Self-criticism and self-compassion: Risk and resilience Web audio at CurrentPsychiatry.com Dr. Warren: Exploring the function of self-criticism in patient’s lives Self-criticism and self-compassion: Risk and resilience Being compassionate to oneself is associated with emotional resilience and psychological well-being Ricks Warren, PhD, ABPP nce thought to only be associated with depression, self- Clinical Associate Professor Department of Psychiatry criticism is a transdiagnostic risk factor for diverse forms of University of Michigan Medical School psychopathology.1,2 However, research has shown that self- Ann Arbor, Michigan O compassion is a robust resilience factor when faced with feelings of Elke Smeets, PhD personal inadequacy.3,4 Lecturer Faculty of Psychology and Neuroscience Self-critical individuals experience feelings of unworthiness, infe- Maastricht University riority, failure, and guilt. They engage in constant and harsh self- Maastricht, Netherlands scrutiny and evaluation, and fear being disapproved and criticized Kristin Neff, PhD and losing the approval and acceptance of others.5 Self-compassion Associate Professor involves treating oneself with care and concern when confronted with Department of Educational Psychology University of Texas at Austin personal inadequacies, mistakes, failures, and painful life situations.6,7 Austin, Texas Although self-criticism is the aspect of perfectionism most associated Disclosures with maladjustment,8 one can be harshly self-critical without being a The authors report no financial relationships with any company whose products are mentioned in this article perfectionist. Most studies of self-criticism have not measured shame; or with manufacturers of competing products. however, this self-conscious emotion has been implicated in diverse forms of psychopathology.9 In contrast to guilt, which results from acknowledging bad behavior, shame results from seeing oneself as a bad or inadequate person. Although self-criticism is destructive across clinical disorders and interpersonal relationships, self-compassion is associated with healthy relationships, emotional well-being, and better treatment outcomes. Recent research shows how clinicians can teach their patients how to be less self-critical and more self-compassionate. Neff6,7 proposes that self-compassion involves treating yourself with care and concern when being confronted with personal inadequacies, mistakes, failures, and painful life situations. It consists of 3 interacting components, each of which has a positive and negative pole: • self-kindness vs self-judgment • a sense of common humanity vs isolation • mindfulness vs over-identification. continued Current Psychiatry BRIAN STAUFFER Vol. 15, No. 12 19 Self-kindness refers to being caring and depression 2 years later, and—in males— understanding with oneself rather than 10 years later in their medical careers harshly judgmental. Instead of attacking better than a history of depression.11 Self- and berating oneself for personal shortcom- critical perfectionism also is associated ings, the self is offered warmth and uncon- with suicidal ideation and lethality of ditional acceptance. suicide attempts.12 Self-criticism has been shown to Self-compassion Humanity involves recognizing that predict depressive relapse and residual humans are imperfect, that all people fail, self-devaluative symptoms in recovered make mistakes, and have serious life chal- depressed patients.13 In one study, currently lenges. By remembering that imperfection depressed and remitted depressed patients is part of life, we feel less isolated when we had higher self-criticism and lower self- are in pain. compassion compared with healthy controls. Both factors were more strongly associated Mindfulness in the context of self- with depression status than higher perfec- compassion involves being aware of one’s tionistic beliefs and cognitions, rumination, Clinical Point painful experiences in a balanced way that and maladaptive emotional regulation.14 Self-compassion neither ignores and avoids nor exaggerates painful thoughts and emotions. Self-criticism and response to treatment. is more than the Self-compassion is more than the In the National Institute of Mental Health absence of self- absence of self-judgment, although a defin- Treatment of Depression Collaborative judgment; rather, ing feature of self-compassion is the lack of Research Program,15 self-critical perfec- it provides several self-judgment, and self-judgment overlaps tionism predicted a poorer outcome across with self-criticism. Rather, self-compassion all 4 treatments (cognitive-behavioral ther- access points for provides several access points for reducing apy [CBT], interpersonal psychotherapy reducing self-criticism self-criticism. For example, being kind and [IPT], pharmacotherapy plus clinical man- understanding when confronting personal agement, and placebo plus clinical man- inadequacies (eg, “it’s okay not to be per- agement). Subsequent studies found that fect”) can counter harsh self-talk (eg, “I’m self-criticism predicted poorer response to not defective”). Mindfulness of emotional CBT16 and IPT.17 The authors suggest that pain (eg, “this is hard”) can facilitate a self-criticism could interfere with treat- kind and warm response (eg, “what can I ment because self-critical patients might do to take care of myself right now?”) and have difficulty developing a strong thera- therefore lessen self-blame (eg, “blaming peutic alliance.18,19 myself is just causing me more suffering”). Similarly, remembering that failure is part of the human experience (eg, “it’s normal to Anxiety disorders mess up sometimes”) can lessen egocentric Self-criticism is common across psychiatric feelings of isolation (eg, “it’s not just me”) disorders. In a study of 5,877 respondents and over-identification (eg, “it’s not the end in the National Comorbidity Survey (NCS), of the world”), resulting in lessened self- self-criticism was associated with social criticism (eg, “maybe it’s not just because phobia, findings that were significant after I’m a bad person”). controlling for current emotional distress, neuroticism, and lifetime history of mood, anxiety, and substance use disorders.20 Discuss this article at Depression Further, in a CBT treatment study, baseline www.facebook.com/ Several studies have found that self- self-criticism was associated with sever- CurrentPsychiatry criticism predicts depression. In 3 epide- ity of social phobia and changes in self- miological studies, “feeling worthless” criticism predicted treatment outcome.21 was among the top 2 symptoms predict- Self-criticism might be an important core ing a depression diagnosis and later psychological process in the development, depressive episodes.10 Self-criticism in maintenance, and course of social phobia. Current Psychiatry 20 December 2016 fourth-year medical students predicted Patients with social anxiety disorder have less self-compassion than healthy controls disorder mediated the relationship between and greater fear of negative evaluation. childhood abuse and body dissatisfaction In the NCS, self-criticism was associ- and depression. Numerous studies have ated with posttraumatic stress disorder shown that shame is associated with more (PTSD) even after controlling for lifetime severe eating disorder pathology.33 history of affective and anxiety disorders.20 Self-compassion seems to buffer against Self-criticism predicted greater severity of body image concerns. It is associated with combat-related PTSD in hospitalized male less body dissatisfaction, body preoccupa- veterans,22 and those with PTSD had higher tion, and weight worries,36 greater body scores on self-criticism scales than those appreciation37 and less disordered eat- with major depressive disorder.23 In a study ing.37-39 Early decreases in shame during of Holocaust survivors, those with PTSD eating disorder treatment was associated scored higher on self-criticism than sur- with more rapid reduction in eating disor- vivors without PTSD.24 Self-criticism also der symptoms.40 distinguished between female victims of domestic violence with and without PTSD.25 Self-compassion could be a protective fac- Interpersonal relationships Clinical Point 26 tor for posttraumatic stress. Combat vet- Several studies have shown that self- Self-criticism also erans with higher levels of self-compassion criticism has negative effects on interper- showed lower levels of psychopathology, sonal relationships throughout life.5,41,42 is associated with better functioning in daily life, and fewer • Self-criticism at age 12 predicted less body dissatisfaction, symptoms of posttraumatic stress.27 In fact, involvement in high school activities and, at independent of self-compassion has been found to be a age 31, personal and social maladjustment.43 self-esteem and stronger predictor of PTSD than level of • High school students with high self- depression combat exposure.28 criticism reported more interpersonal In an early study, self-criticism scores problems.44 were higher in patients with panic disorder • Self-criticism was associated with lone- than in healthy controls, but lower than in liness, depression, and lack of intimacy patients with depression.29 In a study of a with opposite sex friends or partners dur- mixed sample of anxiety disorder patients, ing the transition to college.45 symptoms of generalized anxiety disorder • In a study of college roommates,46 self- were associated with shame proneness.30 criticism was associated