Keywords

What Is Self-Compassion?

Clenched Fist Exercise

In order to understand self-compassion, consider the following guided skill-building exercise to explore what self-compassion may feel like in your body.

Skill-Building Exercise: Clenched Fist Exercise (Adapted from [1])

Take a moment while reading this. Place both of your hands in front of you, palms facing up. Slowly begin to clench your fists. Continue to squeeze until your hands are tight enough to be slightly uncomfortable. As you hold your clenched fists, notice the sensations in your hands, arms, shoulders, chest, and the rest of your body. Do you feel tight? Rigid? Stressed? This is a way to relate to what it can feel like moving through life with a highly self-critical, perfectionistic lens. It is often harsh, painful, and stress-inducing.

Now release your hands and open them with palms facing up. Feel the difference in sensation in all your body parts. You may notice a sense of relief, freedom, and spaciousness. This is what it may feel like to be kinder to ourselves, less self-critical, and acknowledge that imperfection is part of the common human experience.

To finish off, place one hand over the other on your chest. Again, notice what it feels like to do this. Does it feel strange or natural? Do you notice any resistance? Try to slowly and kindly let go of any judgments you may have, and really start to notice the warmth of your hands on your chest. You may start to feel a sense of comfort. This is what self-compassion can feel like, and what this chapter aims to help the reader work toward.

Defining Compassion

Before beginning to understand self-compassion, it is important to first define and explore the concept of compassion and the importance of compassion within medicine. Compassion may be defined as sensitivity to the pain or suffering of another, coupled with a deep desire to alleviate that suffering [2]. Compassion includes being touched by the suffering of others, offering understanding and kindness, and being moved so that one responds to another’s pain [3]. After all, the Latin etymology of “compassion” means “to suffer with” [4]. Thus, compassion toward another individual involves warmth and a desire to help. Importantly, it also involves an understanding that suffering and imperfection is part of the shared human experience.

Most physicians are motivated by a deep-seated desire to help others. This is a common reason for choosing a career in medicine. Compassion is also emphasized and taught within medical training. Physicians are expected by their profession, by patients, and by regulatory bodies to provide compassionate care. Most physicians are adept at providing compassion to others. However, turning compassion toward themselves can be foreign and particularly challenging. Going back to the Clenched Fist exercise, physicians often find it easier to feel compassion toward their patients (i.e., having an open hand), but when it comes to turning that compassion toward themselves, this can be much more challenging, and they may experience a lot of resistance (i.e., a clenched fist).

Defining Self-Compassion

Kristin Neff is widely recognized as a pioneer researcher of self-compassion. In 2003, she first operationalized the construct of self-compassion by dividing it into three components: (i) self-kindness, (ii) mindfulness, and (iii) a sense of common humanity [3]. In its most basic sense, self-compassion involves being compassionate toward oneself, or compassion that is directed inward.

The first component, self-kindness , entails being warm, compassionate, and understanding toward oneself when an individual does not live up to their own expectations or the expectations of others [3]. When one makes a mistake or fails, rather than beating oneself up, self-kindness encourages the individual to show caring toward themselves. Self-kindness therefore is in direct contrast to, and reduces, self-criticism, self-condemnation, blaming, and rumination [3].

The second component, mindfulness , is a modern term first derived from Buddhist and Hindu traditions. One of the more popular definitions by Jon Kabat-Zinn (founder of the Mindfulness-Based Stress Reduction (MBSR) program), is “paying attention on purpose, in the present moment, and nonjudgmentally” [5]. In the context of self-compassion, mindfulness refers to the ability to acknowledge and accept suffering while it is happening, or to “be with” suffering, while also creating separation from and not over-identifying with thoughts and feelings associated with suffering [3]. In essence, it encourages one to acknowledge their own pain without becoming absorbed or swept away by their aversive reaction to this pain. This “makes us more willing to accept, experience, and acknowledge difficult feelings with kindness—which paradoxically helps us process and let go of them more fully” [3]. Mindfulness allows an individual to see their situation with clarity so that they may respond to it effectively. This component of self-compassion may sound simple, but in the face of suffering, many individuals do not recognize that they are suffering, thus preventing them to be able to respond appropriately. Becoming mindful of suffering, so that one can respond, is a critical first step to being able to effectively respond to challenge in a way that supports health and resilience.

The third and final component, a sense of common humanity , involves recognizing that suffering and personal inadequacy are part of the shared human experience, something that all individuals go through rather than being something that happens to “me” alone [3]. This recognition helps one realize that all humans are flawed and make mistakes and that pain and suffering is a natural part of life, for every human being, without exception. Therefore, to make mistakes and to suffer is completely normal and natural rather than an indication that one is “flawed” or that one’s life is not happening as it is “supposed” to. Being aware of common humanity in the midst of suffering can provide a sense of interconnectedness and comfort in knowing that one is not alone.

Self-compassion teaches an individual to become an inner friend or ally to themselves, rather than an inner enemy [1]. In the face of suffering, it encourages one to ask “What do I need right now?” And gives permission to act or to respond to this need. This may be particularly relevant for physicians who are focused on meeting the needs of others, while not being aware of, or sacrificing, their own needs.

Table 2.1 outlines the three components of self-compassion (self-kindness, mindfulness, a sense of common humanity), and also pairs each component with counterparts to aid with understanding. Self-kindness can be contrasted with self-judgment, mindfulness with over-identification, and a sense of common humanity with isolation.

Table 2.1 The three components of self-compassion [3]
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Skill-Building Exercise: How Self-Compassionate Are you?

If you would like to learn how self-compassionate you are, you can complete the free self-compassion scales available online, such as the scale developed by Neff and colleagues. (See section “Additional Resources”, for further information.) It is helpful to have an objective assessment of your baseline measure of self-compassion. As you learn about self-compassion and apply the concepts in this chapter (along with self-compassion practices in Chap. 15), you can return to the scale you initially completed to gauge your progress.

Key Points

  • Self-compassion encourages us to mindfully accept moments of pain and suffering, to embrace ourselves with kindness and care in response, and to remember that imperfection and suffering is part of the shared human experience [3].

  • When feeling intense moments of self-criticism, rumination, and blaming, try to remember the Clenched Fist exercise and what it felt like to release your fists.

Skill-Building Exercise: Reflection

Imagine if you were feeling overwhelmed after a difficult clinical day. Perhaps you had to deal with an agitated, angry family member or witnessed a bad patient outcome. Perhaps systemic challenges made it difficult to get your patient the care they needed. Now imagine a friend or colleague walked into the room, sat down beside you, put their arm around you, listened to your distress, and then helped you to work out a plan or solution. What would that feel like? Now imagine if that friend or colleague were you. By learning self-compassion, you can be there to support yourself in any moment. This offers a coping mechanism, and a supportive ally, that is with you at all times.

Self-Compassion for Skeptics

Common Myths

People often have hesitations or misperceptions about self-compassion. If, as a reader, there are questions that are already arising in this regard, this is absolutely normal and expected. Before reviewing the evidence that supports the many benefits of self-compassion, it is important to start by addressing the myths that can prevent people from being open to considering self-compassion as something worth learning about or something that may be helpful or relevant in their own life. Below are some of the common myths and reservations that come up around the concept of self-compassion, followed by the facts.

Self-compassion will make me lazy and unmotivated. I’m a doctor, I have to work hard to get through my training! Self-compassion would probably make me study less and skip work whenever I feel like it.

One of the most common concerns people have with self-compassion is that it will impact their motivation and ambition. This is amplified by the fact that many physicians have traditionally sought motivation through self-criticism, which is commonly reinforced within the culture of medicine. Self-criticism motivates individuals through the fear of failure and shame [6]. For many, self-criticism/the fear of failure can be a very effective source of motivation in the short term. The issue, however, is that too much self-criticism can undermine self-confidence and leads to a fear of failure in the long term. Self-criticism is linked to depressive vulnerability, negative rumination, anxiety, and feelings of worthlessness, shame, and guilt [7,8,9].

Motivation through self-compassion, on the other hand, can help us maintain our self-confidence and feel emotionally supported while working toward our goals. In a study of 222 undergraduate students, those who had higher levels of self-compassion had less anxiety and higher levels of intrinsic motivation [6]. Additionally, the positive relationship between self-compassion and intrinsic motivation was mediated by greater perceived competence and mastery of goals (i.e., learning for the sake of learning, irrespective of outcome) associated with self-compassion [6]. These findings suggest that individuals who are self-compassionate may be better able to see failure as a learning opportunity and to focus on accomplishing goals, as opposed to ruminating on low self-worth and failure. In other words, people who are more self-compassionate are less afraid of failure and are more likely to try again and to persist after making a mistake [1].

Kristin Neff and Christopher Germer highlight that there is an important active component of self-compassion that is related to motivation. They refer to the yin and yang of self-compassion [1, 10]. The yin of self-compassion refers to what are generally seen as the “softer” attributes, or “being with oneself” in a compassionate way—comforting, soothing, and validating oneself [1]. The yang of self-compassion, on the other hand, is about “acting in the world”—protecting, providing, and motivating oneself [1, 10]. This concept of the yin and yang emphasizes that at times we may need to care for ourselves by providing comfort or soothing (i.e., by resting, speaking to ourselves kindly, or giving ourselves a break). At other times, we need to take the more yang “action-oriented” approach (i.e., by motivating ourselves, standing up for ourselves by saying “no,” or solving a problem and pushing forward toward our goals). Therefore, self-compassion does not mean being self-indulgent. In fact, self-compassion encourages individuals to work toward their long-term goals and to make choices that will support their success, health, and well-being. Self-compassion motivates an individual to reach their goals because they care about themselves and want to reach their full potential, rather than because of a fear of being inadequate [1]. Motivating oneself and working toward achieving one’s goals is, in this sense, a form of self-care.

Skill-Building Exercise: Reflection

Think back to your path of becoming a resident physician and your journey to medical school. What motivated you to study long hours for exams? What motivated you to participate in numerous extra-curricular activities while balancing a course-load? What got you through the long hours of clerkship and call? Was it the fear of not getting into medical school or failing medical school? Was it the love for what being a doctor would entail? Which form of motivation was stronger? How did these different forms of motivation impact your self-esteem and emotional state? Were there any benefits or negative consequences to these forms of motivation?

Now, reflect on the form of motivation you use when working with patients. If you were working with a patient suffering from addiction, would you take a harsh, critical approach by condemning the patient for relapsing and focus on their past mistakes? How effective do you think that would be? Would you take a strength-based approach, validate how common relapse is, focus on previous successes, and encourage them to use the relapse as an opportunity to learn, reassuring them that they are not defined by their relapse, and that change is still possible? How effective would this type of approach be?

Is there a difference between the motivational approach you apply to yourself versus others?

Doesn’t self-compassion mean throwing a pity party for myself? No thanks, I don’t have time to wallow in my sorrows – I have patients to help.

Self-compassion, in fact, is the antithesis of self-pity. Self-pity is a process by which individuals become absorbed and attached to their own problems, forgetting that others are experiencing similar things [3]. As a result, through self-pity, one gets carried away by their emotional reactions (i.e., “over-identification” as shown in Table 2.1). With self-compassion, in contrast, there is a recognition that everyone faces adversity (common humanity), and there is an emphasis on not over-identifying with the emotional reactions that arise from suffering (mindfulness), therefore preventing, or breaking, the cycle of self-absorption. Self-compassionate people are more likely to engage in perspective taking and less likely to ruminate, and in this way self-compassion helps to protect against anxiety and depression [11].

Self-compassion is for wimps. I’m a doctor, I have to be tough and resilient to get through my career.

There is an increasing emphasis in medical education on building resilience in medical practitioners. As emphasized earlier, self-compassionate individuals are kinder to themselves when they fail, are more aware that failure is part of the common human experience, and are thus more able to see failure as a chance to learn and grow, rather than fearing that a negative performance may diminish their self-worth [6]. Being resilient and being kind to ourselves are not mutually exclusive. In fact, the components of mindfulness, common humanity, and kindness can be critical tools in resiliency training.

In a study of 213 medical professionals, allied health professionals, and trainees (physicians (38%), nurses (14%), social workers (24%), dieticians (11%), and others (12%)), resilience was strongly and significantly correlated with both mindfulness (r = 0.5; p < 0.01) and self-compassion (r = 0.54; p < 0.01) [12]. Mindfulness and self-compassion were also correlated with physical health, mental health, and perceived stress [12]. In a different study involving undergraduate students, self-compassion was associated with reduced negative affect and emotional reactivity in response to everyday difficult situations [13].

Self-compassion is too ‘fluffy’ for me. I don’t feel comfortable talking to myself in that way.

For many, the language of self-compassion, including the terms “self-compassion” and “self-kindness,” can conjure up resistance. It is important to remember that self-compassion is about the intention to be kind to oneself. The words can be easily changed and personalized to reflect how one would naturally speak to themselves or others. What feels right and appropriate will be individual to each person and can change over time. Instead of using the word “self-compassion,” for example, one may use the terms “inwardly directed friendliness,” “inner-strength,” “inner-resilience,” “taming your inner critic,” or whatever term feels most authentic. A helpful strategy may be to think of what one might say to a friend or a patient if they were facing the same challenge or experience and use similar language with oneself.

Self-compassion is no different from self-esteem!

Self-esteem is predicated on a positive evaluation of self-worth and may lead to comparison and feelings of superiority to others [6]. This becomes difficult, especially in high-intensity, competitive environments like medicine as there will always be someone seemingly more successful and intelligent. As a result, self-esteem can fluctuate, being present when we succeed, but absent precisely when we need it the most [1].

Self-compassion, on the other hand, does not involve evaluation or judgment of ourselves or others. Instead, self-compassion encourages that individuals accept themselves as they are, especially when they fail or feel inadequate [1]. Self-compassion does not require comparison to our peers or feeling superior to others. Instead, we are reminded that all individuals are imperfect, including ourselves. As such, self-compassion is linked to less social comparison and narcissism [1]. Self-compassion provides a more stable sense of self, as it is not contingent on conditions like material success or positive performance. Kristin Neff explains that the goal of self-compassion is to become a ”compassionate mess,” acknowledging one’s imperfections yet still accepting and relating to oneself in a friendly way despite these imperfections [1].

Skill-Building Exercise: What Do I Need Right Now? (Yin & Yang)

Once we have recognized a moment of distress (mindfulness), we can then reflect and respond (see Fig. 2.1).

Fig. 2.1
figure 1

The 3 R approach to self-compassion (further expanded upon in Chap. 15, Kindness Begins with Yourself)

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Reflect both on what you need in that moment and the common humanity of the situation.

Respond with self-kindness, using the yin and yang approach (see Fig. 2.2).

Fig. 2.2
figure 2

Self-compassionate responding using the Yin-Yang approach

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Key Points

  • Self-compassion is associated with higher levels of motivation: people who are more self-compassionate are less afraid of failure and more likely to persist to achieve their goals [1, 6].

  • The yin of self-compassion refers to “softer” attributes including comforting, soothing, and validating. The yang of self-compassion refers to “action” attributes including protecting, providing, and motivating [1]. It is helpful to ask oneself “what do I need right now?” and choose the approach that is most helpful for the given moment.

  • Self-compassion is an antidote to self-pity. Self-compassionate individuals recognize that all individuals suffer and are less likely to ruminate in the face of mistakes or challenge [1, 11].

  • It is important to use language that feels natural when practicing self-compassion. Individuals may use their own terms; e.g., “inner-friendliness,” “inner strength,” and “inner resilience,” or whatever feels right to them.

  • Self-compassion provides a more stable sense of self-worth than does self-esteem and is there for individuals especially when they fail or feel inadequate [1].

What Are the Benefits of Self-Compassion, and How Does It Work? – A Look at the Evidence

An explosion of research over the last decade has demonstrated the benefits of self-compassion on mental and physical well-being. It is important to note that although self-compassion can vary in different individuals, it is not a fixed trait but rather something that can be learned [1]. Mindful self-compassion developed by Kristin Neff and Christopher Germer was the first training program specifically designed to enhance self-compassion [1]. Mindful self-compassion is an 8-week course that introduces the construct of self-compassion and teaches individuals self-compassion practices (many of which will be introduced in Chap. 15, Kindness Begins with Yourself). People who take the mindful self-compassion course were shown to have increased their levels of self-compassion by an average of 43% [1], in addition to achieving other benefits including reduction in anxiety and depression, enhanced overall well-being, and even improved stability of glucose levels among those with diabetes mellitus [1]. It is noteworthy that the increase in self-compassion and other benefits were maintained 1 year later [1]. Other mindfulness-based training programs, such as Mindfulness-Based Stress Reduction (MBSR) and Mindfulness-Based Cognitive Therapy (MBCT), have also been shown to increase self-compassion, but they do so implicitly as a by-product of mindfulness [1].

Self-Compassion and Psychopathology

Several studies have shown the link between self-criticism and psychopathology, including positive association with major depressive disorder, severity of depression, specific depressive symptoms, and poorer response to treatment [14,15,16,17]. A large meta-analysis by MacBeth and Gumley sought to examine the relationship between self-compassion and psychopathology, primarily depression, anxiety, and stress. Included in the analyses were 14 studies representing 20 participant samples (n = 4007). Their findings showed a strong negative correlation between self-compassion (as scored by the Neff Self-Compassion Scale) and the measures of psychopathology (depression: r = −0.52; anxiety: r = −0.51; stress: r = −0.54) [18]. In other words, individuals who were more self-compassionate had less depression, anxiety, and stress. These findings thus suggest that compassion plays an important role in understanding mental health and resilience.

Self-Compassion and Well-Being

When discussing the benefits of self-compassion, it is important to not only reflect on its role in mitigating psychopathology, but also on its role in overall well-being. Well-being is more than the absence of psychopathology. In psychological research, there are many different conceptualizations of well-being. A meta-analysis of 79 studies by Zessin and colleagues (overall sample size of n = 16,416) examined the relationship of self-compassion to four different forms of well-being: cognitive well-being (one’s cognitive evaluation of life, often called “life satisfaction”); positive affective well-being (the presence of positive or pleasant affects); negative affective well-being (the absence of negative or unpleasant affects); and psychological well-being (fulfillment of one’s true potential and living a meaningful life) [19]. Analyses of the 79 studies found the strongest correlations between self-compassion and psychological well-being (r = 0.62), followed by cognitive well-being (r = 0.47) and negative affect (r = −0.47), and lastly positive affective well-being (r = 0.39) [19]. Thus, individuals with higher levels of self-compassion had a significantly increased sense of meaning and fulfillment in their lives. In interpreting the findings related to increased cognitive well-being or increased life satisfaction, Zessin and colleagues used Diener’s cognitive approach to well-being: top-down and bottom-up theories [19, 20]. In top-down well-being, the development of well-being is associated with an individual’s focus on positive situations and a more positive interpretation of events (e.g., individuals perceive life events, whether negative or positive, in a more positive way, so the impact of the event is buffered by an internal perceptive filter) [19]. On the other hand, bottom-up well-being refers to the process by which positive situations increase the level of well-being and negative situations decrease the level of well-being (e.g., individuals are negatively affected by negative events, and positively affected by positive events, making them more susceptible to the impact of external events) [20]. Therefore, self-compassion could play a role in buffering negative events through cognitive reframing and recollecting more positive memories (e.g., not considering mistakes/failures as negative events, but rather perceiving failures as opportunities for growth and learning, thus integrating them more positively) [19]. Lastly, as explained by Neff and Dahm, self-compassion does not simply lead to the replacement of negative feelings with positive ones, but rather individuals high in self-compassion cognitively accept and integrate negative experiences [21]. There is an acceptance of reality, including negative experiences, in a healthy way.

Additional research has shown that self-compassionate people tend to engage in more healthy behaviors including exercise and proper nutrition [1]. One study of 182 college students demonstrated that self-compassion was positively associated with increased psychological and physical well-being [22]. When investigators delineated the three components of self-compassion (i.e., self-kindness, common humanity, and mindfulness), there was a differential influence of these components on physical and psychological health. Self-kindness and common humanity were predictive of lower depressive symptomatology and increased physical well-being, whereas self-kindness and mindfulness were predictive of better ability to manage life stress [22].

In summary, people with higher levels of self-compassion experience greater physical and mental well-being, as illustrated in Fig. 2.3.

Fig. 2.3
figure 3

Correlation between self-compassion and physical and mental well-being

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Self-Compassion and Its Specific Role in Healthcare Providers

According to the 2018 Canadian Medical Association’s (CMA) National Physician Health Survey, resident physicians reported high levels of burnout, depression, and lifetime suicidal ideation [23]; 48% of residents screened positive for depression, 32% for burnout, and 20% for life-time suicidal ideation [23]. The underlying reasons for high levels of distress among physicians and medical trainees are multifactorial and complex. An important factor that is relevant to the discussion of self-compassion is the continuous exposure of physicians to the suffering and pain of others. Neuroscientific research on mirror neurons has shown that similar brain regions are activated in observers as those activated in a person who is experiencing a particular sensation or performing a certain action [24]. When an individual learns of another’s pain, this stimulates the same brain circuits and regions as if they were the one directly experiencing the pain themselves [25]. This is referred to as empathic resonance [1]. Witnessing suffering can therefore cause vicarious suffering or empathic distress [1]. Although empathy is a good thing, and particularly important for physicians and other caregivers, repeated exposure to patients’ pain and suffering can lead to an accumulation of empathic distress and eventually this can be overwhelming. It may lead to burnout or what is often referred to as compassion fatigue. Compassion fatigue is discussed in more detail elsewhere in this book, but briefly, the term first emerged with the work of Charles Figley who defined it as “the formal caregiver’s reduced capacity or interest in being empathic or ‘bearing the suffering of clients’” [26, 27]. Some researchers have argued that compassion fatigue is a misnomer and that a more accurate term is empathic fatigue [24]. Regardless of the term that one uses to describe this phenomenon, caregiver fatigue is a sign of caring rather than a sign of weakness. In fact, caregivers who are more capable of empathic resonance are more vulnerable to experiencing caregiver fatigue [1]. Therefore, the same quality that makes one a good physician can also make one more vulnerable to suffering. (For further details, see Chap. 10, Recognizing Compassion Fatigue, Vicarious Trauma, and Burnout.)

Kristin Neff also highlights an important difference between empathy and compassion. Empathy refers to a deep understanding of another’s situation, such that the person empathizing is feeling together with the other individual [6]. Although compassion shares the elements of recognizing and relating to another’s pain and suffering, it differs by embracing the suffering but not suffering along with it [7, 8]. While empathy says “I feel you,” compassion says “I hold you” [1]. In this way, Neff explains that compassion is a positive and energizing emotion rather than a distressing one [1]. Compassion allows an individual to offer tenderness, support, and encouragement in a way that is not draining, but rather maintains the well-being of the caregiver [9]. In one study, individuals were trained for several days to experience either empathy or compassion, and then they were shown a short film depicting others’ suffering [24]. When looking at the brain networks that were activated while the participants were watching the films, the individuals who had been exposed to compassion training produced more positive emotions as compared to the individuals that received empathy training [24]. Physicians cannot avoid being exposed to the suffering of patients. However, by changing the relationship to that suffering, physicians may be able to protect themselves from undue hardship.

How can self-compassion be helpful specifically in the medical context? By staying connected to themselves and being mindful of their empathic distress, clinicians can acknowledge how difficult it can be to listen and witness another’s suffering and can allow for self-kindness during these difficult moments. Self-compassion also allows a clinician to recognize and meet their own needs so that they can sustain the ability to be present and available for others [1]. When physicians and other clinicians become so concerned with the needs of others that they do not meet their own needs, they are at risk of becoming depleted and less able to give over time [1]. This can be likened to a healthcare professional putting their own oxygen mask on before helping others. Self-compassion can also help decrease self-criticism and feelings of failure. Physicians and other clinicians can often be self-critical, believing that they are “not doing enough” for their patients. A self-compassionate approach reminds clinicians that they have limited control over others’ suffering, thus relieving the often-held sense of responsibility to “solve” suffering in the moment. Lastly, when a physician is able to comfort and soothe themselves when they are providing care to a suffering individual, the individual benefits through their own empathic resonance. The patient will be more likely to feel calmed and soothed by the calm and healthy mind state of the physician [1].

In a systematic review of 23 studies exploring the role of self-compassion in healthcare providers, all studies reported that self-compassion and well-being were associated with reduced levels of burnout, compassion fatigue, and/or stress symptoms in medical trainees, midwives, psychologists, primary healthcare providers, and other clinicians [27]. Self-compassion is therefore being considered a target variable in several education programs to both improve work-related stress and interpersonal functioning [27].

Skill-Building Exercise: Pause and Reflect

In “The Mindful Self-Compassion Workbook,” Kristin Neff and Christopher Germer share some helpful reflections that remind us of our limited control over the suffering of others [1]. They emphasized how our own life journey is a unique, individual experience, how we are not the cause of another person’s suffering, nor is it always entirely within our own power to diminish the suffering, yet we may still try to help if we can [1].

  • Take a moment to reflect on these words and how they relate to your own experiences.

  • How may this reflection help you to be self-compassionate during times when you are helping someone who is suffering?

How Does Self-Compassion Work?

One hypothesis of the biological effects of self-compassion that is currently under research investigation is the connection between self-compassion and the mammalian care system [1, 28]. When the care system is activated in infants (e.g., through soothing touch and gentle vocalizations), oxytocin and endorphins are released which help the infant feel safe [28]. Compassion is linked to this mammalian care system and could thus play a role in reducing the stress response. This has been shown in studies exploring the role of self-criticism and self-compassion in mediating salivary stress markers [29,30,31]. In particular, perfectionistic self-criticism has been found to increase stress-induced salivary α-amylase and cortisol release, indicators of sympathetic and hypothalamic-pituitary-adrenal (HPA) axis activation [29, 30]. By contrast, self-compassion has been shown to be a negative predictor of stress-induced increases of salivary α-amylase [31]. Although still a working hypothesis, the role of self-compassion in mediating the stress response is a promising area of investigation.

Key Points

  • According to the CMA National Physician Health Survey, residents reported high levels of burnout, depression, and lifetime suicidal ideation [23].

  • There has been an increasing interest in self-compassion training for health-care providers to help address compassion fatigue and burnout [27].

  • Evidence has shown strong negative correlation between self-compassion and psychopathology (e.g., depression, anxiety, stress) [18].

  • Self-compassion has been shown to have strong positive correlations to various forms of well-being. Individuals that are more self-compassionate have increased levels of cognitive and emotional well-being [19].

  • Resilience in healthcare professionals has been shown to be strongly and significantly correlated with self-compassion [27].

  • Self-compassion is associated with better physical health and mental health and less perceived stress, negative affect, and emotional reactivity [1, 19, 22].

Check Your Learning

Case Studies

Case I

Amrita is a general surgery resident in her second year of training. In medical school she enjoyed her surgery rotations particularly because of the demand for precision, working with her hands, and seeing direct results. She also admired many of her preceptors, who excelled at their work and were confident leaders in the operating room.

In her first year of residency, Amrita found the transition of responsibility to be more challenging. She found that as a resident, her preceptors expected a lot from her. It was an unwritten rule in her field to stay late, read around cases, and be heavily involved in research at the same time. With her busy schedule, Amrita found herself rushing to finish an abstract one night to meet a deadline for an upcoming conference. After staying up late into the night, she reported to work the next day to operate. With her recent interest in mindfulness practice, she checked in with herself walking into the OR, noting the heaviness of her eyes and her clouded mind. Although usually very meticulous, today during the surgery Amrita ended up breaking the sterile field. She also struggled when asked about specific anatomy during the cholecystectomy due to not having time to review the night before.

Amrita came home tearful and finding herself overwhelmed by shame and embarrassment. She called her partner saying, “I should have worked harder. All the other residents seem so on top of their game, yet here I am performing at the level of an R1.”

  • Question. How might Amrita handle this situation which would reflect a self-compassionate approach as opposed to a self-critical one?

    1. A.

      Amrita recognizes that she feels guilty and upset by the situation. She reflects that what she needs right now in order to cheer herself up is to put on an episode of her favorite show. She also decides to call her sister and talk through what happened, and then get a good night’s rest.

    2. B.

      Amrita spends the rest of the night replaying the surgery in her mind, questioning herself and her abilities, and fixating on her perceived incompetence. In response, she pulls another all-nighter reading around the next case in hopes of impressing her preceptor.

    3. C.

      Amrita takes some time to reflect on the struggle and stress that arose from her performance, recognizing that her reaction and emotions are normal and understandable given the circumstance. She also reminds herself that this was a common mistake, and that many other residents have likely made similar mistakes. She also recalls her friend at another school experiencing the same doubt when he could not answer several questions during his clinical teaching unit (CTU) elective. She remembers telling him that as a resident, he is still learning, and that the point of residency training is to continuously learn and expand on knowledge and expertise over time. She remembers encouraging him to see this experience as an opportunity to identify learning goals and topics that he can read around, rather than seeing this as an indication of failure. She realizes that this applies to her current situation as well. Amrita reminds herself that she works very hard, cares deeply for her patients, and that there is something she can learn from this situation going forward. She decides to write out a learning plan that she will review with her supervisor the following day. She also reflects on the impact that sleep deprivation had on her ability to focus that day. She decides to go to bed earlier that night to allow herself to get the rest that she needs, knowing that being rested will put her in the optimal state to begin working on her new learning goals.

Answer: A or C ✔

Recall Fig. 2.2 . While answer B may be the typical knee-jerk response for most medical learners when such a situation arises, this is reflective of self-criticism and pushing oneself past one’s limits. Although this may seem like the “yang” action-oriented approach to self-compassion, reflect on what Amrita needs in moment. She already felt tired and absent-minded during the surgery and likely needs rest to perform optimally. Her rumination would likely promote feelings of worthlessness and ineptitude, and could eventually amount to Amrita experiencing shame as she suspects no one else in her cohort would have made the same mistake.

Answers A and C however are more suggestive of a self-compassionate approach to the situation. In answer A, Amrita takes a “yin” approach and recognizes that, in this moment, it would be helpful to watch her favorite show. She also calls her sister and likely receives validation. This helps to provide her with some mental distance from the event and to help diffuse and lessen the intense distressing emotions she is experiencing. By giving herself permission to take a TV break, she demonstrates some kindness to herself and her needs. Similarly, answer C demonstrates the validating component of “yin.” By taking some time to reflect on the common humanity shared by residents, she can see this situation as a learning opportunity and part of her growth as a junior physician, rather than a personal failure. This motivates her to take accountability and develop new learning goals, in keeping with the action oriented “yang” approach. She also recognizes that this is an opportunity to reflect on factors, such as sleep, that may impact on her learning and performance, and that she can optimize over time to increase her chances of success.

Case II

Case II Part I

Kevin is an internal medicine resident in his first year of training. During his rotation in the CTU, he begins to feel the impact of his long hours. Normally a very caring person, he finds himself struggling to be empathetic with most of the patients on his ward. More recently, Kevin has started to have some trouble sleeping and has developed a poor appetite. Despite all that has been going on, Kevin finds himself particularly connected to an older gentleman on his ward – Mr. Chen.

Mr. Chen, a former WWII veteran, was admitted to hospital with an acute kidney injury. Despite initially doing well, recently, his health has been deteriorating. Kevin really enjoys chatting with Mr. Chen, as he reminds him of his own grandfather who also served in the war. One night during Kevin’s call shift, Mr. Chen has a cardiac arrest. A code blue is called and despite several rounds of cardiopulmonary resuscitation, Mr. Chen ends up passing away.

Kevin spends the rest of the shift filled with emotion. After connecting so strongly with Mr. Chen and his family, he feels like he should have done more. He starts to have thoughts about being inadequate and feels as though he may not be cut out for medicine.

  • Question. How might Kevin handle this situation using a self-compassion approach?

    1. A.

      Kevin recognizes the recent changes in his sleep and appetite as a worrying sign. He reaches out to his old roommate Bo, who is a first-year resident at a neighboring school. Bo validates Kevin saying that he too had a similar experience during his internal core of clerkship. He suggests that Kevin reaches out to his Student Affairs office to seek counseling. Kevin is initially hesitant, thinking that his problem is not serious enough to seek counseling for. However, he ends up seeking out support and finds value in his counselor’s non-judgmental approach. Through this experience he realizes that he can be kinder to himself by reflecting more on what was in his control and what was not.

    2. B.

      Kevin opens his daily journal to his first few rotations and reflects on his previous successes and the fulfilling patient interactions he has had in the past. He spends some time writing about his experiences from the call shift and finds comfort in this. He becomes more aware of the emotions that he is experiencing by writing them out and finds himself resisting them less.

    3. C.

      Kevin, feeling extremely guilty about his patient passing away, forgoes his post-call nap to read up on acute kidney failure. He calls his family to let them know that he will not be able to make it to the family dinner as he is extremely busy and needs to do work.

Answer: A or B ✔

Recall Fig. 2.2 . Similar to the previous case, answer C may again be reflective of self-criticism and pushing oneself past one’s limits. Answers A and B are more suggestive of a self-compassionate approach to the situation. In answer A, Kevin takes both a “yin” and “yang” approach by seeking out support from a friend and eventually a counselor. He not only feels validated, but he also is providing for himself and his needs. In answer B, Kevin is able to find comfort through his journaling and taking a mindful approach to his difficult emotions.

Case II Part II

The next day, Kevin comes into work to a note left for him with the nursing staff. He finds a thank you card from Mr. Chen’s family. The note states how thankful the family is that Kevin took the time to hear Mr. Chen’s story and look at him as more than just a sick person. Kevin’s preceptor shares with Kevin the reflections from Kristin Neff and Christopher Germer’s “The Mindful Self-Compassion Workbook” previously discussed in the skill-building exercise at section “Self-compassion and Its Specific Role in Healthcare Providers” [1]. Once again, those authors reminded us about our own life journey as a unique, individual experience; that we are not the cause of another person’s suffering, nor is it always entirely within our power to diminish the suffering, yet we may still try to help if we can [1].

These words remind Kevin that it was not within his power to prevent the outcome of Mr. Chen’s complex medical condition. However, he was still able to help by providing compassionate care and giving Mr. Chen dignity and respect during his final days.

Key Takeaways

  • Self-compassion as defined by Kristin Neff is divided it into three components [3]:

    • Self-kindness versus self-judgment

    • A sense of common humanity versus a sense of isolation

    • Mindfulness versus over-identification

  • With self-compassion we mindfully accept that the moment is painful and embrace ourselves with kindness and care in response, remembering that imperfection is part of the shared human experience [3].

  • Self-compassion increases motivation and resilience [1, 5].

  • Several systematic reviews and meta-analyses have shown the relationship between self-compassion and overall well-being, reduced psychopathology, and health-care provider well-being [1, 19, 22, 27].

Additional Resources

Table 2.2 shows some selected resources about self-compassion. For a more comprehensive understanding of self-compassion, guidance into the practice, and list of exercises and meditations, please utilize the resources listed at the end of this chapter (see Table 2.2) and also read Chap. 15, Kindness Begins with Yourself.

Table 2.2 Additional resources about self-compassion
Full size table