Current interventions to improve mood in diabetes

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Chapter 3. Kindness: The Missing Link?

Introduction

As was briefly noted in the preceding chapter, one mechanism that has been suggested as potentially underlying the beneficial effects of mindfulness training is an increased capacity for self-compassion. Growing evidence suggests that explicitly developing feelings of kindness and compassion towards oneself can improve psychological and physical health (Zessin, Dickhauser, Garbade, 2015; Neff & Constigan, 2014; Germer & Neff, 2013). For a patient population in which the perception of having “failed” to achieve ideal self-management standards is both common and likely to elicit particularly painful feelings, meeting that inevitable suffering with kindness and understanding may be of benefit. This chapter briefly defines self-compassion and differentiates it from mindfulness before reviewing evidence for the mental and physical effects of self-compassion more generally in order to establish a rationale for its possible utility in improving outcomes for people living with diabetes.

Self-compassion: A characterization

Self-compassion is generally seen as an embodiment of three basic components: 1) extending kindness and understanding to oneself rather than responding with harsh self-criticism and judgment; 2) seeing one’s experiences as part of the larger human experience rather than as being separating and isolating; 3) holding one’s painful thoughts and feelings in balanced awareness rather than over-identifying with them (Neff, 2016). While each aspect tends to overlap the others, they are also experienced differently and are conceptually distinct:
For instance, the accepting, detached stance of mindfulness lessens self-judgment. Conversely, if one stops judging and berating oneself long enough to experience a degree of self-kindness, the impact of negative motivational experiences will be lessened, making it easier to maintain balanced awareness of thoughts and emotions. Similarly, realizing that suffering and personal failures are shared with others lessens the degree of blame and harsh judgment placed on oneself, just as a lessening of self-judgment can soften feelings of uniqueness and isolation (Neff, 2003, p. 234).
So, while the foundation of self-compassion is mindfulness, a crucial difference may be the addition of the specific recognition of one’s common humanity, as well as the active and conscious practice of treating oneself with kindness; these qualities are not inherently part of mindfulness per se (Neff, 2003; Bishop, Lau, Shapiro, et al., 2004). Furthermore, while mindfulness is a way relating to internal experience, self-compassion is a way of relating to the experiencer who is suffering (Germer, 2009). Furthermore, while mindfulness training emphasises the non-judgmental acceptance of all thoughts, emotions, and sensations that arise in present-moment awareness, self-compassion cultivates the understanding and capacity to tend to one’s suffering with kindness and understanding.
If I am mindful of a stabbing sensation in my knee, for instance, it means I am aware of the hot pulsating sensation without judgment or resistance, allowing mental space for the sensation to “be” as it is. When self-compassion also arises in response to that pain, feelings of care and concern for the fact that I am experiencing this pain are conveyed, along with the motivation to soothe and comfort myself to the extent possible. Self-compassion involves a bit of a paradox, therefore. At the same time that one’s present moment experience is mindfully accepted without resistance, the wish for the experiencer to be free of suffering in future moments – the motivation that lies at the heart of compassion – is also present (Neff & Dahm, 2014, p. 21).

Self-compassion as a protective resource

Although it has only been systematically studied since 2006, a relatively large research base now shows that reporting greater feelings of kindness, inter-connectedness with others, and a balanced and equanimous view point (i.e., self-compassion) is related to many facets of psychological wellbeing, particularly to greater positive emotionality and less negative emotionality (see reviews, Barnard & Curry, 2011; MacBeth & Gumley, 2012; Zessin, et al., 2015). There is also emerging evidence that the capacity to self-soothe as a consequence of greater self-compassion may also be linked to markers of physical health (Terry & Leary, 2013; Sirois, 2014; Sirois, Kitner, & Hirsch, 2015). The following section briefly reviews the evidence linking self-compassion to outcomes to date, noting the increased research attention for its utility as a protective resource against the negative effect of depression and low mood.
First, self-compassion has been reliably linked to better mood, with reports of greater self-compassion being consistently linked to less anxiety and depression. A strong, negative relationship between self-compassion and psychopathology is reported in a meta-analysis of 20, mainly cross-sectional, studies on the topic (r = −0.54), (MacBeth & Gumley, 2012). These findings are consistent with a more recent meta-analysis of nearly 80 studies (Zessin, et al., 2015) linking greater self-kindness with higher scores on measures of well-being (r = 0.47), including greater positive emotion and lower negative emotionality. As will be discussed more fully below, most included studies are cross-sectional, meaning causality cannot be assumed.
Self-compassion may also function as a protective resource against negative mental states (e.g., Trompetter, Kleine, & Bohlmeijer, 2016). Notably, while a lack of self-criticism is a key feature of self-compassion (and self-criticism predicts both anxiety and depression (Blatt, 1995), evidence suggests self-compassion predicts lower anxiety and depression even after controlling for self-criticism (Neff, Kirkpatrick, & Rude, 2007). Consistent with the idea that self-compassion is not just the presence of positive emotion, one study found that self-compassion partially mediated the negative association between positive mental health and psychopathology, with participants higher in positive emotionality and self-compassion seemingly protected against negative mood states (Trompetter, et al.). One explanation for this finding is that individuals higher in self-compassion are not only higher in positive affective states but they may also be better at regulating negative emotions in the face of difficult feelings and circumstances. In theory, more self-compassionate individuals may manifest better emotional regulation through qualities of mindfulness (i.e., not trying to repress or avoid painful feelings as they arise but being open to these with equanimity), as well as possessing a greater capacity to experience their own support, care, and kindness (Neff & Dahm, 2015). Conversely, it may be that people higher in psychopathology, for example, depression, may be less able to be kind to themselves or be less able to access a balanced mind state or a sense of common humanity when they suffer. Consistent with this hypothesis, Trompetter et al. (2016) found people higher in depressive symptoms have an impaired ability to treat themselves with kindness when they suffer, or in other words, to be self-compassionate.
Secondly, self-compassion may have positive effects on physical health through both direct (physiological) (Gilbert, et al., 2009; Rockliff, Karl, McEwan, Gilbert, & Matos, 2011; Breines & Chen, 2013) and indirect (behavioural) processes (Terry & Leary, 2011; Sirois, et al., 2015). Suggestions that self-compassion might protect against the physiological effects of stress are consistent with results of a brief compassion-focussed intervention during which participants were instructed to imagine compassion for themselves being directed towards them from an external compassionate figure. Results showed reductions in cortisol levels in the compassion group, compared to persons randomized to a relaxation condition or to complete a control task (Rockcliff, Gilbert, McEwan, Lightman, & Glover, 2008). The same exercise also increased heart-rate variability, associated with a greater self-regulatory ability (Porges, 2007). While preliminary, the suggestion that self-compassion may have direct physiological effects linked to a greater capacity to self-soothe has important implications for physical health in general, and in particular for patient populations such as those living with diabetes, in which stress and distress are not only common, but predictive of worse health outcomes.
One explanation for these apparent calming effects is found in an evolution-based model regarding the protective capability of self-compassion. This approach proposes that the brain-body processes stimulated by the compassion system may directly counter the effects of stress (Gilbert, 2009). So, for example, when the ‘self’ is attacked through self-criticism or negative self-evaluation, the same physiological responses are activated as would be in response to a threat or attack from an external source, with the associated release of cortisol and adrenalin required for fight or flight (Cosley, McCoy, Saslow, & Epel, 2010; Rockcliff, Gilbert, & McEwan, 2008; Arch, Brown, Dean, & Lanady, 2014; Rockcliff, et al., 2011). In theory, self-soothing processes associated with evolved attachment systems, studies have found increased oxytocin and opiates are released by gestures of self-compassion, a process that is thought to create a sense of safety and calm, with flow on neuro-biological effects (Gilbert, 2009; Rockcliff, et al.).
In parallel to physiological processes, self-compassion may promote better physical health through behaviours aligned to greater care of the physical self. Both theory and data suggest self-compassion may act as an emotion regulatory strategy linked to more adaptive reactions to disease and illness, as well as greater motivation to act in ways consistent with better health outcomes. For example, the trait self-compassion has been linked to behaviours such as attending to physical symptoms more quickly (Terry & Leary, 2011). More broadly, evidence from a recent meta-analysis of 15 studies (n = 253) showed that self-compassion was consistently associated with greater practice of a range of positive health behaviours including healthy eating, regular physical activity, stress management and positive sleep habits (Sirois, et al., 2014).
In the context of a chronic disease then, being self-compassionate may entail caring and comforting the self and facilitate the adoption of health behaviours aligned with greater well-being (e.g., seeking and/or adhering to medical treatments and regulating negative affect) (Scheier & Carver, 2003; Terry & Leary, 2011). Furthermore, because failure to meet personal health goals often triggers feelings of shame and guilt and is linked to goal disengagement rather than persistence (Sirois & igu re, 2013), responding to failure with self-compassion may facilitate behaviours consistent with desirable health outcomes. For example, understanding failure is part of the human condition, and responding with self-kindness and a sense of equilibrium instead of being caught up in negative self-evaluation and rumination, may free up self-regulatory resources that can be applied to the enactment of positive health behaviour (Sirois, et al., 2014; Terry & Leary, 2011). As such, self-compassion may be a desirable resource, predictive of better overall health outcomes for both healthy and medically unwell populations.

Self-compassion among patient groups

While the vast majority of studies so far have taken place among medically healthy participants, there are a small handful of studies in patient populations. In general, such studies have demonstrated a similar pattern of effect on indices of negative and positive emotionality, as well as predicting better outcomes on condition-specific metrics (Pinto-Gouveia, Duarte, Matos, & Fraguas, 2014; Wren et al., 2012; Brion, Leary, & Drabkin, 2014). For example, one study of self-compassion among cancer patients found lower self-compassion predicted greater depressive and stress symptoms, and lower scores on quality of life dimensions (Pinto-Gouveia, 2013).
Another study among obese patients with chronic musculoskeletal pain showed self-compassion predicted less negative affect, greater positive affect, and less pain catastrophizing and pain disability (Wren, et al., 2012). Finally, a study among patients with HIV/AIDS showed trait self-compassion was associated with more adaptive reactions to having the condition, including less negative emotion, better psychological adjustment overall, and evidence of coping more successfully with their illness (Brion, Leary, & Drabkin, 2014).
Although, there had been no studies investigating self-compassion among diabetes patients prior to the publication of evidence reported in this thesis, the suggestion that self-compassion predicts better health outcomes in both healthy and patient populations has important implications for patients living with diabetes. As was outlined in Chapter 2, self-criticism and rumination (implying an absence of self-compassion) are both common among diabetes patients given the demands of coping with the disease as well as being strong predictors of depression (Joeng & Turner, 2015; Pinto-Gouveia, Castilho, Matos, & Xavier, 2013). Increasing the capacity to self-soothe by responding to one’s suffering with kindness and understanding may therefore offer some form of protection against the often devastating consequences of negative mood states. Furthermore, the increased capacity to self-regulate may be important in terms of the links between negative mood and metabolic outcomes. Self-compassion may therefore be a crucial missing element in current diabetes treatment paradigms, providing an overall supportive context in which suffering can be met with constant kindness, with beneficial flow-on effects on both psychological and physical health.
Drawing from existing empirical studies in healthy and patient populations, the following chapter presents a review of the available evidence for the utility of self-compassion in this patient group, together with a theoretical rationale for its likely benefits. Potential cognitive, behavioural and biological processes for the beneficial effects of self-compassion on mood and metabolic outcomes are described and it is suggested that greater self-compassion may be associated with lesser negative emotionality and stress reactivity. It is further suggested that patients higher in self-compassion may be better able to self-regulate health behaviours and maintain essential medical regimes, resulting in better glycaemic control and better overall physical and mental health outcomes.

Does Kindness Matter? Diabetes, Depression, and Self-compassion: A Selective Review and

Research Agenda

Preface

As detailed in the preceding introductory chapters, living with diabetes can be hard. Frequent opportunities for self-criticism are not hard to find; for example, one might consider self-care or diet to be inadequate or be disappointed with the results of blood glucose testing. Within the context of this thesis, how one tolerates the distress evoked by self-management failures is seen as likely to be crucial in determining subsequent mood, behavioural, and metabolic outcomes for diabetes patients.
Conversely, a central tenant of this thesis is that the development of self-compassion skills might help diabetes patients adapt to difficult circumstances in several ways. Firstly, self-compassion may assist by increasing positive mood states and ameliorating negative mood states (MacBeth & Gumley, 2012). Secondly, it may enable one to confront the realities of one’s physical and medical condition without the added stressors of self-judgment, isolation, and over-identifying with either the condition or with suffering itself, thus enabling action-taking consistent with effective self-care (Terry & Leary, 2011; Sirois, Kitner, & Hirsch, 2015). Thirdly, self-compassion might be related to biological markers associated with diabetes via self-compassion’s association with positive mental states, which are themselves linked to physical health (Boehm, Vie, & Kubzansky, 2012).
At the time the following published article was conceived, evidence for self-compassion was, in general, relatively scattered, particularly with regard to associations between self-compassion and physical health. Furthermore, most evidence was derived from studies conducted among medically well populations, with only a very small handful of preliminary studies investigating its application to medically unwell populations (for example, Pinto-Gouveia, Duaret, Matos, & Fraguas,2013; Brion, Leary, & Drabkin, 2013). More importantly, there had been no prior studies of self-compassion among diabetes patients, a population in which psychological suffering is considerable, and for whom there is a commensurate need for effective intervention. Therefore, constructing a preliminary rationale and theoretical model by which self-compassion might be beneficial to patients living with diabetes, and delivering that to practitioners and researchers, was a necessary first step in the thesis process.
As such, the following chapter presents a preliminary review and research agenda for subsequent investigations of the utility of self-compassion among diabetes patients. Previously published in Diabetes Spectrum, this is a novel contribution to the field and posits that self-compassion may be a crucial missing link in current literature, providing an overall supportive context in which suffering can be met with constant kindness.

Citation

Friis, A.M., Consedine, N.S, & Johnson, M. H. (2015). Does kindness matter? Diabetes, depression, and self-compassion: A selective review and research agenda. Diabetes Spectrum. doi:10.2337/diaspect.28.4.252

Table of Contents
Abstract 
Acknowledgements 
List of Tables 
List of Figures
Awards and Publications Relevant to PhD Candidature 
Chapter 1. Overview
1.1 Introduction
Chapter 2. The Scope of the Problem
2.1 Introduction
2.2 Clinical management
2.3 Mood difficulties common
2.4 Current interventions to improve mood in diabetes
2.5 Time for the third wave?
Chapter 3. Kindness: The Missing Link? 
3.1 Introduction
3.2 Self-compassion: A characterization
3.3 Self-compassion as a protective resource
3.4 Self-compassion among patient groups
Chapter 4. Does Kindness Matter? Diabetes, Depression, and Self-compassion: A Selective Review and Research Agenda 
4.1 Preface
4.2 Abstract
4.3 Introduction
4.4 Depression in diabetes: The status quo
4.5 Current treatment approaches
4.6 Self-compassion: Does kindness matter?
4.7 Depression and self-compassion: Common pathways?
4.8 Self-compassion and hypothesized effects in diabetes self-management
4.9 Summary
Chapter 5. Self-Compassion Buffers the Negative Impact of Distress on HbA1c
5.1 Preface
5.2 Abstract
5.3 Introduction
5.4 Procedure
5.5 Measures
5.6 Participants
5.7 Analytic strategy
5.8 Results
5.9 Discussion
5.10 Limitations and future directions
Chapter 6. Paradoxical Effects of Self-Compassion on Mood and Teeth Flossing Behaviour in an Experimental Setting 
6.1 Preface
6.2 Abstract
6.3 Introduction
6.4 Method
6.5 Measures
6.6 Data analyses .
6.7 Results
6.8 Discussion
6.9 Limitations
Chapter 7. Kindness Matters: A RCT of a Mindful Self-compassion Intervention Improves Depression, Distress, and HbA1c Among Diabetes Patients
7.1 Preface
7.2 Abstract
7.3 Introduction
7.4 Research design and methods …
7.5 Results
7.6 Discussion
7.7 Limitations and strengths of the study
7.8 Future directions
7.9 Conclusions
7.10 Acknowledgements
Chapter 8. General Discussion and Clinical Implications 
8.1 Overview
8.2 Summary of key findings
8.3 Kindness Matters: Self-compassion and improved self-regulation
8.4 Clinical implications and future directions
8.5 Limitations
8.6 Conclusion
References
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Kindness Matters Investigating the mental and physical health benefits of self-compassion in diabetes