makes suffering persist or amplify, or do we synchrony of body movements predicted the
accept what is happening as a foundation for quality of the alliance as rated by the patient at
change? Radical acceptance takes clients just as the end of therapy (Ramseyer & Tschacher,
they are, without judgment or an obligation to 2011). Recently, Lecchi et al. (2019) found a sig-
change. The central paradox of self-compassion nificant correlation between the perceived
is: “When we suffer, we practice self-compassion strength of the alliance and neural synchrony as
not to feel better but because we feel bad” measured by dual EEG in therapist–client dyads,
(Germer & Neff, 2019, p. 109). The challenge is and Zhang et al. (2018) discovered that the thera-
to temporarily suspend the change agenda and peutic alliance was particularly strong when the
allow kindness to flow naturally in response to right temporo-parietal junction, a part of the
suffering. This is a radical step for most thera- brain associated with mentalizing and under-
pists, and a subtle distinction that can make all standing, was synchronized between counselors
the difference in therapy. and clients.
There appears to be a strong relationship
R2: Resonance. Resonance is the primary mode between interpersonal synchrony and treatment
of engagement in a compassionate therapeutic outcome (Altmann et al., 2020; Galbusera et al.,
relationship. It refers to affective attunement 2018; Ramseyer & Tschacher, 2011, 2014),
between the therapist and client— a sense of including that low therapist–client synchrony is
“feeling felt” (Siegel, 2010, p. 136). Daniel associated with premature termination of treat-
Stern (2018) defined affective attunement as ment (Schoenherr et al., 2019). Clients tend to
“the performance of behaviors that express the feel seen, heard, and understood by their thera-
quality of feeling of a shared affect state with- pists when they are synchronized. However,
out imitating the exact behavioral expression Paulick et al. (2018) found that patients with the
of the inner state” (p. 142). Attunement best therapy outcomes experienced only a
between a parent and child is necessary pre- medium level of interpersonal synchrony during
condition for healthy emotional attachment therapy. This may be because a therapist some-
(Schore, 1994). When attunement was lacking times needs to regulate a client’s emotional
in childhood, it can be learned in psychother- arousal by embodying an emotional state oppo-
apy. The process of attunement in psychoanal- site that of the client, such as calmness in the
ysis is known as intersubjectivity. Buirski midst of fear. There also seems to be a trade-off
et al. (2020) wrote about intersubjectivity: between the enjoyment of interpersonal syn-
“We now appreciate that in addition to attun- chrony and the ability to self-regulate—the more
ing to affect and putting words to affective we rely on others to regulate our emotions, the
390 C. Germer
less we may regulate our own emotions R3: Resource-Building. The third “R” of the ther-
(Galbusera et al., 2019). apeutic bond is resource-building—the
The relationship between interpersonal syn- desired outcome of psychotherapy. In
chrony and the therapeutic alliance is also strong, compassion-based psychotherapy, the desired
but it is less reliable than treatment outcome outcome is enhanced emotion regulation by
(Koole & Tschacher, 2016). For example, Reich cultivating the resource of self-compassion. In
and colleagues (Reich et al., 2014) found that this section, we go beyond resonance and
synchrony of vocal pitch of the patient and thera- engage our clients in explicit conversations
pist negatively correlated with ratings of the ther- about their experience in- and outside of ther-
apy relationship. The authors surmised that apy to help them respond to their difficulties a
matching of pitch, especially if a client is more compassionate manner.
depressed, could amplify the distress of the client
or that it could be interpreted by the client that the Resource-building continues to rely on the
therapist lacked confidence in how to move the inquiry method, especially listening and speak-
session forward. ing from embodied experience. Inquiry is a self-
Currently, there does not appear to be any to-
other dialogue that mirrors the self-to-self
research on self-compassion and interpersonal relationship that mindfulness and compassion
synchrony. However, one study found that a sense teachers wish to cultivate in their students. In
of perceived emotional synchrony during collec- MSC training, inquiry usually follows an experi-
tive dancing explained increases in kindness and ential practice (e.g., meditation, class exercise),
a sense of common humanity on a self-report but in psychotherapy we do not necessarily have
scale of compassion for others (Pizarro et al., a practice to anchor the conversation so we focus
2020). on emotional challenges that the client may expe-
On a practical level, how might a therapist rience during or outside therapy. The therapist
maintain resonance while being actively engaged then asks the client to share precisely what was
with a client? A helpful practice taught in MSC experienced and how the client responded. For
teacher training that is applicable to psychother- example, in the clinical vignette given earlier,
apy is to “follow the pings” (Germer & Neff, after the therapist shared the “ping” of feeling sad
2019). A ping is a moment of salience that a ther- while the client was speaking, and if the client
apist experiences in his or her body, or “what acknowledged he was actually quite sad about
stands out” while the client is talking, usually an fighting with his son, the therapist follow up by
emotion such as fear, sadness, relief, or awe. asking, “And how do you care for yourself when
When it is the therapist’s turn to speak, the thera- you are sad?” or “Right now, what do you think
pist can share her or his embodied experience in you need when you feel sad like this?” or “If you
a validating, clinically relevant manner. For had a friend in the same situation as you, what
example, a therapist can say to a client, “When might you say to your friend, heart-to-heart?” All
you spoke about how angry you were toward these questions direct the client to explore how he
your son, I felt sad because I know how important could respond compassionately to his emotional
it is for you to have a close relationship with your pain, thereby building the resource of self-
son.” Carl Rogers (1951) noted that empathy in compassion. The conversation also opens the
psychotherapy was not simply sharing the emo- door to practicing at home what was discovered
tions of a client, but also “sensing meanings of in session.
which [the client] is scarcely aware” (p. 142). In compassion-based psychotherapy, the
This is a practice of listening and speaking from “pings” are not always moments of pain and self-
embodied experience rather than getting caught compassion is not the only resource that is culti-
up in our thoughts and having intellectual conver- vated. In order for clients to do the hard work of
sations in therapy. engaging with suffering, their strengths also need
to be validated and reinforced, such as courage, therapy have been shown to enhance both the
perseverance, insight, or sense of humor. Positive therapeutic alliance and treatment outcomes
regard in good times and bad is a hallmark of (Samstag & Norlander, 2019).
effective psychotherapy. In a meta-analysis of To explore the impact of therapeutic interven-
positive regard in therapy, Farber et al. (2019) tions on self-compassion levels and treatment
found that positive regard significantly predicted outcome, Galili-Weinstock et al. (2020) com-
treatment success. The authors suggested that pared the use of directive interventions (e.g.,
positive regard strengthens a client’s sense of teaching skills, encouraging behaviors, review-
agency and ability to succeed in therapy. They ing homework) to common factors interventions
advised therapists to “allow yourself to express (e.g., validation and empathic listening) in the
positive feelings to clients” but also to “monitor context of psychodynamic psychotherapy.
your positive regard and adjust it as a function of Positive change in therapy was predicted by
particular patients and specific situations.” directive interventions. Interestingly, clients with
(p. 314). Positive regard needs to be tempered low self-compassion at the outset of therapy
with clinical wisdom, or, as Marsha Linehan showed greater increases in self-compassion
(2009) quipped, “What good is compassion if it after treatment when their therapists used less
doesn’t actually help!” validation and empathic listening. In light of ear-
In sum, the three Rs of radical acceptance, lier research that the alliance is less related to
resonance, and resource-building can serve as a treatment outcome in short-term therapy (Blatt,
guide for creating a compassionate therapeutic 1995), the authors speculate that validation might
relationship. Next, we turn our attention to the be more useful in longer-term therapy. Another
third level of integrating self-compassion into explanation could be that old relational wounds
psychotherapy—compassionate interventions. are more likely to be activated when a therapist is
Skillful application of compassionate interven- empathic and validating (see “backdraft,” below).
tions relies on the previous two levels—compas- In the current discussion, we are referring
sionate presence and the compassionate alliance. only to directive interventions as compassionate
interventions. Less directive interventions, such
as when the therapy relationship itself is the treat-
Level 3: Compassionate Interventions ment intervention, were already discussed in the
context of compassionate presence and the com-
An intervention in psychotherapy is broadly passionate alliance. Compassionate interventions
understood as an action taken to bring about posi- are exercises and practices that clients can prac-
tive change in a client or patient. In the psycho- tice at home between therapy sessions. Directive
dynamic tradition, interventions are typically interventions make sense because psychotherapy
embedded in the therapeutic relationship (e.g., is usually only 1 h per week and practicing self-
attunement or intersubjectivity) while the client compassion at home multiples the amount of
is invited to explore hidden feelings or reflect on time available to cultivate a new mental habit. We
the experience of therapy itself. In CBT, interven- know from research on neuroplasticity that the
tions usually refer to tasks that are designed to practice of meditation can change the structure of
achieve specific goals, such in vivo exposure or the brain (Kang et al., 2013; Lazar et al., 2005;
challenging irrational thinking to alleviate social Valk et al., 2017) and that the quantity and qual-
anxiety. Interestingly, naturalistic research has ity of meditation practice impact the results
shown that clinicians conducting brief psychody- (Goldberg et al., 2020; Hasenkamp & Barsalou,
namic therapy frequently included CBT interven- 2012).
tions in their psychodynamic treatment, a There are still relatively few research studies
phenomenon known as the “smuggling hypothe- that test the efficacy of individual self-compassion
sis” (Ablon & Jones, 1998; Ablon et al., 2006). practices in clinical populations. Most outcome
CBT interventions in psychodynamic psycho- research on self-compassion training evaluates
392 C. Germer
multicomponent self-compassion training (e.g., could explicitly add self-compassion by encour-

MSC, CMT). Individual meditation practices, aging clients to be kind and understanding toward
such as loving-kindness meditation or compas- themselves precisely because our minds have a
sion meditation, are not usually designed to culti- tendency to distort the facts of our lives.
vate self-compassion. There are a few exceptions Interventions should be built on the founda-
in the research literature, such as brief self- tion of therapeutic presence and the therapeutic
compassion meditation training for body image alliance. If self-compassion practices are sug-
distress (Albertson et al., 2015; Toole & gested to a client without a strong therapeutic
Craighead, 2016) and chronic pain (Lutz et al., bond and agreement about the tasks and goals of
2020). therapy, the client is less likely to practice them,
Nonetheless, there are wealth of practices avail- especially when difficulties arise. Non-
able to clinicians that can be customized for indi- compliance with directive interventions does not
vidual clients to cultivate self-compassion. For have to end compassion-based therapy—it is
example, the MSC training program contains simply an invitation to back up and collaborate
seven formal meditations and twenty informal more meaningfully in the process of designing
practices (mindfulness and/or self-compassion) home practices. Some clients entirely refuse to
(Germer & Neff, 2019). CFT provides a range of do home practices, which means that therapists
compassion and self-compassion practices focused need to focus on enhancing self-compassion
on (1) developing an inner compassionate self, (2) through their compassionate presence and a com-
compassion flowing out from oneself to others, (3) passionate alliance until their clients are moti-
compassion flowing into oneself, and (4) giving vated to practice on their own.
compassion for oneself (Gilbert, 2010a, b; Kolts, A helpful challenge for therapists who want to
2016). Workbooks are proliferating that help read- design home practices for their clients is to do so
ers to cultivate self-compassion (e.g., Bluth, 2017; without ever mentioning the term “self-
Irons & Beaumont, 2017; Neff & Germer, 2018). compassion.” This is because striving to become
Learning self-compassion from a workbook alone more self-compassionate can be demoralizing,
has been shown to increase self-compassion levels especially for clients who are low in self-
(Held et al., 2018). compassion. Ideally, interventions should be co-
CBT has traditionally emphasized directive created with clients based on what transpired in
interventions and many CBT exercises can be the therapy session. Rather than “teaching” self-
reconfigured to cultivate self-compassion. For compassion, clinicians can help their clients
example, if a person wants to do exposure ther- notice their emotional pain in the here-and-now,
apy for agoraphobia, intentional self-soothing recognize ways that they are not alone, and
practices can be practiced during the exposure respond with kindness as they might with a good
experience. Similarly, behavioral activation for friend. A client is more likely to follow a treat-
depression, such as scheduling enjoyable activi- ment recommendation when a home practice is a
ties, could be accompanied by a practice to moti- genuine relief, which makes the practice self-
vate oneself to do those activities with kindness reinforcing. It is easy for clinicians to work in
and encouragement rather than self-criticism. this way when they adopt an attitude of radical
Third-wave CBT, such as ACT, can also be acceptance. Rather than striving to fix the client
enhanced with explicit self-compassion (Neff & or remove their pain, the challenge is to meet
Tirch, 2013). For example, ACT focuses on mak- “what is” with kindness and compassion, both in
ing space for cognitive distortions, rather than the therapy relationship and during home
disputing or succumbing to them. Therapists practices.
Self-Compassion for Emotion 2008). Research shows that self-compassion mit-

Regulation igates the effect of trauma among people with
childhood abuse and neglect (Vettese et al., 2011)
Due to the proliferation of therapies, clinical sci- as well as women with severe and repeated inter-
entists have turned to discovering underlying personal trauma (Scoglio et al., 2018). Self-
mechanisms or processes of change to make compassion was also found to mediate the link
sense of what is happening in therapy (Carey between perceived parental maltreatment (abuse
et al., 2020). Emotion regulation is a key mecha- or indifference) and mental health symptom
nism of change in psychotherapy (Gratz et al., severity among adult psychotherapy patients
2015; McRae & Gross, 2020). Emotion regula- (Westphal et al., 2016). In a systematic review of
tion refers to the ability to attend to, appraise, and the literature on self-compassion, trauma, and
modulate the intensity and duration of emotional PTSD, Winders et al. (2020) found consistent
states (Gross & Muñoz, 1995). As described evidence that increased self-compassion was
above, self-compassion also has much in com- associated with reduced PTSD. Self-compassion
mon with other mechanisms of change such as has also been linked to greater post-traumatic
the therapy alliance, empathy, positive regard, growth and healing (Wong & Yeung, 2017).
and interpersonal synchrony. However, self- An argument can be made that each of the
compassion is most closely associated with emo- three components of self-compassion—mindful-
tion regulation in the research literature (Allen & ness, common humanity, and self-kindness—are
Leary, 2010; Finlay-Jones et al., 2015; Neff et al., individually effective for regulating emotion. For
2007). example, mindfulness is well-established as a
The role of self-compassion as an emotion change process in psychotherapy (Alsubaie et al.,
regulation process is particularly evident in the 2017; Hölzel et al., 2011b). Common humanity
clinical arena (Inwood & Ferrari, 2018; Kraiss has rarely been studied as a change process in
et al., 2020; Trompetter et al., 2017). Research psychotherapy, but the opposite of common
shows that self-compassion helps to regulate humanity—a sense of isolation—is known to
emotions associated with depression (Bakker negatively impact mental health (Leigh-Hunt
et al., 2019; Diedrich et al., 2017; Diedrich et al., et al., 2017; Ma et al., 2020; Wang et al., 2017).
2014), anxiety (Bergen-Cico & Cheon, 2014; Research on self-kindness is also scarce, but the
Finlay-Jones, 2017), childhood maltreatment opposite of self-kindness—self-criticism—is
(Vettese et al., 2011), trauma (Barlow et al., 2017; prevalent in most forms of psychological distress
Dahm et al., 2015; Scoglio et al., 2018), sub- (Kannan & Levitt, 2013; McIntyre et al., 2018).
stance use (Wisener & Khoury, 2020), bulimia Therefore, we can conclude that each of the three
nervosa (Hessler-Kaufmann et al., 2020), components of self-compassion probably has a
obsessive-compulsive disorder (Eichholz et al., beneficial effect on mental health.
2020), sexual pain (Vasconcelos et al., 2020), and The impact of the three components on mental
caregiver distress (Finlay-Jones et al., 2015; Neff health can be measured using the SCS (Neff,
et al., 2020). 2003). For example, Van Dam et al. (2011) found
Trauma treatment illustrates the role of self- that the isolation and self-criticism subscales sig-
compassion in emotion regulation. Most people nificantly predicted anxiety symptoms and qual-
who experience trauma do not develop PTSD. ity of life in a sample of people with mixed
How trauma survivors regulate challenging emo- anxiety and depression. This is a legitimate use of
tions statistically predicts PTSD better than the SCS, but some clinical scientists attempt to
trauma exposure itself (Barlow et al., 2017). separate the positive subscales (i.e., mindfulness,
PTSD is maintained by experiential avoidance common humanity, self-kindness) from the nega-
(Marx & Sloan, 2005) and self-compassion helps tive subscales (i.e., overidentification, isolation,
people to acknowledge and accept their feelings self-criticism) into two categories—self-warmth
rather than avoid them (Thompson & Waltz, and self-coldness, respectively (Brophy et al.,
394 C. Germer
2020; Muris & Otgaar, 2020). The developer of PNS is actively regulating emotional arousal
the SCS, Kristin Neff, argues that self-compassion (Holzman & Bridgett, 2017). VmHRV may be
is a dynamic system in which all six subscales considered a measure of self-soothing and safe-
change simultaneously, and there is ample evi- ness, often associated with social cues like calm
dence to support this view (Neff & Tóth-Király, voice or a gentle touch (Porges, 2007). Porges
2020). Dividing the components of proposes that the PNS both downregulates the
self-compassion into two subconstructs may be SNS (fight/flight) and motivates affiliative behav-
interesting but given that self-warmth and self- iors such as proximity seeking or caring
coldness change in tandem it is not clear how rel- responses. If a person is stuck in emotional
evant it is to therapeutic interventions. Also, 95% arousal, such as during anxiety or depression
of the reliable variance in responding to SCS (Chalmers et al., 2014; Kemp et al., 2010), then
scale items is explained by a general factor of arousal is less regulated and vmHRV is reduced.
self-compassion and splitting the scale into two Overall, vmHRV is considered a marker for
positive and negative factors has not been shown emotion regulation (Appelhans & Luecken,
to be psychometrically valid (Neff et al., 2019, 2006) and compassion is positively linked to
2020; Neff & Tóth-Király, 2020). Accordingly, higher vmHRV (Di Bello et al., 2020). Self-
self-compassion is best seen as a global psycho- compassion is also associated to higher vmHRV
logical mindstate. (Svendsen et al., 2020). For example, speaking to
oneself in a soothing, compassionate manner
while looking in a mirror has been found to
Neurophysiological Mechanisms increase mvHRV along with positive affect
(Petrocchi et al., 2017). Self-compassionate peo-
Increases in self-compassion are associated with ple are also more likely to maintain higher
changes in the sympathetic and parasympathetic vmHRV in response to stress (Luo et al., 2018).
branches of the autonomic nervous system. The The CFT model of therapy is anchored in
sympathetic nervous system (SNS) directs the physiology, especially by using compassion to
body’s response to dangerous or stressful situa- regulate three subsystems of the autonomic ner-
tions and the parasympathetic nervous system vous system—threat and protection (adrenalin
(PNS) allows the body to rest and relax following and cortisol); drive and excitement (dopamine);
sympathetic arousal. The SNS increases heart and contentment, soothing, and safeness (oxyto-
rate and the PNS reduces heart rate. People with cin, endorphins) (Gilbert, 2010a, b; Panksepp,
high self-compassion had reduced arousal of the 1998). Most therapies help clients to manage
SNS when confronted by a social stressor, as challenges arising from overactive threat or drive
measured by both salivary alpha-amylase systems (Gilbert, 1993). Compassion shifts our
(Breines et al., 2015) and interleukin 6 (Breines physiology into contentment, soothing, and
et al., 2014). Training in self-compassion also social safeness, which is also the physiology of
lowered salivary alpha-amylase and subjective enhanced vmHRV (Geller & Porges, 2014; Kirby
anxiety responses to stress (Arch et al., 2014). et al., 2017a, b). However, compassion is not
People with high-trait self-compassion have always soothing. For example, compassion may
more PNS activity, as measured by vagally medi- need to be fierce and protective, such as defend-
ated heart rate variability (vmHRV) (Kirschner ing a child against danger or saying “no” to an
et al., 2019; Petrocchi et al., 2017; Rockliff et al., unwelcome advance. In that case, we still need to
2008; Steffen et al., 2020; Svendsen et al., 2016). calm and steady ourselves to behave in a wise
The PNS uses the vagus nerve to regulate heart manner, perhaps like a martial artist (Clapton &
rate, and when there is a lot of variability between Hiskey, 2020), which would engage multiple
heartbeats (i.e., high vmHRV), it is a sign that the motivational systems.
Brain Research the right dlPFC when looking at sad images of

themselves, and they also scored lower on depres-
Recent research offers insight into the neurologi- sion severity. The researchers speculated that
cal processes underlying self-compassion (see self-compassionate adolescents required less
Stevens et al., 2018). Longe et al. (2010) explored cognitive effort to regulate their affect because
brain activation differences between self- they were more accepting and less ruminative
criticism and self-reassurance using functional about negative personal information.
magnetic resonance imaging (fMRI). They found Interestingly, when viewing another person’s sad
that self-criticism was associated with activation face, self-compassionate youth had more activity
in the dorsolateral prefrontal cortex (dlPFC; in brain regions associated with empathy (insula,
active while switching attention and response postcentral gyrus, and inferior parietal lobule).
inhibition) and self-reassurance activated the The combined results of this study suggest that
anterior insula (AI; active during interoceptive depressed youth who are also self-compassionate
awareness). However, Kim et al. (2020) found are less focused on their own distress, more
that self-criticism activated and self-reassurance empathic toward others, and require less effort to
de-activated the dlPFC, suggesting that the two regulate their emotions.
functions operate in tandem in the same brain A groundbreaking study on the neurogenetic
region. mechanisms of self-compassion found that carri-
Parrish et al. (2018) conducted a fMRI study ers of a particular form of the gene OXTR
on self-compassion during a stress test. The ven- (responsible for affiliation and associated with
tromedial prefrontal cortex (vmPFC; active dur- oxytocin) displayed high self-compassion (Wang
ing information processing and decision-making) et al., 2019). The researchers observed that activ-
is commonly thought to downregulate activity in ity in the empathy network of the brain (right
the amygdala (active while feeling emotions, esp. angular gyrus, mPFC, and the anterior cingulate
fear) during threat-related emotion regulation. cortex) and also in the executive control network
The researchers found that greater negative cor- (right dlPFC and inferior parietal cortex) medi-
relation between the vmPFC and the amygdala ated the association of OXTR with self-
was associated with high-trait self-compassion compassion. Similar to the Liu et al. (2022) study,
and positive correlation was associated with these findings suggest that highly self-
low-trait self-compassion. Therefore, this fronto- compassionate people do not require as much
limbic circuitry may be considered a neurological effort to be empathic or to regulate their emo-
mechanism by which self-compassion protects tions. In sum, at least two areas in the prefrontal
against stress and negative emotions. In a brain cortex that are commonly associated with emo-
imaging study (Berry et al., 2020; Lutz et al., 2020) tion regulation—the vmPFC and dlPFC—seem
on the impact of 2 weeks of self-compassion to be associated with self-compassionate
training on chronic back pain, where patients responding, but we still have much to learn about
were exposed to self-critical thoughts while in the how the neurophysiology of self-compassion.
scanner, the dlPFC reacted more strongly to
self-criticism after training, suggesting that par-
ticipants were actively regulating their emotional Psychological Mechanisms
response. Patients with high-trait self-compas-
sion had even higher dlPFC responses, indicating Developing Secure Attachment
that self-compassion training helped them deal
better with self-criticism. The psychological construct most commonly
In an fMRI study exploring how self- associated with self-compassion is secure attach-
compassion protects against depression, Liu et al. ment (Gilbert & Procter, 2006; Homan, 2018;
(2022) found that depressed adolescents with Neff & McGehee, 2010; Shaver et al., 2017).
high-trait self-compassion had lower activity in Insecure attachment is consistently linked to psy-
396 C. Germer
chopathology (Gazzillo, et al., 2020; Mikulincer stressful family relationships are negatively
& Shaver, 2012, 2016; Shorey & Snyder, 2006) related with self-compassion (Neff & McGehee,
and enhancing attachment security (“earned 2010, Pepping et al., 2015) and early memories
secure” attachment: (Levy & Johnson, 2019; of warmth and safeness are positively linked to
Pearson et al., 1994) correlates with improve- self-compassion (Cunha et al., 2014; Homan,
ments in therapy (Kinley & Reyno, 2013; Reiner 2018; Steindl et al., 2018). Self-compassion
et al., 2016). Therefore, an underlying mecha- appears to mediate the relationship between inse-
nism of self-compassion in psychotherapy is cure attachment and emotional distress
likely to be the development of secure (Mackintosh et al., 2018), subjective well-being
attachment. (Wei et al., 2011), and mental health in general
Attachment theory is based on the idea that (Raque-Bogdan et al., 2011). The impact of inse-
children seek proximity with attachment figures, cure attachment can also be intergenerational.
especially parents, in stressful situations (Bowlby, Moreira et al. (2015) found that when mothers
1969, 1973, 1980). A caregiver’s ability to pro- had insecure attachment to their own mothers,
vide comfort and security is internalized by chil- their children reported lower quality of life, but
dren as an attachment style. When caregivers are self-compassion mitigates the negative impact of
sensitive and responsive, the child will develop a a mother’s insecure attachment on their children.
secure attachment style that guides the child’s Can cultivating self-compassion increase
feelings, thoughts, and expectations about self attachment security? At the present time, no stud-
and others. When caregivers fail to reliably com- ies were found showing that self-compassion
fort and soothe the child, the child develops inse- priming in the laboratory or self-compassion
cure attachment, especially anxious, avoidant, or training enhanced secure attachment. However,
disorganized attachment (Ainsworth et al., 1978; Pepping et al. (2015) found that secure attach-
Brennan et al., 1998). Insecure attachment is ment priming (imagining a person with whom
associated with emotion dysregulation (Girme you felt safe) increased self-compassion.
et al., 2020; Mikulincer & Shaver, 2019; Additionally, a type of attachment-based com-
Moutsiana et al., 2014). passion therapy increased secure attachment and
Self-compassion is shaped by a person’s self-compassion mediated that outcome
attachment history. Since children internalize (Navarro-Gil et al., 2020). In spite of the lack of
how they are treated, and if they received comfort direct evidence that self-compassion training
and support from primary caregivers when they increases secure attachment but considering that
were in distress, they will probably do the same self-compassion mediates the link between inse-
for themselves later in life (Neff & McGehee, cure attachment and mental health, we can con-
2010; Ross et al., 2019). From a physiological clude attachment, self-compassion, and emotion
perspective, when a child feels securely attached regulation are important, overlapping themes in
to caregivers, her or his soothing system has a mental health (Finlay-Jones, 2017).
chance to develop, and when a child is insecurely
attached, the threat system will become overly
developed (Gilbert & Procter, 2006). Therefore, Working with Fears of Compassion
the shift from insecure to secure attachment in
compassion-based therapy is a shift from threat- According to attachment theory, if a child was
dominated physiological arousal to safeness and neglected or abused by early attachment figures,
soothing. the child is likely to be dismissive, harsh, or criti-
In correlational research, insecure attachment cal as an adult and also likely to feel unworthy or
is associated with lower levels of self-compassion unacceptable (Gilbert & Procter, 2006; Shaver &
(Joeng et al., 2017; Mackintosh et al., 2018; Mikulincer, 2007). Furthermore, when positive
Raque-Bogdan et al., 2011; Wei et al., 2011). emotions arise in relationship to others, they are
Parental rejection, criticism, overprotection, and likely to trigger painful childhood memories of
rejection or harm. These memories feel threaten- makes them available for reprocessing—it pro-
ing just as the actual experiences were threaten- vides an opportunity to receive the kindness and
ing in the past. When painful memories are understanding that was probably lacking when
triggered by compassion, a person is likely to the painful experiences originally occurred. This
develop is likely to develop “fears of compas- is a delicate process and therapists need to make
sion” (Gilbert et al., 2011; Matos et al., 2017). sure that their clients remain within the “window
Examples of fears of compassion are “If I am of tolerance” (Siegel, 1999), especially when
too compassionate with myself, others will reject backdraft consists of traumatic memories. As the
me,” “Being too compassionate makes people resource of self-compassion develops, however,
soft and easy to take advantage of,” and “I try to clients feel safer within themselves and develop a
keep my distance from others even if I know they “secure base” (Bowlby, 2005) from which to
are kind” (Gilbert et al., 2011). Research shows explore the inner and outer world. In this manner,
that fears of compassion are consistently associ- compassion-based therapy can be understood as
ated with mental health difficulties (Kirby et al., a process of reparenting. Research (cited above)
2019), including anxiety (Merritt & Purdon, showing that self-compassion mediates the link
2020), depression (Hart et al., 2020), body image between insecure attachment and psychological
and disordered eating (Ferreira et al., 2019), alco- well-being supports this understanding.
hol misuse (Forkus et al., 2020), and psychosis
(Martins et al., 2017). Fears of compassion can
be considered patterns of avoidance that prevent Alleviating Shame
painful childhood memories from being restruc-
tured in the relative safety of therapy sessions. The alleviation of shame is another mechanism
Therefore, fears of compassion need to be explic- by which self-compassion appears to work in
itly addressed in therapy. psychotherapy. Shame is a “self-conscious” emo-
Baldwin et al. (2020) provide evidence that tion characterized by negative self-evaluation.
people with insecure attachment may feel threat- Helen Block Lewis (1987) wrote that shame is
ened by compassion. They found that, after a “one’s own vicarious experience of the other’s
compassion-focused imagery exercise, inse- scorn…. the self-in-the-eyes-of-the-other”
curely attached individuals had significantly (p. 15). In a moment of shame, our attention is
lower vmHRV. However, after they were primed either directed externally toward what others are
for secure attachment (“visualize someone who thinking about us, or internally toward our own
makes you feel safe and secure”), a subsequent personal characteristics and behavior, but the
imagery exercise actually increased vmHRV, common denominator of shame is how we imag-
suggesting that the exercise had become comfort- ine ourselves to exist in the minds of others
ing and soothing. In other words, insecurely (Gilbert & Irons, 2009).
attached individuals may need additional support Human beings are social animals and need to
to benefit from self-compassion practices. be accepted and valued by others to feel safe
The distress that arises when people give com- (Baumeister & Leary, 1995). Shame seems to
passion to themselves or receive compassion appear very early in life—an early precursor of
from others is known as “backdraft” (Germer, shame is when an infant drops its eyes and head
2009, pp. 150–152; Germer & Neff, 2019). in response to losing facial communication with a
Backdraft can take the form of thoughts and parent (Tomkins, in Stipek, 1983). The full emo-
beliefs, such as “I’m unlovable;” emotions, such tion of shame arises around the second half of the
as grief or shame; body aches and pains; and second year of life when a child becomes self-
automatic behaviors, such as withdrawal or aware (Lewis, 2016). Patterns of rejection in
aggression. Backdraft is an intrinsic part of the early childhood—being blamed, attacked,
transformation process of compassion-based ignored, or abandoned by a primary caregiver—
therapy. Compassion activates old memories and can make a person shame-prone (Claesson &
398 C. Germer
Sohlberg, 2002). Shame is also closely linked to (Ferreira et al., 2014; Serpell et al., 2020), body
insecure attachment (Matos & Pinto-Gouveia, image problems (Ferreira et al., 2013; Huellemann
2014; Schore, 1998). Shame is likely to arise at & Calogero, 2020), shame proneness (Woods &
any stage of our lives, however, when our rela- Proeve, 2014), and stress related to fertility
tionship security is compromised or our social (Galhardo et al., 2013), HIV (Skelton et al.,
standing is in jeopardy (Gilbert, 2007). 2020), imposter feelings (Wei et al., 2020), sex-
Shame has a long history as a predisposing ual minority stigma (Chan et al., 2020), parenting
factor in psychopathology, associated with a (Sirois et al., 2019), and caregiving (Biddle et al.,
broad spectrum of disorders including depres- 2020).
sion, anxiety, eating disorders, PTSD, and sub- In a particularly interesting study, Zhang et al.
stance abuse (Dearing & Tangney, 2011). Shame (2018) found that self-compassion, but not con-
itself can also be traumatic. Steindl et al. (2018) tingent self-worth, mediated the link between
argue that when a shame memory is central to an shame and depression. Contingent self-worth
individual’s personality, it is more likely to be refers to feeling good about ourselves based on
traumatic. Shame becomes central in our lives the support we receive from external sources (e.g.,
when we relive it in words, images, smells, family, friends) whereas self-compassion
thoughts, behaviors, and emotions. Conversely, enhances self-worth by how we treat ourselves.
trauma can lead to shame when people blame Self-compassion is a more stable source of self-
themselves for their traumatic experiences, per- worth because it is not dependent on others. In the
haps concluding that they are “bad,” “defective,” Zhang study, self-compassion dampened the
or “powerless” (Scoglio et al., 2018). Traumatized impact of shame, and therefore the symptoms of
people may also behave in ways that cause more depression, presumably by enhancing self-worth.
shame, such as engaging substance abuse, aggres- Shame and self-compassion were also
sion, or withdrawal (Briere, 2019). inversely related in therapeutic interventions for
Self-compassion is the opposite of shame. The depression (Johnson et al., 2018), PTSD (Au
three qualities that oppose self-compassion in et al., 2017), narcissistic personality disorder
Neff’s (2003) definition of self-compassion— (Kramer et al., 2018), eating disorders (Kelly
self-criticism, isolation, and overidentification/ et al., 2017), body weight shame (Carter et al.,
rumination—are qualities of shame. Research 2020), social anxiety disorder (Khoramnia et al.,
shows that shame and self-criticism occur in tan- 2020); and stress due to intellectual disability
dem, especially in psychopathology (Gilbert & (Goad & Parker, 2020), and body image
Irons, 2005; Werner et al., 2019). Shame is also (Albertson et al., 2015; Amy et al., 2020).
associated with social isolation (Hartling et al., Shame is becoming a target for psychological
2004; Thoresen et al., 2018) and rumination interventions, especially with the emergence of
(Cândea & Szentágotai-Tătar, 2017; Orth et al., compassion-based treatments such as CFT, EFT,
2006). All three factors can be pathogenic. Self- and IFS. CFT was originally developed by Paul
criticism, in particular, is considered a transdiag- Gilbert to treat depressed people who suffered
nostic risk factor in depression, social anxiety, from high levels of shame and self-criticism
eating disorders, personality disorders, and psy- (Gilbert, 2010a, b). He observed that people who
chotic symptoms (Löw et al., 2020; Werner et al., were shamed in childhood found it difficult to
2019). access feelings of warmth, kindness, and com-
Many studies have shown that self-compassion passion. These clients were also afraid of com-
and shame are inversely associated. In the clini- passionate connections that might heal those old
cal arena, self-compassion was associated with wounds. Therefore, the primary objectives of
lower levels of shame and psychological distress CFT treatment are to address fears of compassion
among people struggling with depression (Sick and to help clients activate compassion for them-
et al., 2020; Steindl et al., 2018), trauma and selves. Preliminary outcome studies on CFT have
depression (Ross et al., 2019), eating disorders shown reductions in shame along with clinical
improvement in eating disorders (Carter et al., ness into parts (Dorahy et al., 2017; Platt et al.,
2020; Kelly et al., 2017), depression (Gilbert & 2017). In IFS, the emotion of shame is a burden
Procter, 2006), social anxiety (Boersma et al., carried by an “exile”—a child part, tucked away
2015), PTSD (Au et al., 2017), perfectionism and stuck in time. Self-criticism is the work of a
(Matos & Steindl, 2020), chronic pain (Håkansson “manager” who is trying to suppress the emotion.
et al., 2015), and personality disorder (Lucre & Unfortunately, self-criticism is likely to cause
Corten, 2013) although well-controlled studies more shame, which then evokes a “firefighter”
are still needed to confirm that CFT reduces who may engage in risky behaviors or be aggres-
shame across diagnoses. sive toward others (Sweezy, 2013). Each part is
Shame is also a focus of treatment in the EFT trying to help us in some way and needs to be
model and is considered a central feature of psy- treated with deep respect and compassion, and
chopathology (Greenberg, 2010; Greenberg & when that happens, the part feels safer and is will-
Iwakabe, 2011). The purpose of EFT is to help ing to let go of its burdens or responsibilities. The
clients regulate their emotions. EFT assumes that physiological basis of change in IFS is similar to
maladaptive emotions such as toxic shame are CFT and EFT, namely, the reduction of threat and
not changed through reasoning or new skills, but the cultivation of inner safety and security.
rather by activating more adaptive emotions such
as anger, grief (Shahar, 2020). EFT for shame
begins by helping clients acknowledge shame, Conclusion
usually by a therapist empathizing with painful
emotions underlying shame, such as betrayal or In summary, self-compassion is a key factor in
humiliation. When the client is ready to address mental health with wide-ranging implications for
shame, a new experience may be created to trans- psychotherapy. Self-compassion has been present
form the painful emotion, for example, by using throughout the history of psychotherapy but is
the two-chair dialogue technique in which clients now emerging as a unique construct and specific
enact two parts of themselves—the self-critic and target of treatment within the mindfulness-,
the object of criticism (Shahar et al., 2012). The acceptance-, and compassion-based psychother-
two-chair technique evokes self-compassion, apy paradigm. Compassion-based therapy is
which is considered in EFT to a transformative mostly oriented toward cultivating self-
emotional experience (Shahar, 2020). compassion in the client. Self-compassion appears
EFT and CFT are both based in attachment to be a transdiagnostic and transtheoretical change
theory. The role of the therapist is to facilitate process underlying most, if not all, forms of ther-
secure attachment by creating corrective emo- apy. Self-compassion can also be integrated into
tional experiences that are internalized by the cli- therapy by cultivating compassionate presence, a
ent over time (Karris & Caldwell, 2015). CFT compassionate therapeutic alliance, or by custom-
therapists are more likely than EFT therapists to izing compassionate interventions for clients.
explicitly teach self-compassion through home Ideally, all three levels are blended together in
practices. Karris and Caldwell (2015) recom- self-compassion-based treatment.
mended blending of EFT with CFT for couples Understanding the mechanisms of change
struggling with trauma and shame. underlying self-compassion in psychotherapy
IFS is another empirically supported, self- can assist in the process of integrating self-
compassion- based therapy that works directly compassion into therapy. For example, self-
with shame. IFS was developed by Richard compassion in therapy has much in common with
Schwartz (Schwartz, 1995; Schwartz & Sweezy, positive regard, empathy, and mindfulness as
2019) and works entirely with parts, or subper- common factors in effective treatment.
sonalities, of ourselves. This approach is particu- Interpersonal synchrony is also linked to self-
larly helpful for treating shame because shame compassion, albeit indirectly through therapeutic
can lead to dissociation and splitting of conscious- presence and the treatment alliance. The mecha-
400 C. Germer
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Compassion Focused Therapy –
What It Is, What It Targets, 23
and the Evidence
James N. Kirby and Nicola Petrocchi
Introduction 2021). In contrast, one approach to cultivating

compassion that began as a therapy and is begin-
There is an increasing recognition within mental ning to be applied more commonly to community
health and psychotherapy of the crucial role that settings is compassion-focused therapy (CFT).
compassion has in helping alleviate suffering and This chapter will (1) discuss the definition of
in promoting well-being (Forster & Kanske, compassion from a CFT perspective, (2) review
2021). There are many different approaches that the origins of CFT and compassionate mind
can help cultivate a compassionate mindset, with training (CMT), (3) discuss social mentality the-
some of the most evaluated being mindful self- ory which underpins both CFT and CMT, (4)
compassion (Neff & Germer, 2013), cognitively describe a case formulation using CFT, and (5)
based compassion training (Pace et al., 2009), describe a new 12 module CFT intervention.
compassion cultivation training (Jazaieri et al.,
2013), and mindfulness-based compassionate
living (Schuling et al., 2021). These programmes Compassion Definition
all aim to explicitly cultivate compassion, are
time-limited, usually spanning between 8 and 12 A defining feature of CFT is the definition of
sessions, and include various experiential exer- compassion, which is “the sensitivity to suffering
cises, imagery exercises, and meditations to help in self and others, with a commitment to alleviate
foster a compassionate mindset. These pro- and prevent it” (Gilbert, 2014, p. 19). As the defi-
grammes were initially developed to help those nition suggests, compassion can be directed to
in the community struggling with stress and self- others, it can be directed towards the self (self-
criticism; however, these programmes are now compassion), and we can also receive compas-
being applied to clinical settings as well, such as sion from others. Interestingly, many
those experiencing depression (Schuling et al., compassionate approaches do not emphasise the
importance of receiving compassion from others
to the same degree, despite research suggesting
J. N. Kirby (*)
Compassionate Mind Research Group, School of that receiving compassion from others is possibly
Psychology, The University of Queensland, more important than self-compassion in buffer-
St Lucia, QLD, Australia ing against depression (Hermanto et al., 2016).
e-mail: [email protected] Compassion is contextual and interactional, and
N. Petrocchi the emotions, reasoning, and behaviours recruited
Department of Economics and Social Sciences, John will be dependent on the nature of the suffering
Cabot University, Rome, Italy

https://doi.org/10.1007/978-3-031-22348-8_23
418 J. N. Kirby and N. Petrocchi
encountered. This definition conceptualises com- their own suffering and learn wise and effective
passion as a motivation, which is rooted in mam- ways to help reduce their suffering.
malian caregiving. This evolutionary approach
argues that compassion evolved from caring
behaviour, as a result of mammalian K-selected The Origins of CFT
reproductive parental investment strategies
(Kirby et al., 2017a, b). K-selected reproductive CFT is an integrated and evolutionary-informed
strategies are those where there is live birth, small biopsychosocial and contextual model of therapy
numbers of young, and heavy parental invest- developed by Paul Gilbert (2020). The origins of
ment post-birth (e.g. elephants, chimpanzees, CFT date back to the late 1980s when Gilbert
humans). Thus, parents are highly attuned to sig- was studying and using evolutionary models of
nals of distress from their young, with attachment psychology with traditional cognitive behaviour
bonds forming, with parents providing important therapy (CBT) to help those with clinical depres-
sources of growth and physiological regulation of sion. A core insight during that period, which led
the infant (Mayseless, 2016). to his book, Depression: From Psychology to
According to this definition, compassion can Gilbert, P. (1984), was that the emotional tone
be conceptualised as an evolved algorithm that (i.e. hostile) and not just the content of the inner
operates on a stimulus detection/stimulus thoughts mattered, and this would relate to inter-
response system (Gilbert, 2020, and see Chap. 4). nal physiology. Specifically, Gilbert theorised
Specifically for the compassion algorithm, the that when challenging your dysfunctional auto-
stimulus detection involves being sensitive to sig- matic thoughts and examining alternative ones,
nals of suffering and distress (e.g. threats, dan- the tone of voice and the feelings associated with
ger), and the stimulus response system enables that experience mattered. The content could be
behaviours which are congruent to the context of identical, but how that content was experienced
suffering that help to alleviate it. Therefore, the in terms of emotion and feeling was critical. If
actions enabled in the stimulus response will the approach to challenging thoughts was critical,
vary – there is no one compassionate behaviour. attacking, or hostile, this would result in a domi-
For example, in contexts of sadness, the compas- nate–subordinate internal relating style, which
sionate response could be comfort, whereas in would maintain the depressive brain state. In con-
the context of anxiety the compassionate response trast, Gilbert hypothesised that if one was to use
could be validation, encouragement, and gradual a more compassionate, friendly, reassuring tone
exposure. In CFT, there are specific skills taught when challenging inner thoughts, this could lead
to help those engage with distress that is often to a different experience, which would have a dif-
avoided (e.g. anxiety). In addition, skills are also ferent physiological pattern in the body, thus
taught to help with stimulus response, which will began the compassion-focused approach to ther-
enable actions that help alleviate the distress, for apy, specifically to help with depression.
example, soothing rhythm breathing or compas- Importantly, there is now research supporting the
sionate imagery. need for such an approach. For example, Whelton
In CFT, a core emphasis is on the qualities of and Greenberg (2005) examined the emotional
courage and wisdom. That is, the therapist tone when engaging in self-criticism. The
emphasises to the client that it takes courage to researchers found that those who were high self-
engage with life difficulties and suffering which critics adopted tones with high levels of contempt
cause pain. Equally, it takes wisdom to engage in and disgust compared to controls. Moreover,
actions to help effectively alleviate the suffering those with high levels of self-criticism were less
in the long term. This definition of compassion is resilient, less assertive, and more submissive than
shared with the client, and it is discussed collab- controls. They concluded that when it comes to
oratively, specifically how the aims of the CFT self-criticism, the emotional tones of contempt
approach will be to help the client to engage with and disgust are critical in the genesis of d epressive
23 Compassion Focused Therapy – What It Is, What It Targets, and the Evidence 419
mind states, which is what Gilbert was attempt- self,” which is used as a mindset to help soothe
ing to shift in the 1980s. and encourage the individual when working with
life difficulties.
CFT is an open-ended therapeutic approach,
Compassion-Focused Therapy based on the evolutionary model of social men-
and Compassionate Mind Training tality theory, which Gilbert describes in Chap. 4
of this book (see also Gilbert, 2020). The aims of
One of the key aspects of the origin of CFT is the CFT are to address the key targets of self-
emphasis on “motivational focus”; that is, the criticism, shame, threat, fear, and trauma that
approach to CFT is to orient the therapeutic underpin so many mental health disorders by
approach in compassion. Using this compassion- using a compassion-focused approach character-
ate mindset, one can then engage in the therapeu- ised by affiliative relating (both to ourselves and
tic tasks necessary to help the specific difficulty others) and behaviours to help alleviate suffering
(e.g. anxiety, depression). As a result, CFT is an and improve quality of life and well-being. In
integrated model, which includes a range of dif- CFT, core therapeutic tasks such as assessments
ferent techniques and processes common among and case formulations, along with the therapeutic
almost all therapies, for example, Socratic dia- bond, guide the therapy process. CFT has been
logues, guided discovery, inference chaining, used for a range of different clinical presenta-
psychoeducation, mindfulness, exposure, behav- tions, including, but not limited to, depression
ioural practice, which are common among many (Falconer et al., 2016; Noorbala et al., 2013;
of the therapy schools (e.g. cognitive-behavioural Savari et al., 2021), obsessive compulsive disor-
therapy, acceptance and commitment therapy, der (Petrocchi et al., 2021), psychosis (Braehler
dialectical behaviour therapy; Gilbert, 2020). et al., 2013), personality disorder (Lucre &
There is a growing recognition by scholars in Corten, 2013), anxiety (Cuppage et al., 2018;
mental health and psychotherapies for the need to Gharraee et al., 2018), posttraumatic stress disor-
move to a more process-based approach to ther- der (Daneshvar et al., 2020; Lawrence & Lee,
apy, focusing on identifying the processes that 2014), eating disorder (Kelly & Carter, 2015;
give rise to better mental health, rather than stay- Steindl et al., 2017), substance use disorder
ing fixed in separate schools of therapy (Gilbert (Carlyle et al., 2019), chronic pain (Dhokia et al.,
& Kirby, 2019; Hoffman & Hayes, 2020). As 2020), problematic sleep (Eslamian et al., 2019),
such, there should be increased convergence and intellectual disability (Clapton et al., 2018).
among the many schools of therapy, as the sci- The evidence in support of this approach is con-
ence indicates which factors are more and less stantly growing, with a recent systematic review
supportive of good mental health. Indeed, in indicating most support for its approach being in
many ways this is already happening, with almost a group format delivery with at least 12 sessions
all therapies including identified therapeutic (Craig et al., 2020). The systematic review also
active ingredients such as exposure, mindfulness, identified that CFT led to reductions in symp-
breathing, imagery, behaviour activation, and the toms among difficult-to-treat clinical popula-
inclusion of homework (Gilbert & Kirby, 2019). tions, such as forensic populations, eating
CFT includes these active ingredients as part of disorders, and personality disorders.
its approach, as the science indicates that they are CFT also has a specific skill-based programme
effective in helping with life challenges (e.g. called compassionate mind training (CMT). The
emotional difficulties, tragedies). However, aim of CMT is the same as CFT to help address
where CFT might be unique relative to other ther- core issues of self-criticism and shame by using a
apeutic models is its definition of compassion as set series of compassion-focused strategies and
a motivation, and its emphasis on an evolutionary exercises. CMT is time-limited and can be deliv-
functional approach to compassion and emo- ered as briefly as using a 15-minute audio-guided
tions, and the development of the “compassionate- exercise (Kim et al., 2020), to a 2-hour brief
s eminar (Matos et al., 2017a, b), to four module kinds of stimuli in the environment and then
sessions (Maratos et al., 2019), and to a longer respond to those stimuli in appropriate ways
eight-session programme (Irons & Heriot- (Gilbert, 2020). For example, in hostile environ-
Maitland, 2021). CMT is aimed for those in the ments “threat detectors” tend to be sensitised,
community dealing with stress and self-criticism, whereas in safe, caring environments, detectors
but not necessarily meeting criteria for a clinical of opportunities for affiliative (play, curiosity,
disorder. Unlike CFT, CMT does not include trust) are sensitised.
individual assessments and case formulations to In CFT, there is a central focus placed on two
guide the therapeutic process. Rather, CMT is a of these motives: competitive and compassionate
manualised programme, which delivers set skills motives. The competitive motive posits that indi-
to the target group that aim to cultivate a compas- viduals monitor social relationships and engage
sionate mindset. In the delivery of CFT, these in social comparisons to determine their relative
specific CMT exercises are used when needed, rank or status (e.g. “am I superior or inferior to
according to the CFT formulation. CMT/CFT are others”), which then can lead to feelings of exter-
highly related, with the key point of difference nal shame (e.g. “others see me as less than or
being that the former is a manualised skill-based inferior”), and this results in submissive or
programme aimed specifically at developing the aggressive behaviours (e.g. hiding, avoidance, or
compassionate-self to support well-being, perfectionistic over-compensation). The key vul-
whereas the latter is an open-ended therapy nerability factor in a competitive motive is when
guided by assessment and formulation, using an individuals are competing to avoid inferiority,
arrangement of active ingredients to help allevi- and thus, rejection or exclusion by others
ate suffering for the specific life challenge pre- becomes central. A recently published meta-
sented in therapy. analysis on competitive motives and social rank
has supported this model in understanding
depression, anxiety, and other clinical disorders
A Brief Overview of Social Mentality (Wetherall et al., 2019).
Theory The other motive is compassion, which is
focused on alleviating distress, and can facilitate
Social mentality theory has been outlined else- self-reassurance and encouragement. Thus, rather
where (Gilbert, 2020) and in another chapter in than activating a rank social mentality (both with
this volume (Gilbert, Chap. 4). Essentially, it is ourselves and others), and subsequently being
an evolutionary model that suggests that individ- self-critical when triggered by threats, one can
ual patterns of cognition, affect, physiology, and consciously activate a compassionate mentality
behaviours are determined by the contextual and be self-reassuring, thus buffering themselves
social roles in which the individual is engaging from the deleterious effects of depression and
(Gilbert, 2020). CFT is based on social mentality anxiety (Petrocchi et al., 2021). This theoretical
theory. We have many social motives (e.g. com- model was recently tested with 1695 participants
petitive, cooperative, sexual, and compassionate) when examining body weight shame, with results
that can lead to different role relationships with finding support for how social mentality theory
others (e.g. parent–child, therapist–client, predicts the associations between social rank,
employer–employee) and ourselves. Gilbert self-relating, and mental health (Carter et al.,
(2020) suggests that each social mentality has its 2021b). The aim of CFT is to shift people from
own feature detector and that environments can relying on competitive social mentalities that fea-
shape how these feature detectors are tuned. ture self-criticism and shame, to that of a com-
Feature detectors enable animals to identify and passionate mind.
pay attention to (take an interest in) different
Three Affect Regulation Systems tems, given it is focused on harm avoidance

(Gilbert, 2014). The drive system refers to seek-
Motives have evolved to perform important life ing out, obtaining resources (e.g. food, status,
tasks, such as avoiding harm, cooperating with sexual opportunities, and friendships), and
others, and finding reproductive partners, all of achieving desired goals (Gilbert, 2009). The
which aid in survival and reproduction (Gilbert, emotions elicited in the drive system include pos-
2020). Importantly, emotions help guide the itive emotions of excitement, pleasure, and hap-
enactment of the motive, providing the energy or piness. Finally, the function of the soothing/
information signals as to whether one is being affiliative system is to slow the organism to allow
successful or if the motive is being impeded. A for important physiological actions such as
defining feature in CFT is its model of affect reg- recovery and rest and digest, and emotions con-
ulation. The model is referred to as the three nected to this system include feeling calm, con-
affect regulation systems of emotion. It is tent, and peaceful. According to Gilbert’s model,
depicted in Fig. 23.1 and is informed by affective the soothing system is linked to the parasympa-
neuroscience research into the evolutionary func- thetic nervous system which activates a slowing
tions of emotion (Depue & Morrone-Strupinsky, down of the autonomic nervous system. It is also
2005; LeDoux, 1998; Panksepp, 2010). linked to the experience of intra- and interper-
These three emotion regulation systems inter- sonal safeness, which, for humans, is not neces-
act and include the following: (a) the threat/self- sarily derived from the absence of threats, but
protect system, (b) the drive/reward system, and more specifically from the presence of “affiliative
(c) the affiliative/soothing system. The function and helping others,” and our own ability to com-
of the threat system is to detect and respond to passionately self-soothe when stressed. Indeed,
threats (physical and social) in order to provide from an evolutionary point of view, it is crucial to
self-protection and to avoid harm and danger. consider the sense of safeness in the context of
This system is responsible for the physiological interpersonal motivations, that is, what makes the
fight/flight response (sympathetic system) when internal and external world safe for humans
faced with threat (Gilbert, 2014). As such, the (Petrocchi & Cheli, 2019). Gilbert (2014) pro-
threat system is the most dominant emotion regu- poses that these three emotion regulation systems
lation system and is prioritised over the other sys- are influenced by motivation. How these systems
Fig. 23.1 The

Driven, excited, vitality Content, safe, connected
interaction between the
three major emotion
regulation systems.
Non-wanting/
From Gilbert, The Incentive/resource- Affiliative-focused
Compassionate Mind focused
(2009), reprinted with
permission from Wanting, pursuing, Safeness-kindness
Constable & Robinson achieving, consuming
Ltd. Soothing
Activating Threat-focused
Protection and
safety-seeking
Activating/inhibiting
Anger, anxiety, disgust

operate is contextual, and in some contexts, it is many reported fearing compassion. Just like any
important to have more dominant threat-drive motivation, fears associated with the expression
system (e.g. responding to a crisis). The key, of compassion may lead to its downregulation
however, is to examine how these systems are (Gilbert et al., 2011; Gilbert & Mascaro, 2017).
operating across all contexts, and the theory pos- Specifically, fears of compassion relate to the
tulates that if one is compassionately motivated avoidance or fear response that individuals can
there is greater balance between these systems. have to all three flows of compassion (for the self,
Conversely, if one is competitively motivated, from others, and to others). These might include
there is an over-reliance on the threat-drive sys- beliefs that compassion is a weakness or self-
tems, which is theorised to be a vulnerability fac-indulgent or that compassionate efforts will be
tor for distress and mental health difficulties seen as incompetent, unhelpful, rejected, or in
(Gilbert, 2009). How these systems are activated some way aversive (Gilbert & Mascaro, 2017). A
can be triggered by external (immediate threat in reluctance to engage in compassion can also stem
front of you) and internal factors (judgements we from the fear that one might suffer too much per-
make). Therefore, a balance of these three affect sonal distress (Vitaliano et al., 2003), or the fear
regulation systems is required to obtain success- that compassion will be perceived by others as a
ful emotion regulation. form of manipulative self-interest (Gilbert &
The aim of CMT/CFT therefore is to cultivate Mascaro, 2017). In the first group evaluation of
the compassionate motive to bring about a greater CMT, Gilbert and Procter found those with high
balance of these three systems, with emerging self-criticism and shame were fearful of compas-
research supporting this approach. For example, sion, believing it would lead them to become
Matos et al. (2017a, b) examined a brief 2-hour overwhelmed or too deeply saddened, or even
CMT seminar using a randomised controlled trial that they were undeserving of compassion.
design with 97 participants and found it led to Moreover, the participants indicated that they did
improvements in positive affect, soothing affect, not like to receive compassion from others, fear-
and reductions in negative affect. In addition, at ing that if they let others in, they would see the
post-intervention, heart rate variability (HRV), a “bad in them”; thus, it was safer to keep people at
physiological index of parasympathetic activa- an “arm’s distance,” so that they could not be hurt
tion, increased compared to a control condition, (Gilbert & Procter, 2006).
indicating CMT leads to improvements in the To understand how fears of compassion can
soothing system, theorised to be connected to the manifest, Gilbert (2020) draws upon evolution-
parasympathetic system, as proposed by Gilbert’s ary models, attachment theory, and classical con-
three emotion regulation system. This was repli- ditioning. Specifically, Gilbert postulated that a
cated in a recent study using a brief 15-minute fear of compassion can develop in those who
CMT exercise, the compassionate-self, where have learned associations between prosocial
Kim et al. (2020) found that this practice actions and aversive outcomes. For example,
improved the parasympathetic system, as mea- children can be punished by parents or other
sured by HRV. “authoritative” figures (e.g. teachers) for being
too generous, kind, and compassionate, as it
might be seen as naïve or inappropriate (Matos
Fears of Compassion et al., 2017a, b). As a result, the punishment (e.g.
being yelled at, anger, criticism), is paired with
Not all individuals respond favourably to compassion, and thus, individuals can become
compassion-focused approaches; in the first ever fearful or avoidant of compassion in the future. In
evaluated group delivery of CMT, Gilbert and addition, if one is raised in an environment where
Procter (2006) found that people with high self- there is little modelling of compassionate behav-
criticism and shame found self-compassion and iour and high levels of shame, this too can lead to
receiving compassion extremely difficult, and fears of expressing compassion (Matos et al.,
2017a, b). Meta-analytic research has since found helpful, and reassuring towards our inner strug-
the importance that fears of compassion have as a gles). The significance of this is that compassion
unique contributor to general mental health and has a vagal component that regulates autonomic
well-being (Kirby et al., 2019). Specifically, physiology, which is postulated to be the key to
Kirby et al. (2019) meta-analysed data from over the successful self-regulation of daily setbacks in
5000 participants and found medium to large everyday life (Di Bello et al., 2020). The role of
effect sizes between both fears of self-compassion the vagus nerve is to help downregulate our phys-
and fears of receiving compassion, and adverse iological responses in times of threat or suffering
outcomes such as shame, self-criticism, depres- (acting as a “vagal brake”), hence the clear links
sion, and anxiety. Moreover, these effects were to compassion (Kirby et al., 2017a, b). This is
significantly greater for those with clinical disor- why scholars have suggested that HRV can be
ders compared to those without. As a result, one considered a key physiological measurement of
of the core tasks in CFT is to explore the client’s compassion (Di Bello et al., 2020).
fears of compassion as part of the therapeutic HRV is a robust predictor of improved mental
journey. Indeed, CFT interventions have been and physical health (Di Bello et al., 2020; Kirby
found to be effective in reducing fears of compas- et al. 2017a, b). A recent meta-analysis found sig-
sion (e.g. Kelly et al., 2017; Savari et al., 2021). nificant moderate effect sizes (g = 0.54) between
higher baseline HRV and compassion (Di Bello
et al., 2020). It is typical within CFT/CMT
Compassion and Physiology research to examine baseline HRV, with evidence
supporting increases to baseline HRV at post-
The evolution of caring and the “hyper-affiliative” intervention (Matos et al., 2017a, b; Kim et al.,
motivations of human beings were paralleled by 2020). HRV, however, is dynamic, and if a person
the evolution of a range of physiological pro- is under threat, it will drop temporarily. A better
cesses, including the interplay of hormones oxy- measure of HRV is “vagal flexibility” also known
tocin and vasopressin, and the development of a as HRV reactivity (Balzarotti et al., 2017). Vagal
branch of the parasympathetic system, the flexibility refers to how the HRV signal responds
myelinated vagus nerve (Porges, 2007). The after a threat disappears. A recent evaluation of a
result of the regulatory activity exerted by the 12-session protocol of CFT found that those with
vagus nerve is the dynamic balancing of the sym- secure attachment styles had greater HRV reac-
pathetic and parasympathetic nervous systems tivity or vagal flexibility than those with insecure
that gives rise to the variability in heart rate attachment styles (Steffen et al., 2021). This was
(Porges, 2007). This in turn enables a calm physi- assessed by measuring the HRV signal during a
ological state that enables social affiliations, car- threat exercise, through self-critical writing, then
ing, and sharing and inhibits sympathetically examining the HRV signal during a recovery
driven threat-defensive behaviours (e.g. fight/ period. The researchers found that participants
flight). In support of this, research has shown that with secure attachment styles were better able to
vagal tone, as measured by HRV, is critically engage with the threat task, as evidenced by a
important for compassion (Stellar et al., 2015). significant decrease in HRV. Moreover, during
Higher HRV (i.e. more variability of the inter- the recovery period, the HRV signal recovered to
beat intervals) is related with greater ability to baseline more quickly for those with secure
regulate stress and arousal (Thayer & Lane, attachment than for those with insecure attach-
2009), which, for humans, mostly stem from per- ment styles.
ceiving social safeness both in their “external Compassion should not be confused with
world” (e.g. in social environments dominated by chronic inflexible state of soothing positive emo-
compassionate dynamics) and “internal world” tions and the “removal or denial” of the suffering,
(when we create internal relationships with our- which acts by simply reducing the threat or anxi-
selves based on the intention to be supportive, ety experienced. Indeed, in order to fully engage
in actions aimed to alleviate (self or others’) dis- options in terms of intervention target points.
tress, the pain should resonate with, and empathic Fig. 23.2 is an example of a shame-based formu-
sensitivity should be experienced first. This lation for an example client, in this instance a
observation has led Di Bello, Ottaviani and parent struggling in their role who is highly self-
Petrocchi (2021) to conduct a study with the critical of their parenting, and fears being judged
intention to shed light on the complex nature of as a bad parent.
the relationship between compassion and HRV. The shame-based formulation links parenting
They measured HRV in students exposed first to to past experiences, to key fears, safety behav-
a video inducing empathic sensitivity (the first iours, unintended consequences, and self-to-self-
component of compassion) and then to another relating. A core aspect of this shame-based case
video eliciting compassionate actions (the second formulation model is differentiating the source of
component of compassion). They found that fear (or threat) or safety as being from an external
HRV decreased after the first video but signifi- or internal source. External sources are the minds
cantly increased after the second video, suggest- of others, that is, “how do others see me or judge
ing that it is simplistic to link compassion with me?”. Internal sources are one’s own views and
higher vmHRV. Indeed, compassion-focused judgements. External sources of shame are more
interventions might often produce increased sen- powerful in impacting depression and anxiety,
sitivity to emotional pain, which is naturally compared to internal sources of shame (Kim
associated with lower HRV. However, such inter- et al., 2011). External sources of shame can be
ventions are also associated with a concomitant internalised, such that our parents (external
increase in willingness to take actions to alleviate source) can judge us as annoying, which we can
one’s suffering, which is ultimately associated then adopt and believe that we are annoying
with increased vmHRV. Thus, CFT adopts a (internal source). It is important to differentiate
nuanced perspective on the complex physiologi- between the sources of shame, threat, and safety
cal regulation that underlies compassionate as being either external or internal, as the inter-
responding to suffering. ventions to address them will differ. In the case of
external threats and shame, assertiveness training
may become important, whereas in the case of
Applying CFT to a Case: The Basics internal shame, developing self-reassuring self-
relating styles may be more critical.
When applying CFT to a case, the target popula- To aid in the development of this formulation,
tion will inform how the intervention itself is the client can be asked to complete measures
delivered. For example, what is offered to parents such as the Early Life Events Scale, which
of children with chronic illness might be different assesses for the emotional memories of child-
to that of teen parents, where there is often a lot hood, including whether you recalled being
of social shame, which will be different again to devalued or frightened (Gilbert et al., 2003). In
an adult client with depression. Thus, it is impor- addition, the Others as Shamer Scale can be used
tant to be guided by the science, that is, what the to assess for external shame (Goss et al., 1994),
research suggests to be most helpful when tailor- with the External and Internal Shame Scale for
ing CFT to that specific population. Given CFT internal shame (Ferreira et al., 2020). The Forms
attempts to engage in motivational shifting from of Self-Criticism and Self-Reassurance Scale
competitive to compassionate motives, a core tar- (Gilbert et al., 2004) can be used to assess differ-
get addressed in the model is self-criticism and ent forms of self-criticism, with two key forms of
shame, as these are central in competitive inadequacy and self-hatred being linked to men-
motives. Therefore, when using a CFT approach, tal health difficulties. Finally, the Fears of
a shame-based formulation may prove to be help- Compassion Scale (Gilbert et al., 2014) can also
ful. The formulation may help the client make be used to determine how the client views differ-
sense of current difficulties and to also provide ent experiences of compassion. Identifying fears
of compassion have been shown to be important CFT Intervention Components

for treatment, with recent research reporting that
fears of compassion can interfere with treatment There can be many different intervention compo-
progress for social anxiety disorder, obsessive nents within a CFT approach. Often specific
compulsive disorder, generalised anxiety disor- CMT exercises are used and applied to the case
der, and depression (Merrit & Purdon, 2020). formulation developed with the client. For exam-
Like other therapy models, there are many ways ple, in relation to the client case formulation
to develop a case formulation, with the shame- depicted in Fig. 23.2, the self-critical parent may
based formulation being one such example in be guided in how to ground in the body and to
CFT. An alternative CFT case formulation could slow down when feeling overwhelmed, and then
be to use the three affect regulation systems how to switch to a compassionate motivation by
model with a client, with interventions aimed to using imagery, such as the compassionate-self or
develop the soothing/affiliative system (e.g. the ideal compassionate other exercises. This can
soothing rhythm breathing), or alternatively help shift the self-relating style from being one
develop the drive system (e.g. behaviour activa- characterised by attacking self-criticism, to a
tion). After assessment and case formulation, relating style that is validating, encouraging, and
interventions can be introduced, and in partner- self-reassuring. To help researchers in their con-
ship with the client, specific exercises and strate- tinued evaluation efforts of CFT, Kirby, Gilbert
gies can be implemented to help shift from and Petrocchi have recently attempted to manual-
competitive to compassionate motives. ise the CFT process in a 12-module intervention.
The manualised protocol can be delivered over
any required number of sessions. For example,
Safety/Defensive
Past Experiences Key Fears Behaviours Unintended
Critical mother, External: External Consequences
bullied Being seen as a bad Always put others External
Distant father, often parent first – be submissive Lack of parental
angry and Failing as a parent Never get angry or support
authoritarian Being rejected by annoyed by kids Can’t be the parent I
Self As others Need to be a strong want to be
Small (e.g., I often Being criticized by parent
my own parents Blame my own Internal
had to give in) Feeling alone,
Unlovable (e.g., I Internal
parents
isolated
rarely felt I Feeling alone Avoid public
Feel weak
mattered) Feeling a failure - a situations with kids
Feel trapped
An embarrassment bad parent Internal
(e.g., I would be Felling unlovable Criticize myself first
yelled at for no clear and vulnerable for my parenting
reasons) mistakes
Others As Don’t ask for help, I
Hurtful can do it by myself
Scary Ruminate
Unavailable
Powerful
Self-to-Self Relating
Style: Blaming, attacking,
criticizing
Left feeling confused,
depressed, fearful, and
overwhelmed
Fig. 23.2 An example of a shame-based CFT formulation for a self-critical parent

you may deliver one module for one two-hour Table 23.1 A 12 module compassion-focused therapy
intervention
session; conversely, you may deliver a module
across two or three one-hour sessions. The num- Module Content
ber of sessions will be influenced by several fac- 1: Introduction Aim: To understand how
to Compassion individuals experience
tors, including the target population, severity of and the tricky compassion, fears they have
symptoms, as well as external pressures such as brain towards compassion and beginning
number of sessions available for access under psychoeducation of the evolved
health system options. The structure of the 12 mind, and how it functions.
Module exercises: Large group
modules is described in Table 23.1, which out- discussions, pair exercises,
lines the aim of each module and a brief overview compassionate imagery, and the
of some of the module exercises. realities of life meditation.
This 12-module protocol was evaluated in a 2: Three types of Aim: To introduce evolutionary
emotion functional analysis of emotion,
recent randomised controlled trial (RCT) exam-
assist individuals to understand the
ining its effectiveness at helping with body nature and function of threat-based
weight shame (Carter et al., 2021a). The CFT emotions (anger, anxiety, and
intervention was delivered in weekly 2-hour disgust), drive-based emotions
happiness and excitement), and
modules. Each module included (a) didactic pre-
soothing-based emotions (safeness
sentation of material by facilitator; (b) guided and contentment) and help
meditation or imagery exercises; (c) pair exer- individuals clarify compassion as
cises; and (d) large group discussions. As out- a motive.
lined in Table 23.1, the first five sessions of the
discussions, pair exercises, and
programme aimed at developing the participants soothing rhythm breathing
“compassionate-self.” Thus, the programme exercise.
started with psychoeducation on defining com- 3: Attention Aim: To introduce individuals to
passion, how the mind works, and the three affect training and the nature and function of
mindfulness attention (how to pay attention to
regulation systems that underpin CFT. The pro- attention), with introductions to
gramme sessions then transitioned to active skills mindfulness-based practices.
training by focusing on body posture, soothing Module exercises: Large group
rhythm breathing, attention and mindfulness, and discussions, pair exercises,
connecting mindfulness skills with
the development of the compassionate-self. The breathing, grounding, and body
remaining seven sessions used the participant’s awareness skills such as use of
compassionate-self to work on difficult emo- body posture, facial expressions,
tions, specifically self-criticism, shame, self- and voice tones
4: Safety/ Aim: To introduce individuals to
compassion, assertiveness, and forgiveness. In
safeness and the concept of safeness (affiliative
each session, there was a guided meditation or Compassion and exploratory focus) and how
visual imagery exercise which was recorded and from others that differs to safety (threat
sent to the participants as part of personal prac- focused). To explore how it feels
to experience compassion from
tice between sessions. Each participant also
others. Discussions on how and
received a workbook with the key content cov- why our relationships are
ered across the 12 sessions. After each session, important to us and support a
the participants received a standardised email range of physiological processes
within us.
summarising the core components of the session,
along with the live audio recording of the in- discussions, pair exercises,
session meditation or imagery exercise. Results breathing exercises, compassionate
from the RCT found that the CFT intervention imagery, and safe place imagery.
compared to a waitlist control group significantly (continued)
reduced shame, self-criticism, as well as signifi-
Table 23.1 (continued) Table 23.1 (continued)

Module Content Module Content
5: The Aim: To introduce individuals to 9: Deepening Aim: To help individuals deepen
compassionate- the nature and concept of, the Compassion for compassion for the self by
self compassionate-self. The self facilitating broader abilities to
compassionate-self includes three opening and tolerating emotional
key qualities: Wisdom, strength, and motivational experiences
and commitment. These qualities Module exercises: Large group
are described and explored. discussion, pair exercises,
Module exercises: Large group experiential exercise (directing
discussions, pair exercises, compassion towards others and
breathing exercises, and self), compassionate letter writing,
cultivating the compassionate-self making compassion-focused
6: Multiple Aim: To introduce group members flashcards, and breathing
selves to the concept of multiple selves, exercises.
with a particular focus on 10: Aim: To help individuals
threat-based emotions, examining Compassionate understand assertiveness and how
specifically angry-self, anxious- assertiveness assertiveness is linked to strength
self, and sad-self. and authority of compassion.
Session exercises: Large group Thus, allowing for individuals to
discussion, pair exercises, express themselves confidently not
exploration and experiential aggressively or passively.
practice of multiple selves and Module exercises: Large group
responses, compassionate imagery, discussion, pair exercises
and breathing exercises. (unhelpfulness of aggressive,
7: Self-criticism Aim: To help individuals passiveness, and passive–
understand the forms and aggressive responses), refection of
functions of self-criticism and how compassionate-self-identity, and
to use the compassionate-self to breathing exercises.
work with disappointments, 11: Forgiveness Aim: To introduce individuals to
setbacks, and rejections. exploring how to engage in the
Module exercises: Large group flow of compassion for others as
discussion, pair exercises, well as forgiveness and how the
experiential exercises (self- suffering of others can influence
monitoring), breathing exercises, us and what we feel in our body
compassionate imagery, and and what we do.
breathing exercises. Module exercises: Large group
8: Shame and Aim: To help individuals discussion, pair exercises,
guilt understand the evolution of the practising of perspective taking
threat, drive, and soothing systems and empathy, and breathing
in social relationships. Exploration exercises
of social rank systems and 12: Envisioning Aim: To revisit the journey the
emotions: Shame (external, a compassionate group has been on and invite
internal), humiliation, and guilt. future individuals to consider prevention
Module exercises: Large group and emergency strategies for
discussion, pair exercises, future difficulties and envision
experiential exercises what a compassionate future
(experiencing shame and how the would involve.
compassionate-self works with Module exercises: Large group
shame), and breathing exercises discussion, pair exercises (how to
(continued) cultivate and strengthen
compassion), acknowledgement of
challenges, self-gratitude letter,
compassionate imagery
(compassionate wishes), and
breathing exercises
cantly improved levels of self-compassion and tions, Craig et al. (2020) found that CFT shows
self-reassurance. promise for a range of mental health problems,
This 12-session protocol was also used in a especially when delivered in a group format over
recent pre-post evaluation of 31 participants who at least 12 h. The authors also found that CFT was
were attending university counselling centre well accepted by clients and clinicians and that a
(Steffen et al., 2021). Steffen et al. (2021) found standard manual and protocol might facilitate
the intervention improved levels of compassion future research, promoting the widespread imple-
and reduced self-criticism and shame. They also mentation into mainstream clinical practice.
examined HRV, and while they found no signifi- Indeed, the 12-module intervention by Kirby et al.
cant pre-post-changes in baseline HRV at the discussed previously will allow researchers to
group level, they did find that those who reliably compare a standardised CFT protocol across sam-
improved in self-compassion (as measured by the ples with appropriate treatment fidelity checks.
Compassion Engagement and Action Scale) also Moreover, it will allow for assessment of the spe-
had a significant increase in HRV from baseline to cific psychophysiological impact of each compo-
post-intervention. Furthermore, they found those nent of the intervention. For example, researchers
with secure attachment styles had greater HRV will be more able to conduct dismantling trials to
reactivity compared to those with insecure attach- monitor changes produced by each module of the
ment styles. Steffen et al. (2021) suggested one protocol, and potentially isolate the “active ingre-
method to help support continued practice of the dients” of CFT, with the intention of delivering an
exercises designed to increase HRV is to include intervention that is powerful and parsimonious at
HRV biofeedback within the sessions. As the study the same time.
did not have a control group, it is recommended There are two major future research endeav-
that future research integrating HRV biofeedback ours for CFT to target over the next 10 years.
include an active comparator condition so that the First, researchers should continue to examine the
effects can be attributed to the CFT protocol. efficacy of CFT using RCTs with clinical popula-
tions and comparing its effectiveness to other
active therapies. Second, attention should be
Future Work given to examining the active processes within
for Compassion Focused Therapy CFT. There are many components within CFT
that are used as part of the therapeutic change
Over the past years, many studies have begun to process. For example, the psychoeducation pro-
explore the effectiveness of CFT and CFT-based cess of the evolved “Tricky Brain” is a core com-
approaches on several mental health outcomes. In ponent that aims to de-shame the difficulties the
his review of the literature, Kirby (2016) identified client is experiencing. However, whether this
at least five randomised controlled trials, yielding component acts as an active ingredient within the
promising preliminary evidence for the effective- therapy process is unknown. When we refer to
ness of CFT, both as group-based intervention or active ingredients within a therapy, we are refer-
as unguided self-help, in clinical and nonclinical ring to those aspects of the intervention that help
samples. However, since that time there have been drive a positive impact, are conceptually well
additional RCTs examining CFT with populations defined, and related to a proposed mechanism of
which have included youth forensic populations action (Sebastian et al., 2021). The question of
(Ribeiro da Silva et al., 2020), those who experi- which components are effective for which popu-
ence body weight shame (Carter et al., 2021a), lations remain an ongoing scientific discovery.
those with chronic pain (Dhokia et al., 2020), There are many studies that have evaluated iso-
those transitioning to motherhood (Kelman et al., lated CFT components such as the compassionate-
2018), those with paranoid ideation (Ascone et al., self (Kim et al., 2020) or the ideal
2017), and those with PTSD (Daneshvar et al., compassionate-other (Rockliff et al., 2013) or a
2020). In a recent systematic review of effective- form of compassionate imagery (Carlyle et al.,
ness and acceptability of CFT in clinical popula- 2019). However, these interventions are exam-
ined by themselves, not as a component within a Carter, A., Gilbert, P., & Kirby, J. N. (2021a).
Compassion-focused therapy for body weight shame:
larger therapy intervention. We hope that the A mixed methods pilot trial. Clinical Psychology and
manualised CFT protocol developed by Kirby Psychotherapy, 28, 93–108. https://doi.org/10.1002/
et al. (2021) will usher in a new wave of cpp.2488
evaluations, allowing for specific examination of Carter, A., Gilbert, P., & Kirby, J. N. (2021b). A sys-
tematic review of compassion-based interventions
components and active ingredients within the for individuals struggling with body weight shame.
therapy process. Psychology & Health, 1–31. https://doi.org/10.1080/
08870446.2021.1955118
Clapton, N. E., Williams, J., Griffith, G. M., & Jones,
R. S. (2018). ‘Finding the person you really are …
Conclusion on the inside’: Compassion focused therapy for adults
with intellectual disabilities. Journal of Intellectual
This chapter has examined the origins of CFT, Disabilities: JOID, 22(2), 135–153. https://doi.
how it aims to target the processes of self-criticism org/10.1177/1744629516688581
Craig, C., Hiskey, S., & Spector, A. (2020). Compassion
and shame that can arise due to having a dominant focused therapy: A systematic review of its effective-
competitive social mentality, which can lead to ness and acceptability in clinical populations. Expert
many different mental health difficulties. The aim Review of Neurotherapeutics, 20(4), 385–400. https://
of CFT is to help cultivate the compassionate doi.org/10.1080/14737175.2020.1746184
Cuppage, J., Baird, K., Gibson, J., Booth, R., & Hevey, D.
social mentality, which enables the individual to (2018). Compassion focused therapy: Exploring the
become an internal source of self- reassurance, effectiveness with a transdiagnostic group and poten-
validation, and encouragement. There have been tial processes of change. British Journal of Clinical
several CFT evaluations using RCTs with many Psychology, 57(2), 240–254. https://doi.org/10.1111/
bjc.12162
different clinical populations. Future work should Daneshvar, S., Shafiei, M., & Basharpoor, S. (2020).
continue to examine the efficacy of CFT for differ- Group-based compassion-focused therapy on experi-
ent clinical populations, along with examining the ential avoidance, meaning-in-life, and sense of coher-
specific active ingredients within the approach that ence in female survivors of intimate partner violence
with PTSD: A randomized controlled trial. Journal of
help bring about positive change. Interpersonal Violence, 37(7–8), NP4187–NP4211.
https://doi.org/10.1177/0886260520958660
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A House with Many Doors –
Toward a More Nuanced 24
Self-Compassion Intervention
Science
Amy Finlay-Jones
Introduction This chapter aims to provide some insight into

the state of the science in the context of these
As demonstrated throughout the chapters in this questions, with a focus on the application of self-
Handbook, there is now a robust body of evi- compassion interventions within transdiagnostic
dence demonstrating the associations between approaches to mental health problems.
self-compassion and adaptive outcomes across a Transdiagnostic frameworks of psychopathology
range of populations and contexts. From a trans- attempt to highlight common factors implicated
lational perspective, the true value of this research in different psychological syndromes that may
is what it means for prevention and intervention serve as efficient intervention targets across a
science; if self-compassion can be effectively range of presenting issues and their comorbidi-
cultivated through intervention, it has the poten- ties (Sauer-Zavala et al., 2016; Fusar-Poli et al.,
tial to deliver a broad range of benefits across the 2019). This chapter first summarizes the observa-
spectrum of health promotion through to clinical tional and experimental literature on self-
intervention. In support of this proposition, the compassion and mental health outcomes,
rapidly burgeoning compassion intervention lit- including depression, anxiety, eating disorders,
erature has demonstrated that self-compassion and posttraumatic stress disorder. The range of
can be effectively cultivated, using a variety of methods that are available to cultivate self-
different techniques. As this literature advances, compassion are then discussed alongside evi-
we are able to start asking more nuanced ques- dence of their effectiveness in clinical populations
tions: Which self-compassion interventions are and in the context of head-to-head trials that have
most effective for which outcomes? What are the sought to determine relative effectiveness of dif-
active ingredients of self-compassion interven- ferent self-compassion interventions.
tions that drive outcome change? Who do such Furthermore, evidence regarding predictors,
interventions work (and not work) for, and under moderators, and mediators of treatment outcome
which circumstances? And finally, what are the is presented with a view to elucidating what is
mechanisms underpinning treatment effects that known about whom self-compassion interven-
can explain why these treatment works? tions work for, under which circumstances, and
how. Putative mechanisms underpinning these
interventions, including self-compassion, emo-
A. Finlay-Jones (*) tion regulation, and negative self-relational pro-
Telethon Kids Institute, Nedlands, WA, Australia cesses, are discussed.

https://doi.org/10.1007/978-3-031-22348-8_24
434 A. Finlay-Jones
Self-Compassion and Risk community (Körner et al., 2015) and clinical

and Resilience to Psychopathology populations, as well as in a range of specific pop-
ulations, including adolescents (Pullmer et al.,
Research examining the associations between 2019), individuals with chronic illness (Hughes
self-compassion and both adaptive and maladap- et al., 2021), and women in the perinatal period
tive mental health outcomes indicates that in gen- (Carona et al., 2022). While largely correlational,
eral, self-compassion is associated with greater these findings are supported by longitudinal
positive mental health and resilience and reduced research, which has demonstrated that self-
risk of psychopathology and associated out- compassion represents a protective factor in the
comes. A substantial proportion of this work has development of depression over time (Krieger
documented cross-sectional relationships et al., 2016; Raes, 2011; Tobin & Dunkley, 2021).
between self-compassion and internalizing Additionally, depressed patients report less self-
pathology, including depression and anxiety compassion than those who have never been
symptoms. However, self-compassion has also depressed (Krieger et al., 2013), while those liv-
been considered longitudinally and in the context ing with depression report that their condition
of early risk factors to explore its protective role undermines their ability to be self-compassionate
in the development of symptoms of psychopa- (Pauley & McPherson, 2010). Together, these
thology over time. Such studies have found that findings indicate that a lack of self-compassion
self-compassion both mediates and moderates may act as both a precipitating and maintaining
the relationship between risk factors for adverse factor in depressive episodes. Moreover, pooled
mental health outcomes and their symptoms. For effect sizes from meta-analyses (d = 0.40–0.66)
example, the relationship between child maltreat- indicate that the effect of self-compassion inter-
ment and adult depression is mediated by self- ventions on depression symptoms is moderate
compassion (Tao et al., 2021), while (Kirby et al., 2017; Ferrari et al., 2019; Wilson
self-compassion appears to weaken the link et al., 2018).
between stress and depression and anxiety over Self-compassion also shares inverse associa-
time (Stutts et al., 2018). Such associations sug- tions with various facets of anxiety disorder
gest that reductions in self-compassion are one symptomology, including social anxiety (Gill
reason that early risk factors might lead to adverse et al., 2018), obsessive-compulsive disorder
outcomes, but also that the practice of self- (Leeuwerik et al., 2019), and generalized anxiety
compassion can buffer against the deleterious (Hoge et al., 2013). Self-compassion also nega-
effects of such risk factors. tively correlates with specific mechanisms impli-
cated in the onset and perpetuation of these
disorders, such as anxiety sensitivity and worry
Self-Compassion and Mood (Hoge et al., 2013; Raes, 2010). These correla-
and Anxiety Disorders tional studies are supported by longitudinal find-
ings demonstrating that self-compassion predicts
An early meta-analysis of 20 studies found that anxiety over time (Ștefan, 2019; Zhu et al., 2019).
self-compassion was inversely related to symp- Further, self-compassion is associated with
toms of depression, anxiety, and stress in adults, important aspects of functioning among people
with a large effect size (MacBeth & Gumley, living with mood and anxiety disorders. For
2012). Similarly, a recent meta-analysis of 19 example, in a help-seeking community sample
studies with adolescents (10–19 years; N = 7049) with mixed anxiety and depression, Van Dam
found a large effect size for the negative relation- et al. (2011) found that self-compassion was
ships between self-compassion and anxiety, associated with unique variance in symptom
depression, and stress (Marsh et al., 2018). severity and quality of life, over and above that
Relationships between self-compassion and accounted for mindfulness. Pooled effect sizes
depressive symptoms have been observed in both from the intervention literature suggest that the
24 A House with Many Doors – Toward a More Nuanced Self-Compassion Intervention Science 435
impact of self-compassion interventions on anxi- stimuli, reexperiencing the traumatic event, and
ety (d = 0.46–0.57) is moderate (Kirby et al., angry outbursts. A systematic review including
2017; Ferrari et al., 2019; Wilson et al., 2018) 35 studies reporting associations between self-
compassion and posttraumatic stress found
largely consistent evidence of an inverse associa-
Self-Compassion and Eating tion between these outcomes in both univariate
Disorders and multivariate models, although the strength of
these associations varied across studies (Winders
Self-compassion is inversely associated with sev- et al., 2020). Self-compassion is also positively
eral dimensions of eating disorder pathology, in associated with posttraumatic growth, a term
both clinical and non-clinical samples. This used to refer to the phenomenon of experiencing
includes disordered eating (Ferreira et al., 2013; personal development following trauma, to the
Webb & Forman, 2013; Adams & Leary, 2007), point that one achieves a higher level of function-
eating-related guilt (Adams & Leary, 2007), ing than before the trauma occurred (Wong &
drive-for-thinness (Ferreira et al., 2013), and Yeung, 2017). Furthermore, a recent meta-
body image concerns (for a review, see Chap. analysis of self-compassion interventions for
11). Self-compassion is also positively associated posttraumatic stress included 12 studies, eight of
with factors that appear protective for eating dis- which were conducted with clinical samples
orders, such as intuitive eating (Schoenefeld & (Luo et al., 2021). Several of these studies were
Webb, 2013) and positive body image (Siegel uncontrolled, and in the overall sample, a medium
et al., 2020). A recent meta-analysis of 59 studies pooled effect of self-compassion interventions on
found medium-large pooled effects for the rela- PTSD symptoms was reported. In a subgroup
tionship between self-compassion and eating analysis of three controlled interventions deliv-
pathology, body image concerns, and positive ered by a therapist, Luo et al. (2021) reported a
body image (r = −0.34, r = −0.45, r = 0.52, large pooled effect on PTSD symptoms.
respectively), while the pooled effects of self-
compassion interventions on eating pathology
and body image were superior to controls, Cultivating Self-Compassion: A House
g = 0.58, g = 0.39 (Turk & Waller, 2020). with Many Doors
Longitudinal studies demonstrating the relation-
ship between self-compassion and onset of eating In addition to the pooled effects on depression
disorder pathology (e.g., Linardon, 2021; and anxiety reported above, prior meta-analyses
Fresnics et al., 2019) further underscore the of self-compassion interventions have reported
potential of self-compassion as a target for eating moderate effect size improvements in self-
disorders prevention. Importantly, self-compassion (d = 0.52–.0.75), mindfulness
compassion explains more variance in eating dis- (d = 0.54–0.62), and well-being (d = 0.51) (Kirby
order pathology than related constructs, such as et al., 2017; Ferrari et al., 2019; Wilson et al.,
mindfulness (Fresnics et al., 2019; Messer et al., 2018). These findings demonstrate the benefit of
2021). such interventions for promoting resilience as
well as for reducing adverse mental health out-
comes. In many ways, self-compassion cultiva-
Self-Compassion and Posttraumatic tion can be considered a house with many doors.
Stress There are multiple ways that the principles, skills,
and benefits of self-compassion can be accessed
Posttraumatic stress disorder (PTSD) is the term and cultivated, including through modeling (for
given to a cluster of persistent symptoms that example, through the therapeutic relationship;
emerge following trauma exposure – including see Chaps. 20 and 22, or via parent–child rela-
hypervigilance, avoidance of trauma-related tionships, see Chap. 16), scalable public health
436 A. Finlay-Jones
efforts (Mak et al., 2019; Sommers-Spijkerman Carter, 2015) therapy for people with eating
et al., 2018), informal self-compassion practices, disorders.
and meditation training on its own (Galante et al.,
2014), or as part of a multi-component program
(e.g., Neff & Germer, 2013). These latter Compassionate Mind Training Compassionate
approaches are described in further detail in this mind training (CMT) includes psychoeducation
section. on the nature of compassion, fears of compas-
sion, Gilbert’s social mentality theory (see Chap.
Mindful Self-Compassion Training Mindful 4), and the different affect regulation systems that
Self-Compassion (MSC) is an 8-week group drive various mood states. Similar to CFT, CMT
intervention that integrates meditation training includes imagery-based and experiential exer-
with interpersonal exercises and informal prac- cises designed to training attention, reduce physi-
tices to support the cultivation and application of ological arousal, and cultivate the “compassionate
self-compassion. MSC was developed for gen- self” (Gilbert, 2009). Quasi-experimental studies
eral populations, and there have been formal of CMT have reported pre- and post-
adaptations of the program for adolescents (Bluth improvements in self-compassion, well-being,
et al., 2015), as well as for healthcare profession- and distress in community samples (Irons &
als (Neff et al., 2020). Informal adaptations of the Heriot-Maitland, 2021), while a recent RCT of
program have also been trialed, including brief CMT among students with major depressive dis-
formats, and online and video-conferencing order reported significant intervention effects for
delivery (Eriksson et al., 2018). Together, find- self-compassion, depression, and some aspects of
ings from experimental and quasi-experimental rumination relative to no-treatment controls
studies have demonstrated sustained intervention (Savari et al., 2021).
effects of MSC and its derivatives on self-
compassion, depression, anxiety, and stress, in
general adult (Neff & Germer, 2013), adolescent Compassion Cultivation Training Compassion
(Bluth et al., 2015), clinical (Torrijos-Zarcero Cultivation Training (CCT) is an 8- to 9-week
et al., 2021), and at-risk populations (Knier et al., structured protocol that comprises weekly group
2020; Neff et al., 2020), as well as across cultures classes and daily compassion-focused meditation
(Finlay-Jones et al., 2017). practice. The protocol integrates psychoeduca-
tion on mindfulness, compassion, and loving-
kindness, and related socio-cognitive processes,
Compassion Focused Therapy Compassion but is distinguished from MSC, CFT, and CMT
Focused therapy (CFT; Gilbert, 2010) was the in the frequency and duration of the mediation
first explicitly compassion-focused program practices included. Further, unlikely other self-
designed for clinical populations. As documented compassion-based programs, most of the time
in Chap. 23, CFT is an individual or group-based spent in CCT focuses on other-focused compas-
approach that involves imagery-based and expe- sion, although this is grounded in an understand-
riential exercises aimed at increasing capacity for ing of the interconnectedness between self and
self-compassion, safeness, and soothing, and other. Accordingly, cultivating compassion for
reducing fears of receiving compassion from self others is seen to benefit the cultivation of self-
or others. A recent review of 29 studies concluded compassion, and vice versa. RCTs of CCT have
that CFT is acceptable and effective for a range been conducted with general community samples
of clinical populations (Craig et al., 2020), (Jazaieri et al., 2012, 2013; Brito-Pons et al.,
including mixed psychiatric samples (Stroud & 2018) and caregivers of people with mental ill-
Griffiths, 2021), patients with psychosis (Braehler ness (Hansen et al., 2021) and have consistently
et al., 2013), and as an adjunctive (Gale et al., reported treatment effects for self-compassion
2014; Kelly et al., 2017) and standalone (Kelly &
alongside several facets of other-focused com- (MBSR) but who are still experiencing residual
passion, well-being, and distress. symptoms of distress (Van den Brink & Koster,
2015). Like other self-compassion-based inter-
ventions, MBCL involves psychoeducation,
Cognitively Based Compassion meditation and experiential practice, and dyadic
Training Cognitively Based Compassion and group exercises, and it follows a similar for-
Training (CBCT) is framed as a secular protocol mat to MBCT or MBSR. Bi-weekly sessions of
that follows an 8-week format, involving 2-h 2.5 h are delivered for 8 weeks, with an additional
group sessions once a week. Sessions involve half-day silent session, and daily meditation
psychoeducation, group discussion, and guided practices of between 45–60 min. Unlike MBCT
meditation practice derived from Tibetan or MBSR, however, these practices focus explic-
Buddhist mind training (lojong) practices. These itly on the cultivation of self-compassion and
practices involve both attention and awareness compassion toward others. MBCL has an emerg-
(mindfulness) practices, as well as “analytical” ing evidence base supporting its acceptability,
practices focused on compassion for self and oth- feasibility (Bartels-Velthuis et al., 2016; Schuling
ers. Quasi-experimental studies have documented et al., 2018), and efficacy (Schuling et al., 2020;
pre- and post-improvements in biomarkers of ter Avest et al., 2021) with clinical populations.
stress responses among adolescents in foster care For example, among 104 patients with recurrent
(Pace et al., 2012). Experimental and quasi- depression, an RCT of MBCL with 100 found
experimental studies have shown that participa- significant treatment effects on depressive symp-
tion in CBCT improves veteran’s PTSD toms, self-compassion, mindfulness, and quality
symptoms in both within-groups and between- of life that were maintained over six months
groups comparisons relative to active control (Schuling et al., 2020).
(Lang et al., 2019, 2020). Relative to waitlist or
treatment-as-usual, clinical trials have demon-
strated the efficacy of CBCT for improving self- Mindfulness-Based Interventions There are
compassion, depression, stress, and avoidance in several mindfulness-based interventions (MBIs),
cancer survivors (Gonzalez-Hernandez et al., including Mindfulness-Based Cognitive Therapy
2018; Dodds et al., 2015), although no group dif- (MBCT) and Mindfulness-Based Stress
ferences were observed for quality of life Reduction (MBSR) in which compassion is
(Gonzalez-Hernandez et al., 2018). Interestingly, implicitly taught as an attitudinal foundation (see
a recent trial of CBCT has also explored program Chap. 2), even if not taught explicitly. The impact
effects on children when their parents undertake of such programs on self-compassion is sup-
training. In small, waitlist-controlled RCT, ported by a recent meta-analysis (k = 26), which
Poehlmann-Tynan et al. (2020) found significant found a medium pooled effect for pre- and post-
decreases in cortisol were observed for children changes in self-compassion in MBIs compared to
of parents in the CBCT group, despite there being control conditions (g = 0.60, 95% CI = 0.41 to
no group differences in parent cortisol or parent- 0.80, p < 0.001) (Golden et al., 2021).
ing interactions (Engbretson et al., 2020). Demonstrating the overlap between self-
compassion and MBIs, another recent review
included MBIs as part of the group of self-
Mindfulness-Based Compassionate compassion interventions for people with serious
Living Mindfulness-Based Compassionate mental illness and found that MBCT was the
Living (MBCL) was developed as a follow-on most frequently researched intervention for peo-
intervention for people who have completed stan- ple with depressive disorders (Kurebayashi &
dardized mindfulness-based interventions such Sugimoto, 2022). In four non-randomized con-
as Mindfulness-Based Cognitive Therapy trolled trials, significant pre- and post-
(MBCT) or Mindfulness-Based Stress Reduction improvements in self-compassion were observed
438 A. Finlay-Jones
in patients with major depressive disorder or between treatment conditions when self-
bipolar disorder undertaking MBCT (Geurts compassion interventions are compared to active
et al., 2020; Schoenberg & Speckens, 2015; controls (Wilson et al., 2018), suggesting that
Williams et al., 2020; Hanssen et al., 2019). self-compassion interventions may not confer
specific benefits relative to other forms of inter-
vention. Despite some noted limitations of this
Toward a More Nuanced Self- review such as the heterogeneity in the interven-
Compassion Intervention Science: tions categorized as “self-compassion interven-
What, for Whom, Under Which tions” (Kirby & Gilbert, 2019), some studies
Circumstances, and Why? published since have aligned with this conclu-
sion. For example, no differences were found
Despite overlaps in goals, principles, and prac- between CFT and meta-cognitive therapy for
tices, self-compassion interventions differ from reducing anxiety in mothers of children with
each other, and from mindfulness-based inter- cerebral palsy (Negin et al., 2021), and Haukaas
ventions in several important ways. These include et al. (2018) found that a brief (3-week) mindful
differences in where attention is focused (present- self-compassion intervention was comparable to
moment versus past/future; intrapersonal versus attention training in reducing symptoms of anxi-
interpersonal), how experiences and affective ety and depression among a non-clinical student
states are related to (open monitoring and accep- sample.
tance of “what is” versus active cultivation or Other head-to-head studies have demonstrated
savoring of specific experiences or affective mixed results, with some showing that self-
states), and the extent to which meditation prac- compassion-based interventions are superior to
tice is considered a necessary element of the proactive controls for some outcomes. For example,
gram. The focus of psychoeducational content in a clinical sample of patients with chronic pain,
can also vary between programs and may be tai- Torrijos-Zarcero et al. (2021) found that MSC
lored to the specific needs of the population treatment effects were superior to cognitive
receiving the program. For example, Finlay- behavioral therapy for self-compassion and that
Jones et al. (2020) worked with a group of young outcomes for pain acceptance, pain interference,
people with chronic conditions to adapt and tailor catastrophizing, and anxiety also favored the
self-compassion exercises specifically for that MSC group. Studies have also reported head-to-
population. head trials of self-compassion and mindfulness-
based programs, providing some insight into
specific effects of self-compassion practice. For
The What: Differential Outcomes example, one study found that MBSR and CCT
Across Treatment Conditions had comparable effects for improving psycho-
logical well-being and mindfulness; however,
While the experimental literature emphasizes the effects on self-compassion, empathic concern,
promise of self-compassion interventions, key and common humanity were greater in the CCT
questions that need to be addressed are (a) self- group (Brito-Pons et al., 2018). Similarly, in a
compassion interventions superior to other types study comparing CBCT and a support group for
of interventions for improving a specific out- people who had attempted suicide, effects on
come? (b) of the available self-compassion inter- depression, suicidal ideation, and mindfulness
ventions, are some more effective for improving were comparable; however, only the CBCT group
specific outcomes than others? and (c) what are report improvements in self-compassion (LoParo
the “core components” of self-compassion inter- et al., 2018). Moreover, differential changes in
ventions that are most closely linked with inter- proposed treatment mechanisms have been dem-
vention effects? Exploring the first question, one onstrated in head-to-head studies (Roca et al.,
meta-analysis found no difference in outcomes 2021; LoParo et al., 2018; Hildebrandt et al.,
2017); together, these findings highlight the like- to conclude whether the conditions effectively
lihood of both common and practice-specific targeted these outcomes. Further, as the compo-
treatment effects. Other studies have underscored nents of self-compassion are thought to operate
the importance of examining engagement metrics synergistically, there may be risks associated
in addition to effectiveness outcomes when try- with focusing on one component at the expense
ing to determine which interventions are likely to of others. A more pertinent question remains:
be most efficient under real-world conditions. What are the active ingredients needed to opti-
For example, one study comparing MSC, MBSR, mize self-compassion interventions?
and a waitlist control among psychology trainees
reported no differences between the active condi-
tions in terms of effects on mindfulness, self- or Whom and Under Which
F
compassion, and anxiety and found that while Circumstances? Predictors
MBSR was superior for reducing depression, and Moderators of Treatment Effects
adherence rates were higher in MSC (Jiménez-
Gómez et al., 2022). Insights from the mindfulness literature have
While the question of “which intervention, for highlighted the importance of considering not
which outcomes?” remains pertinent, there is just “what” is taught, but also “how” and “in what
also a shift away from distinct therapy “pack- context” teaching occurs. For example, in a
ages” and toward elucidating core components or mixed-methods study, Canby et al. (2021) found
active ingredients germane to effective that participant’s ratings of instructor characteris-
approaches. Insights into core components of tics (such as empathy) predicted changes in
effective self-compassion interventions can be depression and stress, while their ratings of group
provided by dismantling trials that compare, for processes (including hope, safety, social learn-
example, self-compassion interventions that are ing, and interpersonal dynamics) predicted
purely psychoeducational versus those that also changes in stress and mindfulness. Furthermore,
involve a meditation training component. Within they found that while degree of formal medita-
the mindfulness literature, such studies have suc- tion predicted changes in anxiety and stress,
cessfully identified differential mechanisms and informal mindfulness practice did not predict
outcomes specific to particular meditation prac- outcomes. Qualitative data further supported the
tices (Britton et al., 2018), as well as common finding that bonding, feelings of hope, and safe
factors such as participant ratings of instructor emotional expression were integral to partici-
and group (Canby et al., 2021). While disman- pants’ change processes. These findings empha-
tling studies are yet to be conducted in the self- size that our understanding of active ingredients
compassion intervention literature, emerging cannot be reduced to a set of content or practice-
research has considered whether component driven mechanisms but must also include rela-
interventions focused on individual dimensions tional processes. This, in turn, has important
of Neff’s (2003) self-compassion construct (i.e., implications for facilitator training, as well as for
mindfulness, common humanity, self-kindness) the development of interventions where rela-
have differential effects. In a four-group random- tional processes must be explicitly designed and
ized experimental design with adults with Major integrated ahead of time (e.g., self-guided online
Depression Disorder, Ceclan and Nechita (2021) interventions) rather than emerge as part of an
found no differences between groups in pre- and interpersonal dynamic.
post-changes in depression and shame-proneness At present, the impact of therapist and group
and found that outcome improvements were also variables on outcome in self-compassion training
observed in the no-treatment control group. A is unknown. However, there is some evidence
limitation of this study was that the target con- regarding the contextual circumstances that influ-
structs (mindfulness, common humanity, self- ence self-compassion intervention outcome,
kindness) were not measured, making it difficult including intervention dose, setting, and delivery.
440 A. Finlay-Jones
In a moderator analysis of the treatment effects for participants with higher levels of reactivity at
reported in their meta-analysis of self-compassion baseline.
interventions for reducing self-criticism, Wakelin
et al. (2021) found that treatment effects were
greater when self-compassion interventions were The How: Mechanisms of Change
longer. Similarly, in Luo et al.’s (2021) meta-
analysis, longer self-compassion interventions Understanding the theoretical mechanisms that
were associated with better treatment effects for putatively underlie treatment effects supports the
posttraumatic stress. Intervention delivery and capacity to refine interventions and optimize
setting were not significant moderators (Wakelin their impact (Kazdin, 2007). Furthermore, recent
et al., 2021). qualitative work has demonstrated that under-
Studies have also examined participant char- standing “how” self-compassion interventions
acteristics as predictors and moderators of treat- work can influence participation engagement.
ment outcome, providing some insight into the For example, in a qualitative study with youth,
question of “for whom” these interventions are Egan et al. (2022) found that youth were more
most effective. For example, prior work has willing to engage in self-compassion interven-
found no moderating effect of sociodemographic tions because they reduce self-criticism than
characteristics (Sommers-Spijkerman et al., because they increase self-kindness. In this sec-
2018; Goldin & Jazaieri, 2017), or exposure to tion, the theoretical basis and empirical evidence
positive or negative life events (Sommers- for three “clusters” of potential mediators that
Spijkerman et al., 2018) on treatment outcome. have been proposed to underpin the relationship
Findings concerning participants’ psychological between self-compassion interventions and
profiles are mixed. For example, in a meta- improved mental health outcomes: namely,
analysis of self-compassion training for posttrau- increases in self-compassion, improvements in
matic stress, baseline self-compassion was not emotion regulation, and reductions in negative
associated with treatment outcomes for posttrau- self-relational processes such as self-criticism,
matic stress (Luo et al., 2021). Similarly, perfectionism, and shame-proneness. As the
Sommers-Spijkerman et al. (2018) found that focus of this chapter is weighted more toward the
baseline or post-treatment psychological well- relevance of self-compassion for clinical popula-
being did not impact treatment outcomes of CFT, tions, additional mechanisms (such as increased
while Finlay-Jones et al. (2017) found that per- resilience, positive affect, and self-efficacy) that
fectionism did not moderate MSC outcomes. are more relevant to well-being outcomes are not
However, in a trial of CCT, Goldin and Jazaieri discussed. It should be noted, however, that the
(2017) found that people with more emotion reg- literature surrounding such mechanisms is rela-
ulation difficulties, lower mindfulness, and tively underdeveloped. A key goal for future
greater perceived stress at baseline reported research is thus to unpack the different pathways
greater improvements in fears of compassion for by which self-compassion might lead to positive
self, although these variables did not moderate well-being outcomes in both clinical and non-
treatment effects on other outcomes, including clinical populations.
self-compassion and other fears of compassion.
Interestingly, one study found that while MBCT Self-Compassion Tests of mediation effects in
only increased mindfulness for people with high self-compassion intervention studies generally
levels of baseline rumination, CFT enhanced this support the proposition that these programs
outcome regardless of baseline scores improve psychological outcomes by increasing
(Frostadottir & Dorjee, 2019). Furthermore, self-compassion, reducing fears of self-
among African American people who had compassion, and making people more open to
attempted suicide, Sun et al. (2019) found that receiving compassion from others (Matos et al.,
CBCT was more effective that a support group 2022). One exception is a recent meta-analysis of
self-compassion interventions for posttraumatic influence emotion generation and regulation: (1)
stress, which found that while self-compassion selecting which situations to engage in, and
interventions had a small effect on self- which to avoid; (2) attempting to modify a situa-
compassion in clinical populations, there was no tion once engaged; (3) deciding where to deploy,
effect in non-clinical samples (Luo et al., 2021). or focus, one’s attention; (4) changing the way
Nevertheless, changes in self-compassion appear one interprets or appraises the situation; and (5)
to have meaningful implications for clinical out- modulating one’s responses to the situation. In
comes. For example, Geurts et al. (2020) reported addition to influencing normative emotional
that greater pre- and post-changes in self- experiences and responses, each of these stages
compassion during MBCT were associated with has implications for emotion dysregulation and,
greater improvements in depression, while in in turn, for psychopathology. For example, visual
Schuling et al.’s (2020) RCT, changes in self- biases toward threat (a process related to the third
compassion preceded improvements in negative stage that involves increased automatic attention
affect, indicating that self-compassion likely to potentially threatening stimuli, such as angry
plays a mechanistic role in alleviating depressive faces) are thought to play a causal role in anxiety
symptoms (ter Avest et al., 2021). disorders (Van Bockstaele et al., 2014), while
maladaptive cognitive appraisals (stage four) and
deployment of unhelpful emotion regulation
Emotion Regulation Emotion regulation refers strategies (stage five) are associated with a range
to the processes that influence the nature, inten- of psychopathological outcomes (Mennin et al.,
sity, and duration of an individual’s emotional 2007; Mehu & Scherer, 2015).
experiences (Gross, 2015a, b). In turn, these pro- Self-compassion appears to influence affective
cesses can influence the physiological and behav- styles, both in terms of how individuals experi-
ioral consequences of emotional experiences. ence, process, and respond to their emotions on
From a clinical perspective, the emotion dysregu- both the cognitive-affective (Finlay-Jones, 2017)
lation model of mood and anxiety disorders sug- and physiological levels (Guan et al., 2021). Prior
gests that the ways in which individuals work has supported an emotion regulation model
experience and respond to different emotional of self-compassion (Finlay-Jones et al., 2015), in
states play a key role in precipitating and main- which the relationship between self-compassion
taining psychopathology (Hofmann et al., 2012). and depression or distress is mediated by a lower
Similarly, according to the affect regulation propensity toward self-reported emotion regula-
model of eating disorders, binge eating and purg- tion difficulties (Carona et al., 2022; Finlay-Jones,
ing can develop as a form of maladaptive emo- 2017; Bakker et al., 2019; Inwood & Ferrari, 2018;
tion regulation designed to manage negative Eichholz et al., 2020). These include difficulties
cognitive-affective experiences (Stice et al., with emotional awareness, clarity, and acceptance,
1996, 1998; Cardi et al., 2015), while non- as well as problems deploying adaptive emotion
suicidal self-injury is also a maladaptive means regulation strategies and challenges maintaining
of emotion regulation (see Chaps. 6 and 21). impulse control and goal regulation in the face of
Given that emotion dysregulation is a transdiag- difficult emotions (Finlay-Jones, 2017). An impor-
nostic predictor of psychopathology, understand- tant finding from studies with clinical samples is
ing the association between self-compassion and that emotion regulation difficulties mediate the
emotion regulation provides insight into how relationship between self-compassion and symp-
self-compassion might act as a transdiagnostic toms of anxiety (Eichholz et al., 2020) and depres-
resilience mechanism, as well as generate under- sion (Bakker et al., 2019). These findings provide
standing regarding the utility of self-compassion useful guidance for mechanistic testing in inter-
in clinical populations. vention studies, particularly those with a clinical
application.
According to Gross’ (1998, 2015b) process As with the broader emotion regulation litera-
model, there are five interconnected stages that ture (Sheppes et al., 2015), a limitation of exist-
442 A. Finlay-Jones
ing studies is that most have focused on the fifth ences behavior at each of these points, as well as
stage, that is, the implementation of specific reg- the original stages highlighted in the process
ulatory strategies that are associated with adverse model, can provide insights into some of the
outcomes. These have either examined emotion mechanisms potentially underlying the relation-
regulation difficulties using composite measures, ship between self-compassion and psychopathol-
or the use of specific emotion regulation strate- ogy. Testing these proposed pathways using
gies, such as rumination or avoidance, as media- experience-sampling methods with clinical and
tors between self-compassion and a range of non-clinical populations would help to provide a
different mental health outcomes. Additionally, more complete understanding of how self-
because these studies tend to use self-report trait- compassion contributes to emotion regulation,
based measures at a single time point, there is and whether these pathways vary according to
less clarity around the specific ways in which type or severity of clinical presentation. Potential
self-compassion might influence the experience ways in which self-compassion may support
of emotions at different aspects of the emotion adaptive emotion regulation at each of the stages
generation and regulation process. Accordingly, outlined in the extended process model are out-
there is a need for further exploration of how self- lined in Fig. 24.2 and discussed further below.
compassion supports the upregulation of positive
affect and downregulation of negative affect at Identifying the Need to Regulate Emotions As
other stages of the process model. Figure 24.1 outlined by Sheppes et al. (2015), difficulties at the
provides some examples of potential ways in identification stage – including the overrepresenta-
which self-compassion might contribute to more tion and underrepresentation of emotional states -
adaptive emotion regulation at each of these are implicated in a range of mental health problems.
stages. By definition, self-compassion involves mindful
Furthermore, in an extension to the process awareness of emotions, and evidence indicates that
model, Sheppes et al. (2015) highlighted four individuals with higher self- compassion report
specific points at which difficulties in emotion greater emotional awareness and clarity regarding
regulation can be linked to psychopathology: (i) their emotional states. This is reflected in studies
identifying the need to regulate emotions, (ii) documenting associations between self-compas-
selecting from available regulatory strategies, sion and cognitive awareness of affective states, as
(iii) implementation of regulatory strategies, and well as studies that have shown that individuals
(iv) monitoring implemented strategies over with higher self-compassion have greater intero-
time. Understanding how self-compassion influ- ceptive awareness (Barker, 2019).
Fig. 24.1 Examples of ways in which self-compassion might contribute to upregulation of positive affect and down-
regulation of negative affect at each of the stages articulated in Gross’ process model
Fig. 24.2 Examples of ways in which self-compassion might contribute to more adaptive emotion regulation at each
stage of Gross’ extended process model
Interestingly, the implication of this appears to erance for stressful events before explicit
be that individuals with higher self-compassion regulatory attempts are activated. Further, it
are more sensitive to shifts in mood and therefore appears that self-compassion is associated with
may be more likely to report drops in mood fol- spontaneous recovery from negative moods
lowing a negative affective stimulus (Beshai (Beshai et al., 2018), indicating that some of the
et al., 2018). However, the relationship between benefits of self-compassion for emotion regula-
self-compassion and the identified need to regu- tion (and by extension, mental health) may not
late emotions is likely more complex. occur as the result of motivated behavior.
First, not all emotions need to be regulated, Such findings are supported by functional mag-
and attempts to regulate emotions are generally netic resonance imaging work indicating that indi-
enacted when one’s emotional state conflicts with viduals with higher self-compassion require less
one’s desired state or goals (see, e.g., Tamir et al., cognitive effort to regulate their emotions in
2020). As self-compassion is thought to facilitate response to negative affective stimuli (Liu et al.,
a more equanimous response to difficult emo- 2022). Additionally, several studies have found
tions, including increased distress tolerance, it that self-compassion is associated with reduced
may therefore allow for a much wider range of dorso-lateral prefrontal cortex (DLPFC) activity
emotional states to be accepted without explicit (Berry et al., 2020; Liu et al., 2022; Williams et al.,
regulatory attempts. Prior work examining the 2020) and volume (Guan et al., 2021), under both
relationship between self-compassion and experimental and non-experimental conditions.
depressive symptoms in people with unipolar The DLPFC is an area of the brain associated with
depression found that those with higher self- executive function and emotion regulation, and
compassion had greater capacity to tolerate nega- while greater volume in this area has traditionally
tive emotions and, in turn, reported lower been associated with better functioning, Guan
depressive symptoms (Diedrich et al., 2017). et al.’s (2021) findings challenge this assumption.
Other research has indicated that individuals with In addition to finding that self-compassion was
higher self-compassion are less likely to appraise associated with lower DPFC volume, Guan et al.
stressful events as threatening (Chishima et al., (2021) also found that self-criticism was associ-
2018), suggesting that those with higher self- ated with increased volume in this area. They thus
compassion might have a greater window of tol- concluded that higher self-criticism and lower
444 A. Finlay-Jones
self-compassion predispose people to more fre- tion tending to focus on distinguishing broadly
quent activation of cognitive emotion regulation. “adaptive” (i.e., associated with more helpful
This may reflect (a) attempts to regulate negative outcomes) from “maladaptive” (i.e., associated
affect elicited by self-criticism itself; (b) attempts with unhelpful outcomes) strategies. Aligned
to regulate negative affect elicited by external with this perspective, work on self-compassion
events that are more likely to be appraised as and specific emotion regulation strategies has
threatening; or (c) a propensity toward more fre- highlighted that in general, people with higher
quent cognitive emotion regulation that co-occurs levels of self-compassion are less likely to report
with self-criticism but is not driven by it. to use of maladaptive strategies such as rumina-
On the other hand, it is plausible that, given that tion and worry (Raes, 2010), and more likely to
self-compassion reflects a kind and nurturing form engage adaptive strategies such as acceptance
of self-relation, individuals with higher self-com- (Bakker et al., 2019). However, more recent
passion may be more motivated to regulate diffi- advances in the emotion regulation literature
cult emotions where they are appraised as have emphasized that the function of different
overwhelming. Additionally, it is possible that the emotion regulation strategies varies according to
motivations underpinning emotion regulation context and that individual strategies are not nec-
attempts are qualitatively different for those with essarily adaptive or maladaptive (Troy et al.,
higher versus lower self-compassion. For exam- 2013). Accordingly, what is most adaptive may
ple, people with high self-compassion may be be access to a range of potential emotion regula-
more likely to regulate their emotions out of a tion strategies, regulatory flexibility, and the
desire for self-nurturance and goal regulation, capacity to fit the appropriate strategy to the situ-
rather than being driven by aversion or avoidance ation and context (Haines et al., 2016; Bonanno
of difficult emotions. Insights into how self- & Burton, 2013).
compassion relates to this facet of emotion regula-
tion are limited; however, one study found that in Studies are yet to directly test whether self-
the context of behavioral activation (an emotion compassion supports the capacity to flexibly select
regulation strategy that is effective for reducing and match emotion regulation strategies to one’s
depressive symptoms), individuals with higher context; however, there are several findings that
self-compassion were more likely to engage in suggest this might be the case. For example, posi-
values-based behavior (Takagaki et al., 2021). tive associations between trait self-compassion and
Additionally, there is some suggestion that indi- vagally mediated heart rate variability suggest that
viduals with greater self-compassion are more individuals with higher self-compassion also have
likely to have adaptive beliefs about emotion greater emotional flexibility (Svendsen et al., 2016,
(Sydenham et al., 2017) although more explora- 2020). This is reinforced by findings that self-com-
tion of how such beliefs influence emotion regula- passion is associated with more self-reported psy-
tion motivation is required. Further research, using chological flexibility in community (Marshall &
experience-sampling methods (English & Brockman, 2016) and clinical (Davey et al., 2020)
Eldesouky, 2020), may provide useful insights populations. To advance our understanding of the
into the relationship between self-compassion and self-compassion-emotion regulation nexus, future
the motivation to regulate emotions once specific research should identify whether self-compassion is
affective thresholds have been reached. Another also associated with access to a greater range of
opportunity for future research is to determine emotion regulation strategies, particularly among
whether self-compassion intervention influences individuals with mental health problems, who typi-
the thresholds at which individuals identify the cally report restricted emotion regulation reper-
need to regulate their emotions. toires. Additionally, there is a need to examine
whether cultivating self-compassion supports the
Selecting from Available Regulatory capacity to flexibly select appropriate emotion regu-
Strategies Early taxonomies of emotion regula- lation strategies across different contexts.
Implementation of Regulatory monitoring decisions tend to align with their

Strategies Selection and implementation of established regulatory preferences (Ilan et al.,
emotion regulation strategies can play a role in 2019), which has important implications for psy-
psychopathology where maladaptive strategies chopathology risk. Specifically, it has been pro-
are positively valued, such as the role of worry in posed that limited regulatory flexibility – including
anxiety disorders, or where people struggle to insensitivity to context, limited availability of
activate adaptive strategies (such as behavioral different regulatory strategies, and low respon-
activation in depression). As noted above, several siveness to feedback, plays a key role in precipi-
authors have suggested that increased implemen- tating and maintaining psychopathology
tation of adaptive emotion regulation strategies (Bonanno & Burton, 2013; Sheppes et al., 2015).
and decreased use of maladaptive emotion regu- It may be expected that people with greater self-
lation strategies is likely a prominent mechanism compassion are both more aware of their context
driving treatment effects for self-compassion and able to use this information to inform regula-
interventions (Diedrich et al., 2017; Finlay-Jones, tory decisions, have a greater range of emotion
2017). Additionally, findings from one study of regulation strategies at their disposal, and are
individuals with major depressive disorder indi- more able to switch regulatory tactics following
cate that priming participants with self- feedback. Some support for this proposition is
compassion prior to engaging cognitive provided by studies linking self-compassion to
reappraisal enhanced the efficacy of emotion psychological flexibility and adaptive goal disen-
regulation following a sad mood induction gagement and reengagement processes (Beshai
(Diedrich et al., 2016). To date, intervention stud- et al., 2018; Davey et al., 2020; Miyagawa et al.,
ies testing implementation of emotion regulation 2021; Svendsen et al., 2016). However, there is a
strategies as a mediator of intervention effects are need for further study using experience-sampling
relatively few. One study found that reductions in methods to assess variety and change in strategy
experiential avoidance, alongside increases in use across contexts.
self-compassion, mediated the link between
meditation and mental health (Yela et al., 2020).
In contrast, however, one study found that Negative Self-Relational Processes: Self-
changes in emotion regulation and emotional Criticism, Perfectionism, and Shame-
suppression did not mediate treatment effects of Proneness Another proposed reason for the
CCT on depression and stress in caregivers of transdiagnostic utility of self-compassion in clin-
people with mental illness (Hansen et al., 2021). ical contexts is its relationship with negative self-
directed cognitive and affective processes such as
self-criticism, perfectionism, and
Monitoring Implemented Strategies Over shame- proneness (Gilbert & Procter, 2006).
Time Understanding the effect of implemented These constructs are unique but highly intercon-
strategies and knowing when to alter or disconnected transdiagnostic processes in psychopa-
tinue them is a crucial aspect of risk and resil- thology because of their associations with the
ience to psychopathology. The ability to notice onset and maintenance of a range of different
when a deployed emotion regulation strategy is mental health problems (Schanche, 2013; Egan
ineffective and try an alternative strategy is cru- et al., 2011). For example, shame-proneness is
cial for more efficient emotion regulation. It is associated with a range of psychopathological
also closely linked to the other stages of the outcomes, including depression (Kim et al.,
extended process model (i.e., being aware of the 2011), anxiety (Swee et al., 2021; Szentágotai-
need to regulate emotions, having a range of Tătar et al., 2020), eating disorders (Nechita
strategies to choose from, making wise choices et al., 2021), and personality disorders (Rüsch
about those strategies, and deploying them effec- et al., 2007). Self-compassion is often framed as
tively). Research has found that individual’s an “antidote” to self-criticism, perfectionism, and
446 A. Finlay-Jones
shame, and available research has tested models levels of social anxiety (Cȃndea & Szentágotai-
in which self-compassion mediates the relation- Tătar, 2018), while another found that a brief
ship between these processes and adverse mental self-compassion writing intervention led to
health outcomes (Fletcher et al., 2019), as well as reductions in state shame, shame-proneness, and
models in which the relationship between self- depressive symptoms in a student sample, when
compassion and mental health is mediated by compared to an expressive writing control condi-
these processes. Given the likely bidirectionality tion (Johnson & O’Brien, 2013). Further, among
of the relationship between self-compassion and patients with eating disorders, Kelly et al. (2014)
self-criticism, perfectionism, and shame, longitu- found that increases in self-compassion early in
dinal studies are needed to parse these relation- treatment predicted decreases in shame, which in
ships further. turn predicted faster increases in eating disorder
symptoms. Similarly, Kelly and Tasca (2016)
Other research has suggested that self- reported cyclical relationships between shame
compassion can attenuate the adverse impacts of and eating disorder symptoms such that eating
negative self-relational processes on mental pathology increased following periods of ele-
health outcomes. Self-compassion has been vated shame, while shame decreased following a
found to attenuate the links between self-criticism period of fewer eating disorder symptoms.
(Kaurin et al., 2018), perfectionism (Ferrari et al., Moreover, they found that self-compassion
2018), and early shame experiences (Farr et al., appeared to interrupt this cycle, such that shame
2021), such that individuals with these risk fac- was lower after a period of increased self-
tors are less likely to experience distress and compassion (Kelly & Tasca, 2016).
depression the more self-compassionate they are.
These processes also overlap with emotion regu-
lation mechanisms described above. For exam- Future Directions
ple, Farr et al. (2021) found that the relationship
between early shame and distress was mediated In addition to the opportunities for extending the
by experiential avoidance, such that those with self-compassion intervention science described
early shame experiences were more likely to above, there are several general recommenda-
avoid potentially difficult experiences, and expe- tions that can be made to improve the state of the
rience greater distress as a result. However, self- science and optimize its impact. These include
compassion moderated this relationship such that increasing methodological rigor and generaliz-
those with higher levels of self-compassion were ability, considering scalability through econom-
less likely to experience distress, regardless of ics and implementation science, testing
their level of experiential avoidance. theoretical models and mechanisms, and
Findings from the intervention literature also exploring predictors and moderators of treatment
support the role of negative self-relational pro- effects.
cesses in mediating the treatment effects of self-
compassion training. For example, a
meta-analysis of 19 RCTs in both clinical and Increasing Methodological Rigor
non-clinical populations found that compared to and Generalizability
control participants, individuals in self-
compassion- based interventions report signifi- Across prior reviews and meta-analyses, authors
cant improvements in self-criticism, with a have noted that the capacity to reliably estimate
medium effect size (Wakelin et al., 2021). One the impact of self-compassion studies is limited
study found that a brief self-compassion training by the heterogeneity across studies and the num-
was associated with both pre- and post-reductions ber of studies that are only moderate quality (e.g.,
in shame-proneness and social anxiety in a pri- Wakelin et al., 2021). With several sites around
marily female undergraduate sample with high the world now actively researching intervention
science, it is now time for more collaborative work. Accordingly, little is known about how
efforts to generate multi-site trials, align outcome self-compassion interventions work or how they
measures, standardize trial reporting (including should be refined to optimize outcomes. It is
measurement and reporting of variables believed plausible that several theoretical frameworks are
to influence treatment outcome, such as therapeu- necessary to explain the diverse impacts of self-
tic alliance and group process variables), and compassion interventions; however, the develop-
ensure that compassion interventions are tested ment of testable frameworks that include some of
against active conditions with sufficient sample the mechanisms reviewed in this chapter (includ-
sizes. Additionally, a consistent limitation of the ing self-compassion, emotion regulation, and
self-compassion intervention literature is its negative self-relational processes) is a warranted
overrepresentation of Western, educated, indus- direction for future research.
trialized, rich, and democratic (WEIRD) popula-
tions. While this is not unique to the
self-compassion literature, it immensely limits Understanding Predictors
the generalizability, accessibility, and equity of and Moderators of Treatment Effects
the available evidence base.
Given that fear of self-compassion is particularly
elevated in clinical populations, including those
Considering Scalability Through with anxiety disorders (Merritt & Purdon, 2020)
Economics and Implementation and personality disorders (Ebert et al., 2018),
Science determining the effect of baseline fear of com-
passion on treatment outcome is an important
One of the undersold benefits of self-compassion extension of work to date. Understanding which
interventions is that they generally do not require variables influence treatment outcome and why
qualified mental health practitioners to deliver they influence treatment can help to guide deci-
them and they are relatively inexpensive to imple- sions about sequential staging of interventions
ment., Further, many of the established manual- (for example, offering mindfulness-based inter-
ized interventions are supported by robust, vention prior to self-compassion training), as
train-the-trainer teaching models, and thriving well as help guide the therapeutic process (for
communities of practice. This has important example, gradually “titrating” self-compassion
implications for scalability and fidelity of imple- into therapy).
mentation. Future work should therefore focus on
measuring and testing important facets of pro-
gram implementation (such as differences in Conclusion
training models and facilitator experience) as
well as establishing evidence for the cost- Self-compassion is a malleable, transdiagnostic
effectiveness of self-compassion interventions risk, and resilience variable that has the potential
for improving health outcomes. to promote more adaptive functioning across
clinical and non-clinical groups. As the literature
reviewed in this chapter demonstrates, self-
Testing Theoretical Models compassion intervention science is generating
and Mechanisms compelling evidence documenting the benefits of
self-compassion-based interventions in both clin-
While recent work by Ash et al. (2019) has pro- ical and non-clinical populations. Synthesis of
vided a useful, testable model mapping CBCT this literature highlights promising directions for
components to proposed mechanisms and out- expanding the science and translating this evi-
comes, in general, self-compassion intervention dence into more effective, targeted, and scalable
science is absent a coherent theoretical frame- intervention approaches. Specifically, this
448 A. Finlay-Jones
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J., & Gilbert, P. (2013). Exploring change processes in
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and how. org/10.1111/bjc.12009
Brito-Pons, G., Campos, D., & Cebolla, A. (2018).
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Index
A Compassion, xi, xii, xv–xviii, xx, xxi, xxiii, xxiv, 1, 2,

Adaptation, xii, xv, xvi, 99, 101, 113, 117, 137, 148, 167, 5–7, 9–11, 20–22, 25, 28, 33, 34, 37, 39, 41,
168, 173, 174, 233, 264, 335, 348, 353, 436 43, 47, 48, 53–66, 71, 74, 75, 77–80, 82, 83,
Adolescence, xix, 34, 38, 46, 54, 75, 76, 79–80, 89–102, 89, 93, 97, 100, 118, 129, 131, 133–135, 137,
110, 144, 150, 156, 218, 251, 257, 276, 295, 149, 152–154, 167–169, 174, 184, 191, 194,
333, 400 196, 214, 215, 231, 232, 234–238, 240–243,
Alpha-Amylase, 292, 316, 394 251–253, 255–257, 264–269, 271, 273–276,
Athletes, xix, xxiv, xxvi, 12, 146, 189, 194, 195, 201, 280, 294, 298, 299, 301–303, 332, 334, 347,
202, 213–222, 224–226, 296, 315, 317 350–356, 358–362, 373, 380–382, 384–388,
Attachment, xxii, xxiv, xxix, 37, 62–65, 71–84, 92, 150, 390–392, 394, 396–399, 417–420, 422–428,
190, 195, 196, 251, 255, 257, 264, 265, 269, 433, 436, 437, 440, 447
270, 275–281, 298, 332, 336, 347–350, Compassionate mind training (CMT), 56, 65, 221, 301,
352–356, 362, 379, 381, 389, 395–400, 418, 303, 304, 382, 392, 417, 419–420, 422, 423,
422, 423, 428 425, 436
Compassion-based interventions, 42, 172, 174, 237, 354,
382, 384
B Cortisol, 118, 292, 293, 295–297, 300–302, 304,
Body appreciation, xxviii, 8, 12, 43, 184–187, 189, 311–313, 315, 316, 334, 353, 394, 437
192–196, 216, 337, 338 Compassion focused therapy (CFT), xx, xxiii, xxv, 42,
Body dissatisfaction, 43, 44, 95, 183–194 55, 56, 59, 64, 75, 263, 302, 303, 351, 379,
Body image, xxi, xxii, xxviii, 42–44, 81, 84, 95, 173, 381–383, 392, 394, 398, 399, 417–429, 436,
174, 183–188, 190–197, 216, 217, 221, 337, 438, 440
338, 382, 392, 397, 398, 435 Cross-cultural, 130, 131, 133, 135–138
Burnout, 25, 154, 207, 213, 216, 231–238, 240, 242, 243, Culture, 7, 10–12, 25, 28, 74, 101, 114, 116, 129–138,
254, 256, 257, 266, 315, 351, 386 144, 145, 172, 187, 191, 196, 214, 222–225,
233, 240, 241, 256, 257, 436
C
Cancer, xv, xvi, xviii, xxv, 61, 62, 81, 84, 90, 165, 170, D
173–175, 194, 253, 257, 264, 301, 304, 313, Developmental psychology, xxvi, 165
329, 335–338, 382, 437 Diabetes, xvi, 38, 90, 100, 118, 313, 318, 329, 330,
Caregiving, xxiii, 63, 72, 73, 77, 78, 169, 190, 191, 238, 332–335, 382
242, 251, 254–257, 265, 270, 348, 362, 398, Disability, 74, 118, 254, 266, 295, 296, 331, 398, 419
418
Children, xi, xviii, xxiii, xxiv, xxvi, 12, 40, 41, 47, 54,
55, 63, 71–74, 76–79, 82–84, 91, 94, 98, 109, E
114, 137, 138, 171, 188, 195, 226, 251, Emotion regulation, xv, xviii, xxiv, xxix, 37, 42, 46, 63,
253–257, 263–281, 302–305, 321, 334, 349, 71–74, 76, 77, 79, 81, 94, 119, 149, 156,
350, 352, 371, 386, 389, 394, 396, 397, 399, 167–170, 207, 217, 224, 234, 253, 269, 271,
420, 422, 424, 434, 437, 438 275–277, 279, 297, 299, 314, 316–322, 330,
Chronic illness, xi, xvi, xxviii, 170, 266, 311, 333, 339, 331, 337, 350, 354, 370, 371, 373, 379–381,
424, 434 386, 387, 390, 393–396, 400, 421, 422, 433,
Chronic pain, 25, 26, 329, 331–332, 382, 392, 399, 419, 440–447
428, 438 Evolution, 53, 54, 56, 62, 63, 66, 423, 427

https://doi.org/10.1007/978-3-031-22348-8
456 Index
G Minority stress, 96, 143, 145–152, 154, 155

Gender minority, 91, 96, 98, 101, 143–145, 148, 152 Motivation, xii, xxi, 7, 8, 10, 12, 21, 23–25, 34, 43, 44,
Goal setting, 115, 202, 205, 213 53–55, 59, 61, 67, 72, 100, 129, 132, 133,
136–138, 166, 169, 170, 172, 187, 189, 195,
201–208, 215, 216, 223–224, 242, 243, 253,
H 309, 319, 320, 356, 418, 419, 421–423, 425,
Health behavior, 203, 207, 309, 311, 313, 314, 318–322, 444
330, 331, 334, 339 N
Healthcare, xviii, xxiv, 25, 26, 235, 236, 386 Neuroplasticity, 27, 391
Healthy aging, xvii, 118, 121 Non-suicidal self-injury (NSSI), xxi, 80, 95, 96, 98,
Heart rate, 54, 59, 291–293, 315, 317, 386, 394, 423 369–375, 441
Heart rate variability (HRV), 119, 122, 217, 292, 294,
296, 300, 301, 303, 304, 315, 317, 353, 354,
394, 422–424, 428, 444 P
Parenting, xxiii, xxiv, xxvii, 75, 77–79, 82–84, 251,
253–256, 263–281, 301, 302, 304, 398, 424,
I 437
Individual differences, 110, 201, 215, 226, 268, 293, 295, Parents, xii, xix, xxi, 12, 37, 54, 61, 63, 65, 71, 77–80,
309, 310, 313, 320, 321, 336, 353 82–84, 98, 101, 137, 138, 153, 170, 171, 186,
Interpersonal behavior, 251, 252 188, 218, 222, 225, 251, 253–255, 257,
Intervention science, 433, 438–447 263–281, 302, 304, 334, 353, 369, 371, 386,
Intrinsic self-esteem, 34–40, 42, 47, 48 389, 396, 397, 418, 422, 424, 425, 435, 437
Performance, xvii, xix, xxiv, xxvi, 6, 22, 23, 26, 34, 35,
39, 40, 42, 48, 93, 98, 119, 120, 149, 202,
K 204–207, 213–218, 220, 221, 223, 225, 226,
Kindness, xiii, 1, 2, 4, 6, 9, 10, 12, 19, 21–25, 27, 33, 42, 231, 243, 293, 297, 389
43, 61, 62, 71, 77, 79, 82, 89, 95, 109, 129, Personal improvement, 201–208
147, 149, 154, 168, 169, 184, 191, 194, 196, Physiology, 291–294, 296, 300, 394, 418, 420, 423–424
218–220, 233, 237, 239, 253, 254, 257, 264, Positive aging, 109–111, 121–122
269, 274, 309, 330, 349, 352, 354, 356, 372, Post-traumatic stress disorder (PTSD), 27, 76, 169, 171,
389, 390, 392, 397, 398 172, 347–351, 353, 354, 357–360, 362, 369,
383, 393, 398, 399, 428, 435, 437
Psychometrics, xxvi, 10
L Psychotherapy, xx, xxvii, 57, 64, 66, 351, 379–393, 396,
LGBTQ, 154 397, 399, 417, 419
Lifespan, 27, 34, 38, 71–84, 275, 355
R
M Relationships, xx, xxiii, xxiv, xxx, 7, 8, 11, 19, 22, 25,
Measurement, vii, xv, 1–12, 23, 34–38, 130–132, 26, 28, 33–48, 55–58, 61, 63, 66, 67, 72–75,
215–216, 236, 237, 256, 265, 294, 339, 423, 77–83, 89, 92–99, 112–116, 118, 121, 122,
447 130–138, 144, 150–153, 155, 156, 166, 167,
Mechanisms of change, 379, 393, 399, 440–446 169, 173, 174, 184–189, 191, 195, 196, 203,
Meditation, xii, xvii, xx, xxiv, 3, 8, 11, 20–24, 28, 44, 84, 205–208, 217, 221, 223, 224, 234, 235, 237,
101, 137, 192–193, 195, 206, 207, 222, 251–257, 263–281, 292–297, 299–302, 317,
297–299, 301–304, 351, 381, 385, 386, 388, 329, 332–335, 337, 348–353, 355, 358,
390–392, 417, 426, 436–439, 445 371–374, 379, 380, 384, 385, 387–392, 396,
Mentality, 58, 62–64, 190–191, 420, 429 398, 400, 420, 423, 424, 426, 427, 434, 435,
Mentalization, 57, 58, 60, 66 440–446
Mindfulness, xii, xv, xviii, xx, xxii–xxvii, 1–7, 9, 11, 12, Resilience, xv, xvii, xxviii, xxix, 7, 71, 92, 109, 114,
19–28, 38–40, 46, 58, 60, 61, 66, 71, 72, 147–150, 152–156, 165–175, 223–224, 226,
75–77, 82–84, 95, 97, 99, 101, 112, 117, 119, 234–236, 291, 293, 300, 305, 329, 330, 336,
129, 137, 151, 168–172, 174, 183, 184, 186, 351, 359, 374, 375, 434–438, 440, 441, 445, 447
193, 196, 201, 218, 220, 221, 226, 235–238,
240, 251, 254, 257, 263, 264, 267, 269, 270,
273, 275–280, 294, 301–303, 309, 310, 312, S
317, 319, 331, 332, 335–338, 349, 355, 358, Self-awareness, xxii, 53, 57, 58, 195, 219, 221, 222, 254
360, 373, 374, 379–385, 388, 390, 392, 393, Self-compassion, v, vii, xi–xiii, xv–xxv, xxvii–xxix,
399, 419, 426, 434–440 1–12, 19–28, 33–48, 53–57, 59–67, 71–84,
Index 457
89–102, 109–122, 129–138, 143–157, 383, 394, 395, 398, 417, 419, 420, 423,
165–175, 183–197, 201–208, 213–226, 433–437, 439–441, 445
231–244, 251–257, 263–267, 269, 273, 275, T
277–281, 291–305, 309–322, 329–339, Theory, xii, xv, xvi, xx, 1–12, 28, 37, 57, 71–74, 77, 82,
347–362, 372–375, 379–400, 417, 422, 423, 83, 96, 114, 132, 135, 143, 147, 149, 150, 152,
426, 428, 433–448 154, 183, 185, 186, 188–192, 201, 221, 280,
Self-compassionate aging, 121, 122 303, 309, 314, 316, 318–322, 374, 381, 396,
Self-criticism, xii, xv, xxiii, xxv, 2, 4, 7, 8, 10, 11, 26, 27, 399, 422
33, 38, 54–57, 64, 71, 75–79, 90, 94, 97–99, Therapeutic alliance, 384, 387–392, 399, 447
129, 131–134, 136, 172, 173, 190, 202, 205, Therapeutic relationship, 350, 352, 354, 357, 360,
213, 214, 216–222, 225, 231, 239, 240, 243, 387–389, 391, 435
251, 254, 279, 296, 299, 300, 302, 303, 320, Therapy, xvi, xx, xxii, xxix, 12, 33, 46, 59, 64, 80, 83,
330, 331, 334, 352–354, 371–372, 374, 375, 156, 221, 263, 264, 301–303, 312, 332, 333,
382, 383, 385, 392, 393, 395, 398, 399, 335, 347, 348, 350, 351, 354–361, 374, 375,
417–420, 422–427, 429, 440, 443–446 379–394, 396, 397, 399, 400, 417–420,
Self-determination, 34 425–429, 436–439, 447
Self-esteem, 6–8, 33–48, 62, 65, 93, 95, 97, 109–112, Transdiagnostic, xxiii, 8, 72, 95, 275, 292, 329, 330,
115, 121, 149, 185, 189, 192–194, 202, 203, 338, 379, 382–384, 398, 399, 433, 441,
205, 206, 208, 240, 252, 320, 333, 369 445, 447
Self-injury, xxi, 91, 95, 369–375 Transgender, xxviii, 100, 101, 114, 144, 146, 155, 188,
Self-regulation, xi, xxii, xxviii, 63, 71, 72, 77, 98, 135, 195
149, 203, 204, 207–208, 255, 267–270, 272, Trauma, xxii, 4, 41, 56, 57, 61, 71, 72, 76, 77, 81, 84,
273, 292, 296, 298–300, 303–305, 309, 93–99, 101, 170, 171, 173, 256, 257, 264,
314–315, 319–322, 330, 423 347–350, 354–362, 382, 383, 389, 393, 398,
Self-worth, 2, 6, 7, 26, 33–37, 40–42, 44–48, 73, 74, 93, 399, 419, 435
110, 120, 149, 185, 186, 190, 193, 239, 252, Treatment, xix, xxiii, xxviii, 35, 46–48, 61, 76, 81, 83,
371, 372, 398 90, 113, 117, 118, 166, 169, 173, 174, 194,
Sexual minority, 74, 143, 144, 152, 398 203, 298, 315, 329–333, 335, 336, 347–351,
Sleep, 26, 46, 118, 194, 234, 309, 313, 314, 321–322, 354–360, 362, 372, 379–382, 384, 387–393,
337, 362, 419 398–400, 425, 428, 433, 436–440, 445–447
Social mentality theory, 62, 417, 419–422, 436
Sport psychology, xix, xxvi, 214, 218, 225
Stress, xviii, xx, xxiii, xxiv, 4, 8, 12, 21, 25, 26, 45, 71, V
72, 75–78, 81, 84, 89–99, 112, 113, 118, 119, Veterans, xxx, 26, 171, 172, 174, 349, 350, 437
143, 146–148, 150, 152, 154, 165, 166, 170,
171, 205, 207, 217, 219, 221, 231–238, 240,
242, 252, 254–257, 263–266, 269–273, 277, W
280, 281, 291–305, 309, 311–318, 320–322, Weight stigma, 190–192, 195
331, 334, 336–338, 347, 351, 354, 369, 382, Wellbeing, xvi, xx, xxi, xxvii

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Mindfulness in Behavioral Health

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James N. Kirby, Ph.D., is a senior lecturer, clinical psychologist, and co-

Alex Kirk completed his PhD in clinical psychology and neuroscience at

Christine Lathren, Ph.D. is a research assistant professor at the University

Helena Moreira, Ph.D., is a clinical psychologist and an assistant professor

of Coimbra, she did 6 years of postdoctoral studies at the same university,

Amber D. Mosewich, Ph.D., (she/her/hers) is an associate professor in the

Anaïs Ortiz is a doctoral student at the University of Florida. She studies

Alina Pavlova, M.A., M.Sc., is a Ph.D. candidate in the Department of

Nicola Petrocchi, Ph.D., is Adjunct Professor of Psychology at John Cabot

Trisha L. Raque, Ph.D., is a licensed psychologist and an associate profes-

Baljinder K. Sahdra, Ph.D., is a Senior Lecturer and full-time researcher at

Benjamin J. Sereda, M.Sc. (he/him/his), is a doctoral student in the Faculty

applied work and coaching experience, Ben is particularly interested in how

Anna Serlachius, Ph.D., is a health psychologist and senior lecturer in the

Shauna Shapiro, Ph.D., is a best-selling author, clinical psychologist, and

Fuschia M. Sirois, Ph.D., is a professor in the Department of Psychology at

Elizabeth T. Slivjak is a doctoral student in clinical psychology at the

Penelope Strauss, Ph.D., (she/her) is a Research Fellow in Youth Suicide

Tracy L. Tylka (she/her), Ph.D., is Professor of Psychology at The Ohio

Abra Vigna, Ph.D., is an action researcher and evaluator at the University of

Kathryn Ziemer, Ph.D., is a licensed clinical psychologist and the clinical

Introduction The Elements of Self-Compassion

Self-compassion can be defined as compassion According to my model (Neff, 2016), self-­

© Springer Nature Switzerland AG 2023 1

The Structure of Self-Compassion Once people have a moderate level of self-­

takes and failures, adding a source of variance to Self-Compassion Across Groups

Examples of s­elf-­compassionate language are Conclusion

Introduction society with the intent of monetizing wellness

© Springer Nature Switzerland AG 2023 19

Nedlands, WA, Australia Amy Finlay-Jones

1 Self-Compassion: Theory and Measurement�� 1

Introduction The Elements of Self-Compassion

Self-compassion can be defined as compassion According to my model (Neff, 2016), self-

The Structure of Self-Compassion Once people have a moderate level of self-

takes and failures, adding a source of variance to Self-Compassion Across Groups

Examples of self-compassionate language are Conclusion

Introduction society with the intent of monetizing wellness

he Three Pillars of Mindfulness

Introduction case that many internal psychological barriers to

ness of self-esteem-based interventions for self- participant to a self-compassion, self-esteem, or

between humans and other animals (Leary & Knowing Intentionality

Introduction they relate to self-compassion, emotion regulation,

et al., 2007), and rumination (Neff, 2009). A Attachment Theory

The Impact of Trauma in Adulthood

or loss may represent life circumstances in which Implications for Interventions

Introduction tant for adolescents and follow with an overview

Introduction tional, physical, and social well-being, and

Introduction other hand, emotional experiences and their func-

actor Structure of the SCS Across

ful self-compassion program. Journal of Clinical lectic philosophies or individualism-collectivism?

Introduction gests that almost one in two young trans people

Self-Compassion, Discrimination, and Self- Self-Compassion and Gender

Limitations Future Directions

sis that SC supports long-term engagement in A within-person association of mindfulness, self-

thetaskforce.org/injustice-every-turn-report-national- & Adolescent Medicine, 165(6), 527–532. https://doi.

From Risk to Resilience Richardson, 2002; Zautra et al., 2010). In this

Self-Compassion and Resilience (e.g., that others are fundamentally benevolent)

Self-Compassion and Resilience

Introduction body-related behaviors and harmful coping strat-

body scan, the second included affectionate Writing Tasks

Introduction determined motivation, which is seen to have

one’s failure and observing one’s pain with Self-Compassion

In the context of relationships, self-compassion exercise-related self-regulation in a sample of US

Pathways Underpinning pants in the other three conditions (Leary et al.,

he Case for Self-Compassion

Much of the research on self-compassion in Conclusion

Rational-Emotive & Cognitive-Behavior Therapy, 40, 33(1), 1–6. https://doi.org/10.17159/2078-516X/2021/

Introduction risks becoming an “optional extra”. Unfortunately,