Self-Compassion and PTSD Symptom Severity

Brian L. Thompson and Jennifer Waltz

Department of Psychology, University of Montana, Missoula, MT

Neff ’s (2003a, 2003b) notion of self-compassion emphasizes kindness towards one’s self, a feeling of connectedness with others, and mindful awareness of distressing experiences. Because exposure to trauma and subsequent posttraumatic stress symptoms (PSS) may be associated with self-criticism and avoidance of internal experiences, the authors examined the relationship between self-compassion and PSS. Out of a sample of 210 university students, 100 endorsed experiencing a Criterion A trauma. Avoidance symptoms significantly correlated with self-compassion, but reexperiencing and hyperarousal did not. Individuals high in self-compassion may engage in less avoidance strategies following trauma exposure, allowing for a natural exposure process.

Neff (2003a, 2003b) developed her construct self-compassion based on the larger Buddhist notion of compassion (Pali: karuna) and on what is often translated as loving-kindness (Pali: matta; K. Neff, personal communication, June 13, 2005). Karuna refers to a feeling of compassion towards all beings and an awareness of our shared experience as human beings, whereas metta involves conscious goodwill towards others. Self-compassion consists of three components: (a) an attitude of kindness and understanding to one’s self as opposed to harsh judgment; (b) perceiving one’s experiences as part of the larger human condition instead of feeling separate and isolated; (c) being mindfully aware of painful experiences without overidentifying with them (Neff, 2003a).

Researchers have already begun to incorporate compassion-based practices into treatment. In Mindfulness-Based Stress Reduction (MBSR), loving-kindness is introduced during an all-day meditation (Kabat-Zinn, 1990), and health care professionals exhibited significant increases in self-compassion at the end of an 8-week MBSR program (Shapiro, Astin, Bishop, & Cordova, 2005). An 8-week program emphasizing loving-kindness meditation found a reduction in pain and anger in a sample of patients with chronic lower back pain (Carson et al., 2005), and it has been suggested that this program may be helpful in reducing anger in survivors of childhood sexual abuse (Bowman, 2005). More recently, Gilbert and Proctor (2006) developed a program aimed at fostering compassion and decreasing shame and self-criticism in patients with personality and/or mood disorders attending a hospital day treatment program.

Research on the Self-Compassion Scale has found that higher self-compassion is associated with greater psychological well-being: less depression, anxiety, rumination, and thought suppression, and with greater life satisfaction and social relatedness (Neff, 2003b). Increases in self-compassion over a one-month period were associated with decreases in self-criticism, depression, rumination, thought suppression, and anxiety, and with an increase in feeling interpersonally connected to others (Neff, Kirkpatrick, & Rude, 2007). As self-criticism, thought suppression, and rumination are phenomena associated with trauma and Posttraumatic Stress Disorder (PTSD; e.g., Cox, MacPherson, Enns, & McWilliams, 2004; Rosenthal, Cheavens, Lynch, & Follette, 2006; Sharhabani-Arzy, Amir, & Swisa, 2005; Steil & Ehlers, 2000), we were interested in exploring the relationship between self-compassion and trauma symptoms. There are three symptom clusters associated with PTSD: reexperiencing, reactions to internal or external cues of the trauma; avoidance, which includes persistent avoidance of trauma-related stimuli and emotional numbing; and hyperarousal, which includes insomnia, anger, concentration difficulties, and an exaggerated startle response (American Psychiatric Association, 2000).

The purpose of this study was to explore the relationship between self-compassion and posttraumatic stress symptoms (PSS), as an understanding of this relationship could help to inform the integration of compassion-based practices into trauma treatment. Because PSS may be associated with greater self-criticism, we expected that PSS severity would be related to lower levels of self-compassionate kindness and greater self-judgment. In addition, as rumination may also be associated with PSS, we expected that symptom severity would be associated with a lower ability to remain mindfully aware of painful experiences without becoming caught up in those experiences. The third aspect of self-compassion, understanding one’s experiences as part of the larger human condition is a somewhat unique concept in the psychological literature without an obvious parallel; consequently, although we expected, if anything, an inverse relationship with PSS severity, it was less clear whether this element of self-compassion would correlate with symptom severity.

METHOD

Participants and Procedure

These data were part of a larger study. The sample consisted of 210 introductory psychology students (79 men, 131 women) who received experimental credit. Ages ranged from 18–53, with 19 being the median and modal age. Participants completed questionnaire packets in individual rooms to ensure confidentiality of sensitive material.

Measures

The Self-Compassion Scale (SCS; Neff, 2003b) is a 26-item self-report measure consisting of six subscales: self-kindness, extending kindness and understanding to one’s self; self-judgment, being harshly judgmental and critical of one’s self; common humanity, the ability to see one’s experience as part of the larger human condition; isolation, seeing one’s self as separate and isolated from others; mindfulness, the ability to remain aware of one’s painful experiences without becoming absorbed in them; and overidentified, the tendency to overidentify with painful experiences. Examples items include "I’m kind to myself when I experience suffering" and "I try to see my failings as part of the human condition." Items are rated on a 5-point Likert scale from 1 (almost never) to 5 (almost always). Subscales self-kindness, common humanity, and mindfulness were scored such that higher scores reflect greater self-compassion. Subscales self-judgment, isolation, and overidentified were scored such that higher scores reflect lower self-compassion. A total SCS score was calculated by reverse scoring the latter three subscales and summing all six.

The Posttraumatic Stress Diagnostic Scale (PDS; Foa, Cashman, Jaycox, & Perry, 1997) is a 49-item self-report measure of PTSD that corresponds to criteria according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; American Psychiatric Association, 1994). Participants are offered a checklist of 12 traumatic events and 17 items corresponding to each of the three DSM-IV PTSD symptom criteria: reexperiencing, avoidance, and hyperarousal.

RESULTS

Based on the PDS criteria, 100 participants of the total 210 participants met PDS PTSD Criterion A: participants endorsed at least one trauma during which they feared physical injury and/or death for themselves or another, and endorsed a feeling of helplessness and/or terror. This was called the Exposed Group (n = 100; 65 women). Included within this group, were 22 participants who met PDS PTSD criteria. The most common traumas endorsed were accident (n = 30), other (n = 25), which included deaths and near-deaths of friends and family, and sexual assault (n = 14).

Table 1. Means and Standard Deviations for Measures

Note. SCS= Self-Compassion Scale; PDS = Posttraumatic Stress Diagnostic Scale.

Cronbach’s alphas were calculated for each measure: SCS total score (α = .90), self-kindness (α = .78), self-judgment (α = .85), common humanity (α = .79), isolation (α = .77), mindfulness (α = .66), and overidentified (α = .75) subscales; PDS reexperiencing (α = .84), avoidance (α = .81), and hyperarousal (α = .85) subscales.

Histograms indicated a normal distribution for the SCS total score and positive skews for the PDS subscales. Because the PDS subscales did not meet the assumption of normality, nonparametric correlation coefficients were calculated between the SCS total score and each of the three PDS subscales. See Table 1 for means and standard deviations. The SCS total score was significantly correlated with the PDS PTSD avoidance subscale (r = −.24, p ≤ .05), but not with the PDS reexperiencing (r = −.16, ns) and hyperarousal (r = −.20, ns) subscales. Because the PDS PSTD avoidance symptom severity subscale was significantly correlated with the total SCS score, correlation coefficients were then calculated between PDS PTSD avoidance symptom severity and each of the SCS subscales. To control for false-positive rates, the Benjamini-Hochberg (B-H) procedure was employed (Thissen, Steinberg, & Kuang, 2002). None of the correlation coefficients was significant according to B-H criteria: common humanity (r = −.10, ns, B-H critical value = .03); overidentified (r = .15, ns, B-H critical value = .02); isolation (r = .15, ns, B-H critical value = .02); self-judgment (r = .20, ns, B-H critical value = .01); mindfulness (r = −.21, ns, B-H critical value = .008); self-kindness (r = −.21, ns, B-H critical value = .004).

$$ (r eq -0.24,p eq ext{e.g.} eq 0.05) $$

DISCUSSION

Of the three PDS subscales, only avoidance symptom severity was significantly related to overall self-compassion. Experiential avoidance is one construct that offers a way of understanding the association between avoidance symptom severity and lower self-compassion. Experiential avoidance refers to behaviors that reduce engagement with uncomfortable thoughts, emotions, and sensations (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996). Research suggests that experiential avoidance maintains PTSD symptoms over time (Marx & Sloan, 2005). By contrast, higher self-compassion is associated with a greater willingness to engage painful thoughts and emotions and a lower need to avoid painful experiences (Leary, Tate, Adams, Batts Allen, & Hancock, 2007; Neff et al., 2007). Following trauma exposure, trauma-related cues may trigger fear in an individual, which in turn may elicit a judgmental response and avoidance behaviors. Individuals high in self-compassion may be less likely to feel threatened by and, therefore, avoid painful thoughts, memories, and emotions. Instead, they may be more likely to experience a natural process of exposure to trauma-related stimuli.

Some limitations to this study are worth noting. First, is the use of a pencil-and-paper self-report measure of trauma. Although the PDS has excellent psychometric properties and maps onto DSM PTSD criteria well, it is not a substitute for a clinical interview. In addition, as is common with trauma research, a directional relationship cannot be established. It remains unclear whether trauma exposure and PTSD symptoms may lower self-compassion or whether low self-compassion makes one more vulnerable to developing PTSD. There may be other variables not captured in the data that better account for this relationship. For example, a recent study found that in a sample of sexual assault survivors, the relationship between self-blame and PTSD disappears when negative social reactions are accounted for in the model (Ullman, Townsend, Filipas, & Starzynski, 2007). The relationship between self-compassion and PTSD avoidance symptom severity may reflect a broader relationship with general psychological distress. In addition, as with any convenience sample of college students, it is not clear whether the findings would generalize to an actual clinical sample.

Despite the preliminary nature of this study, results offer some support for the notion that trauma survivors, particularly those with PTSD, may benefit from incorporating elements of self-compassion into treatment. As researchers begin to incorporate mindfulness-based practices in the treatment of PTSD (e.g., Batten, Orsillo, & Walser, 2006; Follette, Palm, & Pearson, 2006), self-compassion may be worth integrating into trauma treatment, particularly in addressing self-criticism and rumination.