PSYCH  Vol.11 No.2 , February 2020
Self-Compassion in Clinical Samples: A Systematic Literature Review
Abstract
Self-compassion, broadly, means to treat oneself kindly in times of need, same as one would do with a dear friend (Neff, 2003b). This systematic review focuses on self-compassion as is found in clinical samples. It specifically reviews 28 relevant studies to find out if people belonging in what is called “clinical samples” have lower levels of self-compassion than those of non-clinical samples in the first place and if this is a crucial factor for the appearance of psychopathological symptoms (i.e. anxiety disorders, bipolar disorder, borderline personality disorder, PTSD, depression, schizophrenia etc.), or it is the other way around. Even though most studies tend to agree that low self-compassion and psychopathology are present in clinical samples, no study until now can prove a clause for causality, as most studies were of a cross-sectional design and had a great heterogeneity concerning both mental health issues involved and ages/genders. Future studies could use additional mediators to check out how low self-compassion and mental health are connected. Another question to be asked is if self-compassion is equally important for one’s recovery as it is for the prevention of appearance of mental illness. The systematic review highlights issues from the current evidence that may be used for further research.

1. Introduction

Even though the East and the West have been two worlds apart for a lot of years, lately there’s a shift and the Western world has been looking into what it might learn from its sister world, the East. In the West, psychiatry is still king. In the East, one can find purer solutions to one’s problems: yoga, Buddhism and several other peaceful concepts. One of those notions of the Buddhist philosophy is self-compassion. Self-compassion, a concept firstly researched and defined by Kristin Neff (2003b) actually means to be able to treat oneself as one would be a loved one, in times of need: with kindness, warmth, acceptance. Compassion and self-compassion are, of course, interrelated. “To have compassion means to be attentive to and be touched by one’s pain”, Neff (2003b) writes. To have self-compassion is to be able to do all of the above, when it comes to yourself. Neff (2003b) defines self-compassion as

“being touched by and open to one’s own suffering, not avoiding or disconnecting from it, generating the desire to alleviate one’s suffering and to heal oneself with kindness. Self-compassion also involves offering nonjudgmental understanding to one’s pain, inadequacies and failures, so that one’s experience is seen as part of the larger human experience” (p. 87).

According to Neff’s (2003a) description, self-compassion consists of three elements:

“1) self-kindness—being kind and understanding toward oneself in instances of pain or failure rather than being harshly self-critical, 2) common humanity—perceiving one’s experiences as part of the larger human experience rather than seeing them as separating and isolating, and 3) mindfulness—holding painful thoughts and feelings in balanced awareness rather than over-identifying with them” (p. 85).

These three components, while distinct in their conceptual level, are interconnected and to name a person as self-compassionate, it is crucial that they can exhibit all of them in a degree or another (Neff, 2009).

Research has shown again and again the importance self-compassion can have for a person’s life and the list of evidence keeps growing. Self-compassion is connected with more happiness, greater life-satisfaction, better emotional regulation, a muted sense of self-criticism and a better interpretation of academic failure, to mention just a few of the advantages (Barnard & Curry, 2011; Neff, Hsieh, & Dejitterat, 2005). Self-compassion seems to be a great asset for one’s more positive sense of well-being and it appears to make people feel safer and more in peace with their doings or misdoings (Zessin et al., 2015). Accumulating evidence shows that it acts like an armor, protecting oneself against psychopathological symptoms (Barnard & Curry, 2011; MacBeth & Gumley, 2012). Resilience to mental health issues appears to be interconnected with the ability to be self-compassionate (Trompetter et al., 2016). The bibliography shows that self-compassion is a great source of strength for a person’s mental health and a lot of study findings show that it can be a protective factor against depression and anxiety as rumination and stress tend to be moderated when self-compassion appears (Barnard & Curry 2011; Ehret et al. 2014; MacBeth & Gumley 2012; Samaie & Farahani, 2011). Because self-compassionate people are kind, mindful with their own pain and do not over-identify with it, but treat themselves with support and care, they appear to have a better cognitive reappraisal and acceptance when situations are hard (Allen & Leary 2010; Leary et al., 2007). Research findings depict that people with self-compassion don’t develop depressive symptoms as much but there isn’t sufficient literature on how self-compassion acts as a resilience mechanism in relation to psychopathology (Diedrich et al. 2014; Trompetter et al., 2016).

Reading said literature, the question arises, how is self-compassion connected with the field of mental health when the population is that of a clinical sample? To define mental health can be a tricky issue as psychiatry tends to divide people into mentally healthy or unhealthy (Keyes, 2005). Even though this division doesn’t seem to do justice to either being healthy or unhealthy when it comes to mental states, this paper will adopt the description of modern psychiatry and clinical psychology to have a common ground with the studies being reviewed. What does the literature say about the relationship between self-compassion and what psychiatric tools like the DSM-V (American Psychiatric Association, 2013) and the ICD-10 (World Health Organization, 1992) regard as psychopathology (i.e., major depressive episode, generalized anxiety, borderline personality disorder, bipolar disorder, alcohol dependence etc.)? This systematic review will try to bring forward the body of research dedicated to how exactly self-compassion relates to clinical samples.

At first, MacBeth and Gumley’s (2012) meta-analysis explored compassion and more specifically self-compassion and its associations to psychopathology, but they mostly focused in what they refer to as “common” psychopathology - that is anxiety, depression and stress. They also cared to evaluate how demographic moderator variables like sampling and gender affected the relationship between compassion and psychopathology.

Later, Muris & Petrocchi (2016) attempted a systematic literature search and meta-analysis, too, including a much broader spectrum of psychopathological symptoms. Their main concern was to see if self-compassion could act protectively to psychopathology and also, to explore the relations between the positive and negative aspects of self-compassion and psychopathology, but they only included studies that specifically had to do both with the “positive” and “negative” subscales of these measures, apart from the total scores.

This systematic literature review differs in that it will focus on the research papers published only the last six years (i.e. from 2012 and later) and will explore the relationship between self-compassion and psychopathology in clinical samples. The focal point of this review is to explore if people of clinical samples have lower levels of self-compassion than those of non-clinical samples in the first place and if this is a crucial factor for the appearance of psychopathological symptoms (i.e. anxiety disorders, bipolar disorder, borderline personality disorder, PTSD, depression, schizophrenia etc.) or the other way around. The paper has excluded from its review eating disorders as a systematic review recently published (Braun et al., 2016) sufficiently covered the pertinent topic.

This systematic review focuses on self-compassion as is found in clinical samples. It specifically reviews 28 relevant studies to find out if people belonging in what is called “clinical samples” have lower levels of self-compassion than those of non-clinical samples in the first place and if this is a crucial factor for the appearance of psychopathological symptoms (i.e. anxiety disorders, bipolar disorder, borderline personality disorder, PTSD, depression, schizophrenia etc.), or is it the other way around.

2. Method

Relevant data were collected using Kristin Neff’s website, the Pubmed database and google scholar. At first, Kristin Neff’s homepage was visited and there’s a category there, named “research” (http://self-compassion.org/the-research/), which gives away a collected database of almost everything ever written on the subject of self-compassion. She has categorized the work both according to areas of study and alphabetically. In the area of study “Self-compassion in Clinical Contexts” she has collected 74 relevant publications. After this, pubmed database was used with the search keywords “self-compassion AND clinical samples”, “self-compassion AND psychopathology”, “self compassion AND psychopathology”, “self-compassion AND DSM”, “self compassion AND DSM” and the same keywords were used in Google scholar to see if anything different came up.

The search gave a number of studies, but to include them in the review they had to be written in the English language and to be published from 2012 and later. Papers which didn’t mention research data, literature articles only based on bibliography or opinion and meta-analyses were excluded. There was a compare and contrast with Neff’s list of publications and after reading the titles and the abstracts, 28 papers were selected for this systematic literature review. Selected studies had to do with self-compassion in the field of clinical samples and psychopathology as defined by the ICD-10, DSM-IV and the DSM-V. For the measurement of this concept, most researchers have relied on the Self-Compassion Scale of 26 questions (SCS; Neff, 2003a) or its abbreviated version, the Self-Compassion Scale-Short Form, with 12 questions (SCSSF; Raes, Pommier, Neff, & Van Gucht, 2011).

3. Results

Overall, 28 studies were included in this systematic review and they’re organized alphabetically in the table above (Table 1, Results.) Most of the studies used quantitative methods to analyze their data.

3.1. Self-Compassion and Anxiety Disorders

In a study with people with Generalized Anxiety Disorder (GAD) it was shown that GAD patients reported lower mindfulness and self-compassion levels and higher levels of worry and anxiety (Hoge et al., 2013). According to another

Table 1. Results.

study examining people with obsessive-compulsive disorder (OCD), a significant relationship was found between symptom severity and values in life with the values of self-compassion and courage (Wetterneck et al., 2013). Also, less self-compassion was reported by another study, trying to investigate self-compassion and its correlations, in a sample of persons with social anxiety disorder (SAD). Results indicated that while people with SAD had less self-compassion, it didn’t amount to worse symptoms even though it did bring up a greater fear of any kind of evaluation (Werner et al., 2012).

Another study asserted that self-compassion acts as a buffer against ruminating events that have already happened, something common for people with social anxiety (Blackie & Kocovski, 2017) and something similar was also argued in another study too (Cȃndea & Szentágotai-Tătar, 2018). The same authors (Blackie & Kocovski, 2017) later found that self-compassion can be used to reduce negative and repetitive thinking, so as people with social anxiety will continue having a social life.

Social anxiety and low self-compassion have also been found in people who were brought up by critical parents (Potter et al., 2014).

As far as families and anxiety are concerned, another research (N = 500), indicated that families chaotically-enmeshed appeared to have lower flexibility and self-compassion, too (Berryhill, Hayes, & Lloyd, 2018).

3.2. Self-Compassion and Depression

Low self-compassion is reported in patients with remitted Bipolar Disorder (BD) and their life satisfaction appears to be reduced (Døssing et al., 2015). These findings, as some of other studies’ (Diedrich et al., 2014; Diedrich et al., 2016; Krieger et al., 2016) bring forward that there’s probably a connection between self-compassion and depressive symptoms and self-compassion can be an effective emotion regulation strategy in patients with major depressive disorder. In a longitudinal design study (Krieger et al., 2016) examining the association between depression and self-compassion, the findings indicate that lack of self-compassion is a significant vulnerability factor for depressive symptoms and even a major depressive episode, without necessarily causing depression though.

As far as depression is concerned, a different paper written about two independent studies, a pilot study and a longitudinal one, trying to examine if parents with depression do better at parenting when they’re self-compassionate and how this reflects on their children’s behaviors, found that parents with higher levels of self-compassion were less critical, they could cope better with their kids’ emotions and didn’t attribute everything to their own doings (Psychogiou et al., 2016).

A Self-Criticism/Compassion Mediation Model was constructed for another study (Joeng & Turner, 2015) with university students, which tried to investigate the relationships between internalized self-criticism and depression and the results indicated that self-compassion partially mediated both the relationship between internalized self-criticism and depression, and the relationship between comparative self-criticism and depression.

3.3. Self-Compassion and General Diagnoses of Psychopathology

Another clinical sample, with schizophrenia spectrum disorders this time, was studied by Eicher et al. (2013) and the results show that self-compassion and psychopathology are indeed correlated and the higher the self-compassion the lower the discomfort patients felt with their symptoms. In the same light, a study with a clinical sample of people diagnosed with psychosis, indicated that greater narrative compassion is linked to less negative symptoms, less cognitive disorganization and less excitement (Gumley & Macbeth, 2014). To recover from a psychotic episode is a difficult process but it can get a little easier to handle when patients practise self-compassionate self-acceptance, highlights a qualitative study by Waite et al. (2015).

A recent study (Collett et al., 2016) showed that self-compassion is really low in persons with persecutory delusions, as is their self-esteem and feeling of inferiority. Negative cognitions and decreased positive beliefs are also high in this group. Next, a randomized pilot study intervention with people experiencing borderline personality disorder, shows that three weeks of loving-kindness and compassion meditations had a significant effect on the participants, with their symptoms clearly improving. Self-criticism was lower and self-kindness levels were raised (Feliu-Soler et al., 2016).

3.4. Self-Compassion and Post-Traumatic Stress Disorder (PTSD)

The next studies have to do with post-traumatic stress disorder (PTSD) and self-compassion. In the first of them (Hoffart et al., 2015) it was recognised that people with PTSD symptoms were affected by self-compassion and that even though the kind of therapy plan didn’t seem to have an effect on PTSD, the within-person relationship between self-judgment and subsequent PTSD symptoms was stronger in patients with higher initial self-judgment.

Maheux & Price (2015) examined if self-compassion can act as a protector for PTSD symptoms after exposure to traumatic events and found significant correlations indicating that it might be so. They did another research after that (Maheux & Price, 2016), investigating the relationship between social support and an increased sense of self-compassion as facilitators for recovery in PTSD and discovered a positive relation between social-support and self-compassion, while negative correlations between self-compassion and PTSD, GAD and depression symptoms.

Another study revealed that survivors of childhood sexual abuse show a fear of being self-compassionate and an indirect effect of childhood sexual abuse on symptoms of depression and PTSD (Miron et al., 2016).

Furthermore, a study with women with PTSD asserted that PTSD symptoms were negatively related to self-compassion, as was emotion dysregulation, and positively related to resilience (Scoglio et al., 2015). Similar results were found in another research too, listing that higher levels of self-compassion reduced the relationship between state negative affect and psychopathology, suggesting that they can work as a resilience mechanism against psychopathology (Trompetter et al., 2016).

3.5. Self-Compassion, Internalized Self-Criticism, Fear of Self-Compassion and Shame

A study with a sample of men with hypersexual behavior, shows that self-compassion partially mediated the relationship between shame and rumination and hypersexual behavior, normalizing the effect on people’s suffering, seeing it as part of the human condition (Reid et al., 2014). A different study, trying to establish reliability and normative values on the SCS-SF (Self-Compassion Scale – Short Form) for a clinical sample found that college students who came for help in counseling centers had lower self-compassion (Lockard et al., 2014).

Emotional processing, mindfulness and the ability to have empathy towards other people, as compassion for yourself, found to be negatively correlated with a fear of compassion from others and for self. On the same note, self-criticism had a positive correlation with fears of compassion and happiness, as had depression, anxiety and stress (Gilbert et al., 2012).

Finally, a study with a sample of adolescents who had reported non-suicidal self-injury (NSSI), brought evidence that everyday experiences of external shame, hated self and fear of self-compassion indirectly predict NSSI and there was a strong connection between hated self and NSSI (Xavier et al., 2016).

3.6. Self-Compassion and Therapy Interventions

Last but not least, one study takes a look in alcohol dependent individuals and how they’re influenced by the concept of self-compassion. Participants in this study didn’t experience as much mindfulness, common humanity and self-kindness as the people in the general population. After a 15 weeks follow-up though, in which participants had undergone treatment for their dependency, they were able to report an improvement in depression, anxiety and alcohol use, which was accompanied by a significant increase in self-compassion, mindfulness, common humanity and self-kindness (Brooks et al., 2012). In another research, participants in a combined Cognitive Behavioural Therapy (CBT) and Compassionate Mind Training (CMT) reported significantly higher self-compassion scores post-therapy (Beaumont et al., 2012). Even when there’s a more serious psychopathology involved, like that of a sample recovering from psychosis, Compassion focused therapy (CFT) helped people be more self-compassionate and lower their depression levels and had a better general outcome than the usual treatment (Braehler et al., 2013).

4. Discussion

4.1. Self-Compassion and Anxiety Disorders

Hoge et al. (2013) revealed that Generalized Anxiety Disorder (GAD) patients reported lower mindfulness and self-compassion levels than the control group of healthy adults. This is an important finding, as it shows how self-compassion and specifically mindful awareness can help people with GAD cope better with the perceived ideas of their disability, even though just one measure of disability was used (the Sheehan Disability Scale, SDS). The anxiety and worry levels of patients with GAD were significantly higher so the authors thought that if the patients learn to accept the reality of their symptoms without focusing negatively on them, this might lead them to live better, despite their symptomatology.

The same can be said for people with Obsessive-Compulsive Disorder (OCD) and social anxiety (SAD). The study with the SAD clinical sample insinuates that one of the reasons one might develop social anxiety could be low self-compassion and specifically harsh self-judgment and over-identification with one’s shortcomings (Werner et al., 2012). However, because of the design of the study, causality cannot be ensured. Mindfulness and self-compassion interventions should be further explored concerning anxiety disorders treatment, as one can imagine that treating oneself kindly when in need or when in frustration, can adhere to ease and calm.

Another study asserted that self-compassion acts as a buffer against ruminating events that have already happened, something common for people with social anxiety (Blackie & Kocovski, 2017a) and something similar was also argued in another study too (Cȃndea & Szentágotai-Tătar, 2018). The same authors (Blackie & Kocovski, 2017b) later found that self-compassion can be used to reduce negative and repetitive thinking, so as people with social anxiety will continue having a social life.

As far as families go, children of critical parents had lower self-compassion and were more self-judgmental. They also found that parental criticism was positively connected to social anxiety which can be interpreted like an after-effect of the high criticism these kids have already felt from their family, which is supported by Gilbert et al.’s (2011) finding, that a fear of self-compassion was associated with self-criticism and insecure attachment (Potter et al., 2014). As far as families and anxiety are concerned, another research (N = 500), indicated that families chaotically-enmeshed appeared to have lower flexibility and self-compassion, too (Berryhill, Hayes, & Lloyd, 2018). It would be interesting to do a replication with other mental health issues and perhaps a lot can be tested out with the way families operate (Psychogiou et al., 2016).

There has also been a study where a connection was made between self-compassion and emotional invalidation and their role on psychopathology. Promising findings were shown for the application of self-compassion (Westphal, Leahy, Pala, & Wupperman, 2016).

4.2. Self-Compassion and Depression

Diedrich et al. (2014) revealed that self-compassion could be used with success as another adaptive emotion regulation strategy for patients with major depressive disorder, especially for those suffering from high levels of a depressed mood. Later, Diedrich et al. (2016) showed that self-compassion can enhance the efficacy of explicit cognitive reappraisal as an emotion regulation strategy in individuals with major depressive disorder and even though cognitive reappraisal sometimes is hard to be achieved by people with depression, self-compassion could work as a preparation for it and with good results. Krieger et al. (2016) found that lack of self-compassion is a predictor of depressive symptomatology even though the reverse doesn’t happen. This is an important finding on one hand, but on the other they still cannot claim a causal relationship, as the study hasn’t clearly investigated other mediators. However, one can argue that it is possible to cultivate compassion as other studies have shown. These studies (Diedrich et al., 2014; Krieger et al., 2016) bring forward that there is possibly a connection between self-compassion and depressive symptoms though the kind of relationship and how self-compassion results to the onset and maintenance of the symptoms of depression isn’t yet crystal clear. Thus, it is of great importance to research the role of low self-compassion in the emergence and maintenance of depressive symptoms and see its relevance to treatment and life-satisfaction (Døssing et al., 2015).

Yet another study agrees that self-criticism and depression are linked and gives away that people who are self-critical are those who need more to be self-compassionate and can benefit greatly from that. To manage to see their imperfections as part of their common humanity could be very helpful for these individuals and while it could take too long to completely understand how self-criticism and fear of compassion limits their lives, until then, they might benefit greatly by therapists who can teach them how to be kinder with themselves (Joeng & Turner, 2015).

4.3. Self-Compassion and General Diagnoses of Psychopathology

Additionally, in a sample with Borderline Personality Disorder undergoing a short training program in loving-kindness and compassion meditation (LKM/CM) symptoms were seriously improved as well as their acceptance, self-criticism and mindfulness (Feliu-Soler et al., 2016). Even though this is the first study to examine something like that, teaching LKM/CM to patients with BPD appears to be a valid choice with potentially great results for more kindness towards oneself and less judgement. Neff (2011) has already argued that love and wanting to take care of oneself isn’t compatible with negative feelings of harshness and non-acceptance, so this study seems to be congruent with previous indications.

Patients with persecutory delusions also had low self-compassion and feelings of inferiority, along with low self-esteem and low mood. Unexpectedly, self-stigma was quite on the same levels between the two groups (control group/persecutory delusions group) but the size of the sample might be the case for that. Suicidal ideation in the group with persecutory delusions was also high. This study too, brings forward that negative self-concept in patients with persecutory delusions are a clear treatment target, so self-compassion learning, through Compassion Focused Therapy (CFT) or as part of another therapy treatment could be suitable and help ease the negativity surrounding the delusions. Of course, because of the study design, it isn’t possible to see cause and effect. Future longitudinal studies research with larger sample sizes should be conducted (Collett et al., 2016). A very recent study study (Heath, Brenner, Lannin, & Vogel, 2018) with a sample of 369 subjects showed that self-stigma is moderated through self-compassion and that self-compassion might be a protective factor for the public stigma as well as self-stigma for those that seek psychological help.

Even though Gumley & Macbeth (2014) hypothesized that narrative compassion would correlate with the Self-Compassion Scale in individuals with psychosis, they didn’t find such a thing, but it might have to do with the small size sample. However, greater narrative compassion was associated with less negative symptoms, less cognitive disorganization and less excitement, adding to the general recognition that raised compassion for oneself and others can protect someone from feelings of threat, shame, humiliation and paranoia. Adding to the theory that CFT (Braehler et al., 2013) could help cultivating compassion in people with psychotic symptoms, this study argues that an attachment-based understanding of compassion, and specifically the domains of safe haven and secure base, could add to recovery from this kind of mental health problems (Gumley & Macbeth, 2014).

Another study (Eicher et al., 2013) with patients with schizophrenia or schizoaffective disorder highlighted that there was a negative relationship between self-compassion and measures of insight. Analysis of the findings indicated that those who had a better awareness of their situation had also higher levels of self-judgement, isolation and over-identification. That higher insight seems to be linked to lower self-compassion isn’t very encouraging, if self-compassion is seen as a trait-like feature. However, if self-compassion is seen from a learning standpoint there is room for improvement for everyone and compassionate mind training could really help these kinds of samples too (Gilbert & Irons, 2005). Individuals that are taught how to accept their reality better and treat themselves with kindness and compassion might not manage a disappearance of their symptoms but a might have a better chance of peace and life satisfaction. This is congruent with mindfulness as Kabat-Zinn (1990) sees it, which has to do with a great emphasis on accepting the present experience, regardless of whether the experience is pleasant, unpleasant or neutral.

Another systematic review (Inwood & Ferrari, 2018) found a promising link between self-compassion and emotion regulation, with self-compassion acting as a base to amplify people’s ability to experience their feelings.

Finally, a recent study (Kraiss et al., 2018) used positive psychology tools for assertion of the well-being of bipolar patients and self-compassion seemed to really make a difference in that.

4.4. Self-Compassion and Post-Traumatic Stress Disorder (PTSD)

Victims of childhood abuse also had lower self-compassion and fear of self-compassion. This fear might have to do with trauma pathology the paper suggests, and possibly higher self-compassion protects one from trauma (Miron et al., 2016). Two more studies (Maheux & Price, 2015; Maheux & Price, 2016) bring forward that self-compassion can be an antidote to PTSD symptom severity while a lack of it might be a factor of maintaining PTSD (Hoffart et al., 2015). Another study claims that social support can be extremely helpful for PTSD sufferers and that self-compassion protects from GAD and depression along with PTSD. It isn’t known though, if social support acts proactively as a protector from PTSD or if lack of it would be a risk factor (Maheux & Price, 2016).

Going further, a study examining PTSD symptom severity in traumatized women, supported the existing literature by showing that self-compassion was negatively related to PTSD symptom severity and to emotion dysregulation and positively related to resilience (Scoglio et al., 2015). This study indicates that self-compassion can be used as a resilience mechanism, something that is also supported by Trompetter et al. (2016) whose findings suggest that individuals with high levels of positive mental health possess self-compassion skills that promote resilience against psychopathology.

Last but not least, a recent study (Barlow, Goldsmith, Turow, & Gerhart, 2017) showed significant relations between negative trauma appraisals, childhood abuse, PTSD symptoms and self-compassion, in a sample of 466 university non-clinical students.

4.5. Self-Compassion, Internalized Self-Criticism, Fear of Self-Compassion and Shame

Given that most studies examining self-compassion use the standard Self-Compassion Scale and given that so many papers argue the importance of self-compassion for psychological health (Barnard & Curry, 2011; MacBeth & Gumley, 2012) there was a need to find out about the reliability of the SCS to a clinical sample. Lockard et al. (2014) did so with a large sample of university students and confirmed that. They also found no significant differences between race/ethnicity, sexual orientation, and gender. An important finding was that students who asked for help had low self-compassion levels, same as depressed adults. This is one more study indicating the importance self-compassion could have in a therapeutic setting and also one more study that shows that low levels of self-compassion might lead someone to seek counselling (even if it hasn’t to do with serious psychopathology).

There have been several papers (Gilbert et al., 2012; Gilbert, McEwan, Matos et al., 2011) investigating the potential relationship between people’s abilities to experience and tolerate positive emotions and how this connects to psychopathology. Gilbert et al.’s study (2012) takes this a step further by creating a new scale to measure fear of happiness and examines how it connects to fear of self-compassion, alexithymic traits, mindfulness, and empathy. Fears of positive affect scales (e.g., compassion and happiness) significantly linked to psychopathology and there was also a very high correlation between fear of happiness and depression. Fears of compassion were associated to depression, anxiety and stress, something that has already been explored from the literature (Gilbert, McEwan, Matos et al., 2011; Gilbert et al., 2012).

Reid et al. (2014) studied men with hypersexual behavior and tried to investigate if shame and rumination in these men was mediated by self-compassion. Results indicated that shame and negative feelings were indeed made easier to accept by cultivating self-compassion.

Compassion focused therapy was also found to be an important asset to the minimization of fear of self-compassion and psychopathology which is an indication for the future of therapy in clinical populations (Cuppage et al., 2018).

Finally, Xavier et al. (2016) supported that adolescents with Non-suicidal self-injury (NSSI) are highly self-critical and have feelings of shame and fear of self-compassion while they tend to punish themselves when they fail or don’t do very well. Self-compassion could probably be a great addition to these teens’ lives, helping them to incorporate their experience as the human condition and that failing is human.

4.6. Self-Compassion and Therapy Interventions

One of the first studies to examine self-compassion in a sample with alcohol dependence revealed that the participants were also experiencing depression and anxiety at higher levels than the general population (Brooks et al., 2012). Neff (2003a) has previously found that self-compassion is inversely related to depression and anxiety, something that this study confirms. What is striking in this study is that while participants with alcohol dependence were feeling more isolated and did harshly self-judge, they were also kinder to themselves, something that might had to do with using alcohol as a self-soothing technique. This has to be further researched to see if it is indeed so. Even so, participants reported greater self-compassion in the follow-up assessment and reductions in anxiety and stress. Future studies could benefit from a mindfulness intervention in a longitudinal design, to see how it interacts with that kind of sample.

A similar study, this time with Australian psychology trainees, with a pre-experimental repeated-measures design, asserted that online self-compassion training had a positive effect on the subjects’ feelings of happiness and self-compassion, while depression and stress were decreased (Finlay-Jones, Kane, & Rees, 2017).

Beaumont et al., 2012, designed a prospective comparative study in which two different groups underwent therapy for a trauma related incident with the same therapist, but while one group experienced Compassionate Mind Training (CMT) the other just have some typical Cognitive Behavioural Therapy (CBT) sessions. Even though the authors expected greater differences between the two groups, there weren’t that statistically semantic differences in avoidance, intrusive thoughts, hyperarousal, anxiety and depression. However, their third hypothesis, maintained that the participants in the combined CMT and CBT group would report much higher self-compassion levels and that was the outcome indeed. Even though the sample size wasn’t that big (N = 32), one can safely assume that CMT could be a useful addition to CBT when people are experiencing deep trauma.

Findings of a study (Braehler et al., 2013) with people recovering from psychosis, demonstrate that Compassion Focused Therapy (CFT) could be very useful even when there’s serious psychopathology involved. CFT appears to be a suitable intervention for people recovering from psychosis, helping them to turn off their inner judge and making the handling of distressing voices or internal threats more bearable. CFT was initially developed for people who were unable to feel compassion for themselves (Barnard & Curry, 2011) and people with psychosis are usually one of those groups. “A key aspect of CFT in psychosis involves helping individuals to develop a warm, caring, and attuned attitude towards difficult inner experiences”, writes Braehler et al. (2013). Other positive outcomes in the CFT group were reductions in depression, negative beliefs about psychosis, and fear of relapse. As a lot of people with such diagnoses report feeling ashamed or inferior to other people, CFT looks like it could be valuable.

Lastly, a systematic review showed that mindfulness interventions can help health care professionals to reduce stress (Burton et al., 2017).

5. Conclusion, Limitations and Future Research

In conclusion, this review provides useful information regarding the research of self-compassion in clinical sample. Even though most studies tend to agree that low self-compassion and psychopathology are present in clinical samples, no study until now can prove a clause for causality, as most studies were of a cross-sectional design. Future studies should use additional mediators to check out low self-compassion and mental health. Another question to be asked is if self-compassion is equally important for one’s recovery as is for prevention of appearance of mental illness. From this systematic review, it cannot be known if low self-compassion is a result of psychopathology or a vulnerability factor for it. Of course, this is a difficult thing to prove but maybe a longitudinal study starting with people at an early age could give away the relevant info. Another thing to consider is if self-compassion can help people build resilience to psychopathology and how these two concepts are interconnected. Even though causality cannot be admitted, findings of this review make it clear that self-compassion could potentially help everyone. It probably should be a part of every person’s therapy, whatever the therapeutic approach and CMT could especially help people with severe self-judgement, self-criticism, depression and metaphorical “self-beating”. The “internal judge” could be turned off and a more peaceful life could be achieved. Future research could focus on a single large study to see how if this is actually the case (Germer & Neff, 2013).

This review has its own limitations too. First of all, there was a high level of heterogeneity in the studies included. This was as true for the mental health issues involved as it was for races/ethnicities/genders/ages. A lot of papers included samples with more than one mental health issues. More studies need to be done, with the same issues of mental health and the same ages/genders (MacBeth & Gumley, 2012). Most of the studies didn’t have that large sample sizes which is a limitation for the generalization of the results, too. Another limitation was the sources of collecting data. Pubmed, Neff’s website and Google scholar do not necessarily have available all the relevant studies. One more limitation is that the majority of the studies used mostly white people as a sample. It would be interesting to find out differences between countries or cultures, if there are any. Another thing that should be considered is to check for cultural factors and for gender variables and how they affect levels of self-compassion. Last but not least, there are studies that use the full SCS and others that use the short form. This might be considered a problem too, as it’s not entirely sure that all self-compassion components play the same role when it comes to psychopathology and some of its factors seem to be indicative of psychopathology while others seem to be preventative, so this should be further explored for better classification and better treatment plans (Muris & Petrocchi, 2016).

Cite this paper
Dimitra, A. , Eirini, K. , Christos, P. , Agathi, L. and Anastassios, S. (2020) Self-Compassion in Clinical Samples: A Systematic Literature Review. Psychology, 11, 217-244. doi: 10.4236/psych.2020.112015.
References

[1]   Allen, A., & Leary, M. R. (2010). Self-Compassion, Stress, and Coping. Social and Personality Psychology Compass, 4, 107-118.
https://doi.org/10.1111/j.1751-9004.2009.00246.x

[2]   American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
https://doi.org/10.1176/appi.books.9780890425596

[3]   Barlow, M. R., Turow, R. E. G., & Gerhart, J. (2017). Trauma Appraisals, Emotion Regulation Difficulties, and Self-Compassion Predict Posttraumatic Stress Symptoms Following Childhood Abuse. Child abuse & neglect, 65, 37-47.
https://doi.org/10.1016/j.chiabu.2017.01.006

[4]   Barnard, L. K., & Curry, J. F. (2011). Self-Compassion: Conceptualizations, Correlates, & Interventions. Review of General Psychology, 15, 289-303.
https://doi.org/10.1037/a0025754

[5]   Beaumont, E., Galpin, A., & Jenkins, P. (2012). Being Kinder to Myself: A Prospective Comparative Study, Exploring Post-Trauma Therapy Outcome Measures, for Two Groups of Clients, Receiving Either Cognitive Behaviour Therapy or Cognitive Behaviour Therapy and Compassionate Mind Training. Counseling Psychology Review, 27, 31-43.

[6]   Berryhill, M. B., Hayes, A., & Lloyd, K. (2018). Chaotic-Enmeshment and Anxiety: The Mediating Role of Psychological Flexibility and Self-Compassion. Contemporary Family Therapy, 40, 326-337. https://doi.org/10.1007/s10591-018-9461-2

[7]   Blackie, R. A., & Kocovski, N. L. (2017a). Examining the Relationships among Self-Compassion, Social Anxiety, and Post-Event Processing. Psychological Reports, 121, 669-689. https://doi.org/10.1177/0033294117740138

[8]   Blackie, R. A., & Kocovski, N. L. (2017b). Forgive and Let Go: Effect of Self-Compassion on Post-Event Processing in Social Anxiety. Mindfulness, 9, 654-663.
https://doi.org/10.1007/s12671-017-0808-9

[9]   Braehler, C., Gumley, A., Harper, J., Wallace, S., Norrie, J., & Gilbert, P. (2013). Exploring Change Processes in Compassion Focused Therapy in Psychosis: Results of a Feasibility Randomized Controlled Trial. British Journal of Clinical Psychology, 52, 199-214.
https://doi.org/10.1111/bjc.12009

[10]   Braun, T. D., Park, C. L., & Gorin, A. (2016). Self-Compassion, Body Image, and Disordered Eating: A Review of the Literature. Body Image, 17, 117-131.
https://doi.org/10.1016/j.bodyim.2016.03.003

[11]   Brooks, M., Kay-Lambkin, F., Bowman, J., & Childs, S. (2012). Self-Compassion amongst Clients with Problematic Alcohol Use. Mindfulness, 3, 308-317.
https://doi.org/10.1007/s12671-012-0106-5

[12]   Burton, A., Burgess, C., Dean, S., Koutsopoulou, G. Z., & Hugh-Jones, S. (2017). How Effective Are Mindfulness-Based Interventions for Reducing Stress among Healthcare Professionals? A Systematic Review and Meta-Analysis. Stress and Health, 33, 3-13.
https://doi.org/10.1002/smi.2673

[13]   Candea, D. M., & Szentágotai-Tatar, A. (2018). The Impact of Self-Compassion on Shame-Proneness in Social Anxiety. Mindfulness, 9, 1816-1824.
https://doi.org/10.1007/s12671-018-0924-1

[14]   Collett, N., Pugh, K., Waite, F., & Freeman, D. (2016). Negative Cognitions about the Self in Patients with Persecutory Delusions: An Empirical Study of Self-Compassion, Self-Stigma, Schematic Beliefs, Self-Esteem, Fear of Madness, and Suicidal Ideation. Psychiatry Research, 239, 79-84. https://doi.org/10.1016/j.psychres.2016.02.043

[15]   Cuppage, J., Baird, K., Gibson, J., Booth, R., & Hevey, D. (2018). Compassion Focused Therapy: Exploring the Effectiveness with a Transdiagnostic Group and Potential Processes of Change. British Journal of Clinical Psychology, 57, 240-254.
https://doi.org/10.1111/bjc.12162

[16]   Diedrich, A., Grant, M., Hofmann, S. G., Hiller, W., & Berking, M. (2014). Self-Compassion as an Emotion Regulation Strategy in Major Depressive Disorder. Behaviour Research and Therapy, 58, 43-51. https://doi.org/10.1016/j.brat.2014.05.006

[17]   Diedrich, A., Hofmann, S. G., Cuijpers, P., & Berking, M. (2016). Self-Compassion Enhances the Efficacy of Explicit Cognitive Reappraisal as an Emotion Regulation Strategy in Individuals with Major Depressive Disorder. Behaviour Research and Therapy, 82, 1-10. https://doi.org/10.1016/j.brat.2016.04.003

[18]   D∅ssing, M., Nilsson, K. K., Svejstrup, S. R., S∅rensen, V. V., Straarup, K. N., & Hansen, T. B. (2015). Low Self-Compassion in Patients with Bipolar Disorder. Comprehensive Psychiatry, 60, 53-58. https://doi.org/10.1016/j.comppsych.2015.03.010

[19]   Ehret, A. M., Joormann, J., & Berking, M. (2014). Examining Risk and Resilience Factors for Depression: The Role of Self-Criticism and Self-Compassion. Cognition, 29, 1496-1504. https://doi.org/10.1080/02699931.2014.992394

[20]   Eicher, A. E., Davis, L. W., & Lysaker, P. H. (2013). Self-Compassion: A Novel with Symptoms in Schizophrenia? The Journal of Nervous and Mental Disease, 201, 1-5.
https://doi.org/10.1097/NMD.0b013e31828e10fa

[21]   Feliu-Soler, A., Pascual, J. C., Elices, M., Martín-Blanco, A., Carmona, C., Cebolla, A., Soler, J. et al. (2016). Fostering Self-Compassion and Loving-Kindness in Patients with Borderline Personality Disorder: A Randomized Pilot Study. Clinical Psychology & Psychotherapy, 24, 278-286. https://doi.org/10.1002/cpp.2000

[22]   Finlay-Jones, A., Kane, R., & Rees, C. (2017). Self-Compassion Online: A Pilot Study of an Internet-Based Self-Compassion Cultivation Program for Psychology Trainees. Journal of Clinical Psychology, 73, 797-816. https://doi.org/10.1002/jclp.22375

[23]   Germer, C. K., & Neff, K. D. (2013). Self-Compassion in Clinical Practice. Journal of Clinical Psychology, 69, 856-867. https://doi.org/10.1002/jclp.22021

[24]   Gilbert, P., & Irons, C. (2005) Focused Therapies and Compassionate Mind Training for Shame and Self-Attacking. In P. Gilbert (Ed), Compassion: Conceptualisations, Research and Use in Psychotherapy (pp. 263-325). London: Routledge.

[25]   Gilbert, P., McEwan, K. K., Gibbons, L. L., Chotai, S. S., Duarte, J. J., & Matos, M. M. (2012). Fears of Compassion and Happiness in Relation to Alexithymia, Mindfulness, and Self-Criticism. Psychology and Psychotherapy: Theory, Research and Practice, 85, 374-390. https://doi.org/10.1111/j.2044-8341.2011.02046.x

[26]   Gilbert, P., McEwan, K., Mato,s M., & Rivis, A. (2011). Fears of Compassion: Development of Three Self-Report Measures. Psychology and Psychotherapy: Theory, Research and Practice, 84, 239-255. https://doi.org/10.1348/147608310X526511

[27]   Gumley, A., & Macbeth, A. (2014). A Pilot Study Exploring Compassion in Narratives of Individuals with Psychosis: Implications for an Attachment-Based Understanding of Recovery. Mental Health, Religion & Culture, 17, 794-811.
https://doi.org/10.1080/13674676.2014.922739

[28]   Heath, P. J., Brenner, R. E., Lannin, D. G., & Vogel, D. L. (2018). Self-Compassion Moderates the Relationship of Perceived Public and Anticipated Self-Stigma of Seeking Help. Stigma and Health, 3, 65-68. https://doi.org/10.1037/sah0000072

[29]   Hoffart, A., ∅ktedalen, T., & Langkaas, T. F. (2015). Self-Compassion Influences PTSD Symptoms in the Process of Change in Trauma-Focused Cognitive-Behavioral Therapies: A Study of within-Person Processes. Frontiers in Psychology, 6, 1273.
https://doi.org/10.3389/fpsyg.2015.01273

[30]   Hoge, E. A., Holzel, B. K., Marques, L., Metcalf, C. A., Brach, N., Lazar, S. W., & Simon, N. M. (2013). Mindfulness and Self-Compassion in Generalized Anxiety Disorder: Examining Predictors of Disability. Evidence-Based Complementary and Alternative Medicine, 2013, Article ID: 576258. https://doi.org/10.1155/2013/576258

[31]   Inwood, E., & Ferrari, M. (2018). Mechanisms of Change in the Relationship between Self-Compassion, Emotion Regulation, and Mental Health: A Systematic Review. Applied Psychology: Health and Well-Being, 10, 215-235.
https://doi.org/10.1111/aphw.12127

[32]   Joeng, J. R., & Turner, S. L. (2015). Mediators between Self-Criticism and Depression: Fear of Compassion, Self-Compassion, and Importance to Others. Journal of Counseling Psychology, 62, 453-463. https://doi.org/10.1037/cou0000071

[33]   Kabat-Zinn, J. (1990). Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. New York: Dell Publishing.

[34]   Keyes, C. L. M. (2005). Mental Illness and/or Mental Health? Investigating Axioms of the Complete State Model of Health. Journal of Consulting and Clinical Psychology, 73, 539-548. https://doi.org/10.1037/0022-006X.73.3.539

[35]   Kraiss, J. T., Peter, M., Chrispijn, M., Trompetter, H. R., Stevens, A. W., Neutel, E., Bohlmeijer, E. T. et al. (2018). B-Positive: A Randomized Controlled Trial of a Multicomponent Positive Psychology Intervention for Euthymic Patients with Bipolar Disorder-Study Protocol and Intervention Development. BMC Psychiatry, 18, 335.
https://doi.org/10.1186/s12888-018-1916-3

[36]   Krieger, T., Berger, T., & Grosse Holtforth, M. (2016). The Relationship of Self-Compassion and Depression: Cross-Lagged Panel Analyses in Depressed Patients after Outpatient Therapy. Journal of Affective Disorders, 202, 39-45.
https://doi.org/10.1016/j.jad.2016.05.032

[37]   Leary, M. R., Tate, E. B., Adams, C. E., Allen, A. B., & Hancock, J. (2007). Self-Compassion and Reactions to Unpleasant Self-Relevant Events: The Implications of Treating Oneself Kindly. Journal of Personality and Social Psychology, 92, 887-904.
https://doi.org/10.1037/0022-3514.92.5.887

[38]   Lockard, A. J., Hayes, J. A., Neff, K. D., & Locke, B. D. (2014). Self-Compassion among College Counseling Center Clients: An Examination of Clinical Norms and Group Differences. Journal of College Counseling, 17, 249-259.
https://doi.org/10.1002/j.2161-1882.2014.00061.x

[39]   MacBeth, A., & Gumley, A. (2012). Exploring Compassion: A Meta-Analysis of the Association between Self-Compassion and Psychopathology. Clinical Psychology Review, 32, 545-552. https://doi.org/10.1016/j.cpr.2012.06.003

[40]   Maheux, A., & Price, M. (2015). Investigation of the Relation Between PTSD Symptoms and Self-Compassion: Comparison Across DSM IV and DSM 5 PTSD Symptom Clusters. Self and Identity, 14, 627-637. https://doi.org/10.1080/15298868.2015.1037791

[41]   Maheux, A., & Price, M. (2016). The Indirect Effect of Social Support on Post-Trauma Psychopathology via Self-Compassion. Personality and Individual Differences, 88, 102-107. https://doi.org/10.1016/j.paid.2015.08.051

[42]   Miron, L. R., Seligowski, A. V., Boykin, D. M., & Orcutt, H. K. (2016). The Potential Indirect Effect of Childhood Abuse on Posttrauma Pathology through Self-Compassion and Fear of Self-Compassion. Mindfulness, 7, 596-605.
https://doi.org/10.1007/s12671-016-0493-0

[43]   Muris, P., & Petrocchi, N. (2016). Protection or Vulnerability? A Meta-Analysis of the Relations Between the Positive and Negative Components of Self-Compassion and Psychopathology. Clinical Psychology & Psychotherapy, 24, 373-383.
https://doi.org/10.1002/cpp.2005

[44]   Neff, K. (2003a). The Development and Validation of a Scale to Measure Self-Compassion. Self and Identity, 2, 223-250. https://doi.org/10.1080/15298860309027

[45]   Neff, K. (2003b). Self-Compassion: An Alternative Conceptualization of a Healthy Attitude toward Oneself. Self and Identity, 2, 85-101.
https://doi.org/10.1080/15298860309032

[46]   Neff, K. D. (2009). The Role of Self-Compassion in Development: A Healthier Way to Relate to Oneself. Human Development, 52, 211-214.
https://doi.org/10.1159/000215071

[47]   Neff, K. D. (2011). Self-Compassion, Self-Esteem, and Well-Being. Social and Personality Compass, 5, 1-12. https://doi.org/10.1111/j.1751-9004.2010.00330.x

[48]   Neff, K., Hsieh, Y., & Dejitterat, K. (2005). Self-Compassion, Achievement Goals, and Coping with Academic Failure. Self and Identity, 4, 263-287.
https://doi.org/10.1080/13576500444000317

[49]   Potter, R., Yar, K., Francis, A. J., & Schuster, S. (2014). Self-Compassion Mediates the Relationship between Parental Criticism and Social Anxiety. International Journal of Psychology and Psychological Therapy, 14, 33-43.

[50]   Psychogiou, L., Legge, K., Parry, E., Mann, J., Nath, S., Ford, T., & Kuyken, W. (2016). Self-Compassion and Parenting in Mothers and Fathers with Depression. Mindfulness, 7, 896-908. https://doi.org/10.1007/s12671-016-0528-6

[51]   Raes, F., Pommier, E., Neff, K. D., & Van Gucht, D. (2011). Construction and Factorial Validation of a Short Form of the Self-Compassion Scale. Clinical Psychology & Psychotherapy, 18, 250-255. https://doi.org/10.1002/cpp.702

[52]   Reid, R. C., Temko, J., Moghaddam, J. F., & Fong, T. W. (2014). Shame, Rumination, and Self-Compassion in Men Assessed for Hypersexual Disorder. Journal of Psychiatric Practice, 20, 260-268. https://doi.org/10.1097/01.pra.0000452562.98286.c5

[53]   Samaie, G., & Farahani, H. A., (2011). Self-Compassion as a Moderator of the Relationship between Rumination, Self-Reflection and Stress. Procedia-Social and Behavioral Sciences, 30, 978-982. https://doi.org/10.1016/j.sbspro.2011.10.190

[54]   Scoglio, A. A., Rudat, D. A., Garvert, D., Jarmolowski, M., Jackson, C., & Herman, J. L. (2015). Self-Compassion and Responses to Trauma The Role of Emotion Regulation. Journal of Interpersonal Violence, 33, 2016-2036.
https://doi.org/10.1177/0886260515622296

[55]   Trompetter, H. R., de Kleine, E., & Bohlmeijer, E. T. (2016). Why Does Positive Mental Health Buffer Against Psychopathology? An Exploratory Study on Self-Compassion as a Resilience Mechanism and Adaptive Emotion Regulation Strategy. Cognitive Therapy and Research, 41, 459-468. https://doi.org/10.1007/s10608-016-9774-0

[56]   Waite, F., Knight, M. T., & Lee, D. (2015). Self-Compassion and Self-Criticism in Recovery in Psychosis: An Interpretative Phenomenological Analysis Study. Journal of clinical psychology, 71, 1201-1217. https://doi.org/10.1002/jclp.22211

[57]   Werner, K. H., Jazaieri, H., Goldin, P. R., Ziv, M., Heimberg, R. G., & Gross, J. J. (2012). Self-Compassion and Social Anxiety Disorder. Anxiety, Stress & Coping, 25, 543-558.
https://doi.org/10.1080/10615806.2011.608842

[58]   Westphal, M., Leahy, R. L., Pala, A. N., & Wupperman, P. (2016). Self-Compassion and Emotional Invalidation Mediate the Effects of Parental Indifference on Psychopathology. Psychiatry Research, 242, 186-191. https://doi.org/10.1016/j.psychres.2016.05.040

[59]   Wetterneck, C. T., Lee, E. B., Smith, A. H., & Hart, J. M. (2013). Courage, Self-Compassion, and Values in Obsessive-Compulsive Disorder. Journal of Contextual Behavioral Science, 2, 68-73. https://doi.org/10.1016/j.jcbs.2013.09.002

[60]   World Health Organization (1992). The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. Geneva: World Health Organization.

[61]   Xavier, A., Gouveia, J. P., & Cunha, M. (2016). Non-Suicidal Self-Injury in Adolescence: The Role of Shame, Self-Criticism and Fear of Self-Compassion. In Child & Youth Care Forum (pp. 1-16). New York: Springer. https://doi.org/10.1007/s10566-016-9346-1

[62]   Zessin, U., Dickhauser, O., & Garbade, S. (2015). The Relationship between Self-Compassion and Well-Being: A Meta-Analysis. Applied Psychology: Health and Well-Being, 7, 340-364. https://doi.org/10.1111/aphw.12051

 
 
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