Chapter 4: Teaching Self-Compassion (Excerpt)
The following is an excerpt from Teaching the Mindful Self-Compassion Program: A Guide for Professionals by Chris Germer and Kristin Neff. Translations of the Professional Guide are forthcoming throughout 2020 and 2021. See scheduled release dates here. May this Professional Guide serve you and inform your teaching!
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Other Compassion Training Programs
In addition to MSC, there are currently three structured, time-limited, empirically supported programs designed specifically to train compassion. They are compassion cultivation training (CCT; Jazaieri et al., 2013), cognitively-based compassion training (CBCT; Pace et al., 2009), and mindfulness-based compassionate living (MBCL; Bartels-Velthuis et al., 2016; van den Brink & Koster, 2015). There is also compassion-focused therapy (CFT; Gilbert, 2009), a model of psychotherapy with a well-articulated theoretical base and an abundance of practical exercises. Each of these compassion-based programs has a different origin and emphasis and they vary in format and target audience, but they all share the goal of cultivating compassion toward self and others. We now compare and contrast MSC with these programs, noting the unique strengths of each, as well as examining their base of empirical support.
Compassion Cultivation Training
The CCT program was developed by Thupten Jinpa, a leading Tibetan scholar, and colleagues at Stanford University. The focus of CCT is on cultivating omnidirectional compassion. One session of the 8-week program is specifically dedicated to cultivating self-kindness, and another session focuses on self-compassion. The training sequence in CCT is as follows: mindfulness; loving-kindness and compassion for a loved one; loving-kindness and compassion for oneself; cultivation of a sense of common humanity; kindness toward challenging and difficult persons; and finally active compassion. Compassion for oneself permeates CCT, although less prominently than in MSC. Conversely, compassion for others permeates MSC (there are seven practices and class exercises that cultivate compassion for others), but this emphasis is less prominent than in CCT. This suggests that the two programs are nonredundant and complementary.
In CCT, a variety of meditations build systematically upon one another, culminating in “active compassion,” or Tibetan tonglen meditation. In traditional tonglen practice, the meditator draws in the suffering of others with the in-breath, imagines the suffering dissolving in one’s own radiant heart, and then breathes out compassion to the sufferer. Tonglen has been adapted for MSC as the Giving and Receiving Compassion meditation, in which compassion is both inhaled and exhaled—“in for me and out for you.” In actual practice, both tonglen meditation and Giving and Receiving Compassion provide a sense of breathing suffering and compassion both in and out, even though the meditations have different emphases. Both of these meditations also soften the sense of a separate self and cultivate an experience of common humanity.
Research has established the beneficial outcomes of CCT. A randomized controlled trial (Jazaieri et al., 2013) found that CCT decreased fear of giving compassion to others, fear of receiving compassion from others, and fear of self-compassion in participants, compared to a wait-list control group. It also increased self-compassion (15%). Examining the same sample, Jazaieri and colleagues (2014) found that participation in CCT increased mindfulness and happiness, and decreased worry and emotional suppression compared to the control group. In both sets of analyses, amount of formal meditation practice was related to improved outcomes. Two more studies examined this same sample of CCT participants. Jazaieri and col-leagues (2016) contacted participants twice a day over the course of the 9-week CCT program to determine how often their minds were wander-ing to pleasant, neutral, or unpleasant topics, as well as to assess any car-ing behaviors performed toward oneself or others. Results indicated that compassion meditation decreased mind wandering to neutral topics and increased caring behaviors toward oneself. A path analysis also revealed that greater frequency of compassion meditation practice was related to reductions in mind wandering to unpleasant topics and increases in mind wandering to pleasant topics, both of which were related to increases in caring behaviors for oneself and others. Jazaieri and colleagues (2018) found that CCT participants also increased their acceptance of negative mood states like anxiety or stress and experienced increased feelings of calm over time.
A second randomized wait-list-controlled trial of CCT was conducted in Chile (Brito-Pons, Campos, & Cebolla, 2018). Compared to the wait-list group, CCT participants showed significant improvements in compassion-related outcomes: increased self-compassion (28%), empathic concern, compassion for others, and identification with all of humanity, as well as increased life satisfaction, happiness, and mindfulness and decreased depression, stress, and personal distress. Finally, a pilot study of CCT among health care workers (Scarlet, Altmeyer, Knier, & Harpin, 2017) found significant improvements in participants’ self-compassion (16%), fear of compassion, mindfulness, and level of interpersonal conflict expe-rienced at work. In addition, the results indicated marginally significant improvements in self-reported job satisfaction. In summary, these studies suggest that although CCT is primarily focused on developing compassion for others, it also enhances the well-being of the person practicing compassion.
Cognitively‐Based Compassion Training
CBCT was originally developed by Lobsang Tenzin Negi, a former Tibetan monk, at Emory University to address stress in university students (Reddy et al., 2013). CBCT is a secularized form of Tibetan lojong practice designed to reduce narrowly self-oriented thinking and to broaden and strengthen care and consideration for others. CBCT dedicates its introductory sessions to training in attentional stability and openness to moment-to-moment experience (mindfulness). It then teaches analytical meditations in four modules: self-compassion; common humanity; interdependence, appreciation, and affection; and empathic concern and engaged compassion (Negi, 2009, 2016; Ozawa-de Silva & Dodson-Lavelle, 2011). The analytical modules enlist critical thinking to examine automatic emotional and behavioral reactions that may be misleading and harmful to self and others. Noticing and understanding these patterns, supported by increased attentional stability, enables participants to sustain cognitive insights as well as prosocial affect (such as gratitude and kindness) toward self and others. Self-compassion is understood in CBCT as a healthy motivation to develop realistic and positive attitudes toward difficult life circumstances.
At least nine randomized controlled trials have been conducted on the efficacy of CBCT. For example, Gonzalez-Hernandez and colleagues (2018) examined the impact of CBCT among breast cancer survivors, and found that it increased self-compassion (17%) and decreased stress caused by fear of cancer recurrence. LoParo, Mack, Patterson, Negi, and Kaslow (2018) examined CBCT among African Americans who had attempted suicide, and found that self-compassion significantly increased (8%) compared to a peer support control group. Dodds and colleagues (2015) found that CBCT for women with breast cancer increased mindfulness and physical well-being, and decreased functional impairment, avoidance, and fatigue, com-pared to a wait-list control group. Mascaro and colleagues (2018) found that CBCT enhanced compassion and improved daily functioning in medical students. Compared to a wait-list control group, students randomly assigned to CBCT reported increased compassion, as well as decreased loneliness and depression. Changes in compassion were most robust in individuals reporting high levels of depression at baseline, suggesting that CBCT may benefit those most in need by breaking the link between personal suffering and a concomitant drop in compassion. Other research on CBCT with adolescents in foster care has found that practice time is associated with decreases in anti-inflammatory markers (salivary C-reactive protein concentration; Pace et al., 2013) and with increased hopefulness (Reddy et al., 2013). Finally, CBCT improved outcomes compared to a control group in terms of increased empathetic accuracy and related neural activity (Mascaro, Rilling, Negi, & Raison, 2013). Taken together, these findings indicate that CBCT is an effective method for increasing compassion and improving psychological and physiological health.
Mindfulness‐Based Compassionate Living
MBCL was developed by two pioneering mindfulness teachers in the Netherlands—psychiatrist and psychotherapist Erik van den Brink and meditation teacher Frits Koster—at a mental health center to support clients who benefited from mindfulness practice but felt the need to further develop a kind and compassionate attitude toward themselves. The program is increasingly being offered to the general public and is designed as a deepening course for participants who are already familiar with mindfulness practice, preferably by having taken a course in MBSR, MBCT, or an equivalent.
MBCL is a unique blend of Western and Buddhist psychologies, integrating the work of Paul Gilbert (2009), Tara Brach (2003), and ourselves (Germer, 2009; Neff, 2011a). MBCL combines the evolutionary psychology of CFT, especially the CFT model of emotion regulation and compassionate imagery, with positive psychology and secular adaptations of traditional Buddhist contemplative practices such as metta and tonglen meditation. Important informal practices in MBCL are the Breathing Spaces with Kindness and Compassion, adapted from MBCT’s Three-Minute Breathing Space. Similar to MSC, MBCL explicitly cultivates the qualities of kindness, compassion, appreciative joy, and equanimity. Some elements of MSC found in MBCL include the Self-Compassion Break, the Sense and Savor Walk, the Compassionate Body Scan, Self-Compassion in Daily Life, and the concept of backdraft. Perhaps the characteristic that most clearly differentiates MSC and MBCL is the special focus on cultivating self-compassion in MSC. It is noteworthy that both MBCL and MSC have been mainly influenced by the mindfulness tradition, whereas the other compassion training programs have a stronger Tibetan flavor. Although it used to be a requirement that participants take a course in MBSR or MBCT before taking MBCL, this requirement has now been relaxed.
A pilot study of psychiatric outpatients taking the nine-session MBCL program after having taken MBCT at a local mindfulness training center found that participants reported improved outcomes in terms of increased self-compassion (13%) and mindfulness as well as reduced depression (Bartels-Velthuis et al., 2016). A second pilot study (Schuling et al., 2018) with recurrently depressed participants also found that MBCL increased self-compassion (14%). Early results from a randomized controlled trial (Schuling, 2018; Schuling et al., 2016), moreover, suggest that compared to a treatment-as-usual control group, individuals with recurrent depression who took MBCL after MBCT reported significantly increased self-compassion (15%), mindfulness, and quality of life, as well as decreased depression and rumination.
CFT was developed by eminent British psychologist Paul Gilbert (2000, 2005, 2009) to address self-criticism and shame in an inpatient psychiatric hospital population. CFT is based on evolutionary psychology, cognitive-behavioral therapy, and Tibetan Buddhist psychology. CFT includes a wide range of practices known as Compassionate Mind Training (CMT; Gilbert & Proctor, 2006: Matos, Duarte, Duarte, Gilbert, & Pinto-Gouveia, 2018) that are primarily aimed at developing self-compassion, as we might expect from a clinical program where alleviating personal distress is the first order of business. In CFT, mindfulness is used to stabilize attention for the work of compassion training and to “shine a spotlight” on how the human mind functions, especially in response to threat. This form of treatment helps clients develop the skills and attributes of a self-compassionate mind, especially when their more habitual form of self-to-self relating involves shame and self-attack.
CFT increases awareness and understanding of automatic emotional reactions such as self-criticism that have evolved in humans over time, and of how these patterns are often reinforced in early childhood. The key principles of CFT involve helping people to extend warmth and understanding toward themselves; motivating them to care for their own well-being; and helping them to become sensitive to their own needs, tolerate personal distress, and reduce tendencies toward self-judgment (Gilbert, 2009). Although CFT is a type of individual therapy, it is sometimes taught in a time-limited group therapy format, which can vary in length from 4 to 16 weeks.
The development of CFT preceded that of MSC chronologically, and a number of elements from CFT have migrated into MSC, such as learning that the physiology of compassion is rooted in the mammalian caregiving system (see Chapter 10), visualizing an ideal compassionate image to activate compassion (Chapter 17, Compassionate Friend meditation), and attuning to the soothing rhythm of the breath (Chapter 11, Affectionate Breathing meditation). CFT has three different approaches to evoking self-compassion that are also in MSC: namely, self-to-other compassion (i.e., “How would you treat a friend?”), other-to-self compassion (i.e., “What would a compassionate friend say to you?”), and self-to-self compassion (i.e., “What would your compassionate self say right now?”). Psychotherapists who teach MSC tend to be familiar with CFT as well.
There is a large empirical literature on CFT that cannot be adequately covered here (for reviews, see Kirby, 2017; Leaviss & Uttley, 2015). This research suggests that CFT is effective at increasing self-compassion and treating individuals with a wide variety of clinical conditions. For instance, a randomized controlled trial conducted with outpatients with eating disorders found that 12 weeks of CFT led to greater increases in self-compassion (34%) and reductions in shame and eating disorder pathology than did treatment as usual (Kelly et al., 2017). Another randomized trial (Gharraee, Tajrishi, Farani, Bolhari, & Farahani, 2018) found that 12 weeks of CFT increased self-compassion (28%) and quality of life while reducing anxiety symptoms among individuals with social anxiety. A study by Parry and Malpus (2017) found that 8 weeks of CFT increased self-compassion (32%) and reduced depression and anxiety among individuals with persistent pain. Brähler and colleagues (2013) conducted a randomized controlled trial comparing 16 sessions of CFT to treatment as usual among individuals with schizophrenia and found that the CFT group displayed more compassion toward painful aspects of their psychosis and greater clinical improvements, in addition to bigger reductions in depression and perceived social marginalization. In summary, CFT shows a great deal of promise for helping people with various clinical disorders to develop self-compassion, even if their more habitual form of relating to themselves is maladaptive.
Research suggests that CMT practices are also effective for nonclinical populations. Beaumont, Rayner, Durkin, and Bowling (2017) found that student psychotherapists in training who took six sessions of CMT experienced increased self-compassion (12%) afterward. Similarly, Matos and colleagues (2018) found that just 2 hours of CMT training plus 2 weeks of practice resulted in significant increases in positive affect, improved heart rate variability, and compassion toward self and others, as well as significant reductions in shame, self-criticism, fears of compassion, and stress (the CEAS rather than SCS was used to measure self-compassion).
Research on the MSC Program
Although the MSC program outlined in this manual is still in its early stages, there is increasing evidence to suggest that it is effective at increasing self-compassion and other aspects of psychological well-being, and that the skills of self-compassion learned in MSC are maintained over time. This body of research is covered here in some detail, since it provides empirical support for the program as described in the rest of this book. We first conducted a small pilot study of the MSC program (Neff & Germer, 2013) with 21 participants (95% female; mean age = 51.26 years). We found program participation significantly increased self-compassion (34%), mindfulness, social connectedness, life satisfaction, and happiness and also decreased depression, anxiety, and stress. Based on these encouraging results, we next conducted a randomized controlled study of the MSC program (Neff & Germer, 2013) that compared outcomes for 51 individuals (77% female; mean age = 50.10 years) randomly assigned to either MSC or a wait-list control group. The large majority of participants (76%) reported having prior experience with mindfulness meditation. Participants from both groups were asked to complete a series of self-report scales 2 weeks before and 2 weeks after the MSC program; MSC participants were also assessed 6 months and 1 year later. The questionnaires assessed self-compassion, mindfulness, compassion for others, life satisfaction, social connectedness, happiness, depression, anxiety, stress, and emotional avoidance.
There were no differences between groups at pretest on any of these measures. At posttest, however, MSC participants demonstrated a significantly greater increase in their self-compassion levels (43%) than controls did, with a large effect size indicated. MSC participants also had significantly larger increases in mindfulness, compassion for others, and life satisfaction, as well as greater decreases in depression, anxiety, stress, and emotional avoidance.
Note that significant group differences were not found in happiness or social connectedness. When examining the results further, however, we found that this lack of group differences occurred because improvements were also observed for the wait-list control group. While MSC participants’ scores on all outcome measures increased from pre- to posttest, the control group’s levels of self-compassion, mindfulness, happiness, and social connectedness also significantly increased. This helps explain why MSC participants’ gains in happiness and social connectedness were not significantly greater than those of the control group. The question remains, however: Why did outcomes for the control group improve? To explore the issue further, we contacted control participants after completion of the study to inquire if they had engaged in activities during the study period to increase their self-compassion. Specifically, we asked if they had read books on self-compassion (e.g., Germer, 2009; Neff, 2011a) or visited websites that offered information and downloadable meditations on self-compassion. We also asked if they had tried to bring more self-compassion into their everyday life. Almost all the control participants responded. Fifty percent reported reading books or learning about self-compassion online, and 77% said that they had intentionally tried to practice self-compassion in their lives. This actually strengthens our confidence in the study findings because the members of the waiting-list control group were relatively active in their attempts to increase self-compassion, making comparative gains by the intervention group more marked.
In terms of changes in self-compassion over time, we found that the MSC participants’ self-compassion scores increased from pretest to Week 3 of the program, then increased again from Week 3 to Week 6 of the program, but did not significantly increase from Week 6 to posttest. Moreover, there were no changes in self-compassion when the MSC participants were examined 6 months later (with 92% of intervention participants taking the follow-up survey) and 1 year later (only 56% of these participants took the 1-year follow-up). These results suggest that skills of self-compassion imparted in the MSC program are learned gradually, but that once they are learned, they remain relatively stable. We also asked participants how many times per week they practiced formal meditation, or how many times per week they practiced informal self-compassion techniques in daily life. How often participants practiced self-compassion predicted the degree to which their self-compassion increased. There were no differences between formal and informal practice in predicting self-compassion gains. (The importance of informal practice has been corroborated by research on mindfulness training [Elwafi, Witkiewitz, Mallik, Thornhill, & Brewer, 2013].) Overall, our research implies that self-compassion is a teachable skill that is “dose-dependent.” That is, the more people practice it, the more they learn it.
Gains in other study outcomes were also maintained at the 6-month and 1-year follow-ups. In fact, life satisfaction actually increased from the time of program completion to the 1-year follow-up, suggesting that the continued practice of self-compassion can continue to enhance participants’ quality of life over time. Given there was attrition from the 6-month to the 1-year follow-up, however, these results should be interpreted with caution because those participants who were most satisfied with their lives may also have been the most likely to fill out the 1-year follow-up survey.
The study was further limited by the lack of an active control group— a shortcoming that will need to be addressed in future research. Also, given that most participants had prior mindfulness meditation experience, we can’t know for sure whether the practices taught in the program were only effective for those who already knew how to meditate. On the other hand, the fact that MSC participants increased in well-being, even though most had prior meditation experience, suggests that MSC offers tangible benefits over and above meditation alone.
A second randomized controlled trial has been conducted on MSC (Friis et al., 2016). The study included 63 participants (68% female; mean age = 42.87 years) suffering from Type 1 or Type 2 diabetes. It compared outcomes for those randomly assigned to the MSC program (n = 32) or to a wait-list control condition (n = 31). Measures of self-compassion, depressive symptoms, diabetes-specific distress, and glycemic control (indicated by HbA1c values at the three time points) were taken at the start of the program, at the end of the program, and at a 3-month follow-up.
There were no group differences at pretest on any of these measures. At the 3-month follow-up, however, MSC participants demonstrated a significantly greater increase in self-compassion (27%), and decrease in depression and diabetes distress, compared to controls. MSC participants also aver-aged a clinically and statistically meaningful decrease in HbA1c between baseline and the 3-month follow-up. There were no overall changes for the wait-list control group. These findings suggest that learning to be kinder to oneself (rather than being harshly self-critical) may have both emotional and metabolic benefits among patients with diabetes.
Research has also examined the impact of MSC on health care providers. Delaney (2018) conducted a small mixed-method pilot study of MSC on caregiving fatigue and resilience among nurses. Results indicated that the training increased self-compassion (24%), mindfulness, resilience, and compassion satisfaction, while reducing secondary traumatic stress and burnout. Findings were supported by the qualitative data gathered: Nurses indicated that the training increased their ability to cope, reduced self-criticism, and enhanced positive mental states.
It appears that the benefits of MSC are not limited to Western cultures. A pilot study of MSC was conducted with 44 community females (mean age = 36.6 years) in Beijing, China (Finlay-Jones, Xie, Huang, Ma, & Guo, 2018). Participants were asked to complete a series of self-report scales just before and after the program, and also at a 3-month follow-up. Significant improvements were observed over the course of the program in terms of increased self-compassion (43%), compassion for others, and mindfulness, and reduced fear of self-compassion, rumination, maladaptive perfectionism, depression, anxiety, and stress, with large effect sizes observed. The majority of these improvements were maintained at the 3-month follow-up. This suggests that the MSC program is effective for increasing self-compassion and well-being in non-Western populations.
An adaptation of MSC for adolescents has been created by Lorraine Hobbs and Karen Bluth (2016), called “Making Friends with Yourself” (MFY). Each weekly session in this 8-week course has a specific theme that roughly parallels the themes of the adult program. In general, the program differs from the adult program in that classes are shorter (about 90 minutes) and more activity-based, and guided meditations are shorter, meaning that they are more developmentally appropriate. MFY includes several hands-on activities that encourage participants’ self-discovery of mindfulness and self-compassion. For example, one exercise includes a role play to demonstrate understanding of how we relate to ourselves and set the groundwork for self-compassion practice. There is also an art activity that illustrates the value of imperfection. Discussion of the developing adolescent brain is also woven throughout the course.
Bluth, Gaylord, Campo, Mullarkey, and Hobbs (2016) conducted a mixed-methods study of the MFY program with 34 adolescents (74% female; ages 14–17 years). It compared outcomes for those randomly assigned to the MFY program (n = 16) versus a wait-list control condition (n = 18). Participants from both groups were asked to complete a series of self-report scales at baseline and immediately after the program, assessing self-compassion, mindfulness, life satisfaction, social connection, depression, anxiety, and positive and negative mood. Classes were also audio-recorded and transcribed, and teens gave verbal feedback about the acceptability of the program.
Participants in the MFY program reported significantly greater gains in self-compassion (11%) and life satisfaction, as well as decreases in depression, compared to the wait-list control group, with trends toward significance in terms of increased mindfulness and social connection and decreased anxiety. Given the small sample size, these trends may have been significant with more participants. Teens also generally gave positive feed-back about the program. As one teen said,
“I guess I’m thankful for the tools that I’ve learned, because I get a lot of anxiety about school, especially. I feel like in the last few weeks my anxiety in the moment has decreased because I’m mindful and compassionate toward myself, and I don’t know, I feel much better about a lot of stuff I have to do, because I know it’s not the end of the world if I don’t do it or whatever.” (p. 486)
Bluth and Eisenlohr-Moul (2017) also examined outcomes for adolescents (N = 47, 53% female, ages 11–17) enrolled in MFY in five cohorts. Self-report measures were completed at pretest, posttest, and at 6-week follow-up. Multilevel growth analyses indicated that over time participants increased in self-compassion (17%), mindfulness, resilience, curiosity/exploration, and gratitude, as well as decreased in perceived stress. Similarly, Campo and colleagues (2017) conducted a study of an adapted version of the MFY program taught online to female young adult cancer survivors (N = 25, ages 18–29). Not only did participants report enjoying the program and finding it helpful, they evidenced increased self-compassion (29%), mindfulness, improved body image, posttraumatic growth, and decreased social isolation, anxiety, and depression. These findings are encouraging and suggest that it is possible to teach the skills of MSC at an early age, potentially altering the developmental trajectory of youths in a way that could produce benefits over a lifetime.
Finally, research has been conducted on brief self-compassion training based on the MSC protocol. For instance, Smeets, Neff, Alberts, and Peters (2014) conducted a study in which practices adapted from the MSC program were taught (such as the Self-Compassion Break, Compassionate Letter to Myself, and Finding Loving-Kindness Phrases) to female college students over the course of 3 weeks. Participants included 49 female psychology students (mean age = 19.96 years) entering their first or second year at a European university, who were randomly assigned to either the self-compassion intervention group (n = 27) or an active time management control group (n = 22). Both groups met for three short sessions over 3 consecutive weeks, with two active intervention sessions lasting about 90 minutes and a closing session lasting about 45 minutes. Various self-report scales were administered 1 week before and 1 week after the intervention. It was found that the brief MSC intervention led to significantly greater increases in self-compassion (21%), mindfulness, optimism, and self-efficacy, as well as significantly greater decreases in rumination, compared to the control group.
The success of this brief training is encouraging and suggests that the benefits of self-compassion can be potentially taught without requiring meditation. For this reason, we are currently pilot-testing brief versions of MSC for populations such as teachers, parents of chronically ill children, and health care workers at risk of burnout. Preliminary results of a randomized wait-list-controlled trial of a brief protocol consisting of six 1-hour sessions used with health care workers at a children’s hospital suggest that the brief intervention is effective for this population. Not only did participants report enjoying the program, it significantly increased self-compassion (16%), mindfulness, compassion for others, and compassion satisfaction and decreased stress. There was also a moderator effect so that participants initially low in self-compassion experienced significant reductions in depression (those initially high in self-compassion did not). Moreover, all gains were maintained at 3-month follow-up. These brief interventions are promising given that they require less of a time commitment, and they may be more appropriate for those who are disinclined to adopt a meditation practice and who prefer to simply integrate self-compassion practice into their daily life. Research is in its early stages, however, and it self-compassion in a way that makes an impact over the long term.