Is Your Therapy Missing This Essential Factor?

By Grant H. Brenner

"You've got to think about big things while you're doing small things, so that all the small things go in the right direction." —Alvin Toffler

The cultivation of self-compassion, drawing on ancient healing traditions, has increasingly been shown by Western researchers to have widespread benefits for health and well-being. Self-compassion practice in various forms has been shown to decrease distress, relieve mental illness symptoms, reduce self-criticism, and retrain one to think in healthier and more secure ways about oneself.

When one experiences core difficulties with self-care and self-regard, making any other positive change is orders of magnitude harder.

Self-Compassion, Well-Being, and the Brain

A 2015 meta-analysis in Applied Psychology: Health and Well-Being found that self-compassion and overall well-being were highly correlated across many dimensions, including psychological and emotional well-being, cognitive well-being, and good self-esteem.

Likewise, a 2016 study found that higher self-compassion was associated with greater physical health and reduced symptoms of physical illness. Self-compassion has been associated with increased use of health-promoting behaviors and treating and recovering from trauma, abuse, and neglect, as shown in multiple studies (e.g. in complex trauma, in traumatized first-responders.)

Can the brain change as a result of therapeutic practices? A 2017 study showed that training the brain in mindfulness, compassion, and emotion regulation, and use of more advanced cognitive skills in dealing with emotions and thinking through challenging situations more reflectively lead to changes corresponding to different skills, notably increases in thickness of gray matter on the surface of the brain. In a roughly analogous sense, as targeted physical training strengthens different areas of athletic performance, skill, and power, training different psychological and emotional skills builds up the brain’s strength, causing observable changes in the brain’s structure and function.

What Is Self-Compassion?

Pioneer psychologists (e.g. Gilbert, Neff, Germer), as noted in the paper discussed below, identify three aspects of self-compassion:

"(1) self-kindness (vs. self-judgement), which involves the ability to treat oneself with understanding and avoid maladaptive self-criticism; (2) common humanity (vs. isolation), which involves the recognition that imperfections, failures, and inadequacies are experiences shared by all human beings; and (3) mindfulness (vs. over-identification and rumination), which involves the acceptance and awareness of present-moment mental states without over-involvement with the experience."

While there are several structured approaches intended to develop self-compassion and related qualities such as loving kindness, gratitude, forgiveness, and acceptance, most of these approaches are free-standing methods and practices (e.g. 8 session workshops, ongoing meditation work) or a specific form of therapy, most notably Compassion-Focused Therapy.

Little is known about the role of self-compassion in standard therapeutic approaches which are not designed to assist with compassion-building. Some therapists may work toward self-compassion, while others may not see doing so as an acceptable therapeutic technique, depending on personal proclivities, training, unfamiliarity, stigma, patient preference, and other factors.

What Builds Self-Compassion in General Therapy?

In order to look at this question closely, Galili-Weinstock and colleagues (2019) designed a study to look at how different facets of clinic-based therapy affect compassion before, during, and after treatment. Participants were 89 adults in therapy with a range of different therapists, about 60 percent women, with an average age of 39 years, who were seen over the course of on average two years to treat anxiety and mood disorders, among others.

Therapists followed a primarily psychodynamic model, with elements of other therapies including cognitive-behavioral and dialectical-behavioral approaches varying from therapist to therapist and treatment to treatment.

Research on therapy can look at three areas of therapy technique, as noted in the paper:

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• directive approaches, which involve discussing and setting goals and an agenda;
• exploratory approaches, in which patients are encouraged to discuss experiences, thoughts, and feelings they usually don’t express; and
• common factors, which are shared across therapy in general, and including being empathetic, supportive, and validating.

Researchers rated therapy sessions for the use of these techniques and analyzed for correlations in how measures of self-compassion, therapy outcome, and other measures changed over the course of treatment.

Specific measures in the study included pre-treatment Self-Compassion Scale (SCS); self-compassion changes session-to-session (Self-Compassion Index, SCI); the Outcome Rating Scale (ORS), which estimates four factors of individual symptoms/function, social and work performance, relationships, and overall function; the Working Alliance Inventory (WAI-SR), a measure of the therapeutic bond and working alliance, including agreement on therapeutic goals; and the Multitheoretical List of Interventions-30 (MULTI-30), estimating to what extent therapists used different techniques, including psychodynamic, process-experiential, interpersonal, cognitive-behavioral, dialectical-behavioral, and common factors.¹

How do these three general therapeutic approaches correlate with therapeutic improvement in self-compassion?

Research on Self-Compassion and Therapeutic Outcomes

The research showed that on average, self-compassion increased over the course of therapy. Of note, this is with “therapy-as-usual” (a familiar blend of techniques often referred to as “eclectic,” as many therapists blend different kinds of therapy into their own unique practices)—rather than a specific compassion-informed approach.

An important outcome of any therapeutic effort is increased self-compassion. The research also revealed that the greater the increase in self-compassion over the course of treatment, the better the outcome. Self-compassion was correlated with more effective therapy, as shown in patients higher in self-compassion reporting greater improvement in ORS measures. None of the interventions increased self-compassion from one session to the next, but only over the course of the whole treatment.

How did self-compassion trend over the course of treatment? People with higher self-compassion scores to begin with held those higher ratings across the course of therapy, but on closer inspection of the data, it was folks who started with lower self-compassion to begin with who showed improvement.

People who started with high self-compassion to begin with did not increase self-compassion. However, people high in self-compassion could have room to grow, but might require more focused, advanced work.

Notably, for people starting out with lower self-compassion, common factors seemed to interfere with the development of self-compassion. Less generally supportive therapy was associated with greater self-compassion improvement for those low in self-compassion to begin with.

Higher common factors was associated with a reduction in positive change. It isn’t clear why this is the case, but it may be that compassion toward someone who doesn’t want it or know what it is, who does not feel compassionate toward themselves, or who may feel undeserving or even afraid of compassion—may backfire. Fear of self-compassion, fear of compassion from others, or for others, might get in the way of therapeutic growth, and needs to be addressed first.

Perhaps most important, only therapies with greater directive intervention increased patient self-compassion by the end of treatment. Less directive therapy did not improve self-compassion significantly. This finding needs to be replicated or refuted in ongoing research but is intriguing.

Implications for Therapy

Future research is required to determine what kinds of direction can be woven into therapy in order to make any therapy compassion-informed. Just because exploratory and common factors did not specifically improve self-compassion in this study group, does not mean that those factors are not crucial and useful.

Exploration is necessary for increased self-understanding, requiring greater reflection and contemplation in dialogue with others, including therapists who are trained as expert “partners in thought,” and general therapeutic factors which most therapists are trained to use.

It’s interesting that being too supportive may actually get in the way of increasing self-compassion for people starting low in the first place, but it makes sense, because people low in self-compassion may not be able to respond to warmth and validation, and for those with developmental trauma, a caring other may actually be perceived as a threat and met with mistrust. Patients and therapists would be wise to incorporate compassion into their conversation, at least exploring the possibility of how compassion-based practices might further therapeutic goals.

Given the strong influence that self-compassion has in repairing trauma and improving psychological, physical, and emotional well-being, leaving self-compassion out of the conversation is potentially a missed opportunity.

Timing is critical with self-compassion. As with addiction recovery, people go through stages of change in terms of readiness to move toward compassion, self-forgiveness, acceptance, and a generally loving stance toward oneself. Striking a delicate balance among various factors necessarily requires delicacy—a person’s reluctance to do something arguably good for them, the need to respect autonomy to maintain a healthy, boundaried therapeutic relationship, the moral imperative for the therapist to intervene more actively when appropriate, and the whole gestalt of therapeutic process—along with the ineffable complexity of each individual’s path of personal development.

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