Table 1
Search History.
| # | FIELD(S) | SEARCH TERM(S) APPLIED TO TITLE (TI) OR ABSTRACT (AB) FIELDS ONLY |
|---|---|---|
| 1 | TI OR AB | (“self compassion” OR “Self kindness” OR “Self regard” OR “Self worth” OR “Self appreciation”) |
| 2 | TI OR AB | (MH “Self Concept”) OR (MH “Compassion”) |
| 3 | TI OR AB | (MH “Self Concept”) AND (MH “Compassion”) |
| 4 | / | S1 OR S2 OR S3 |
| 5 | TI OR AB | (veteran or ex-service or ex-military) |
| 6 | TI OR AB | (MH “Veterans+”) |
| 7 | / | S5 OR S6 |
| 8 | / | S4 AND S7 |
| 9 | LIMIT | to year = 2000–2019 |
| 10 | LIMIT | to academic journals only |
| 11 | / | Exported/duplicates removed |
[i] Note: (CINAHL, EBSCO, MEDLINE, PsycInfo, SocINDEX, Web of Science).
Figure 1
PRISMA Flow Diagram of the Selection of SC Studies Among Veterans.
Note: Adapted from Tricco et al. (2018).
Table 2
Overview of 17 Studies Included in the Review.
| CITATION | COUNTRY | TYPE OF STUDY | SAMPLE* (SETTING) | AIM | DESIGN, METHOD & SC MEASURES/EDUCATION | LIMITATIONS STRENGTHS | FINDINGS EXPLORED | ||
|---|---|---|---|---|---|---|---|---|---|
| SC ASSOCIATED WITH FACTORS (E.G., PTSD OR OTHERS) | MH, PH AND WELLBEINGPOSITIVE OUTCOMES | ACCEPTABILITY | |||||||
| Bergen-Cico et al. (2018) | USA, NY state, Syracuse. | Mixed method Quasi –experiment. | Veterans with symptoms of PTSD
(intervention in the recreation facility for veterans and their
families transitioning to civilian life &
outdoor). N = 48 (34 in the intervention group and 14 in the control group). No significant differences between groups in age or outcome variables. Caucasian = 84% Male = Predominantly (N or % not reported) Age = 41 years in the intervention group and 43 years in the control group. Education = N/A Unemployed/retired = N/A Army = 50% & Marines = 30% Deployments = 80% Post 9/11 veterans & 20% Vietnam War veterans. PTSD = All participants. | To measure the potential impact of a therapeutic dog ownership and training programme for Veterans with PTSD. | Quasi-experimental design with 2 groups.
Group 1 = Dog owner-trainer intervention ‘Dogs2Vets’
(12/18 months, consisting in 90 minutes weekly training sessions),
Group 2 = a wait list control. Baseline, 12-months follow-up questionnaires, followed by a qualitative online survey (emailed an opened question: how did the Dogs2Vets program benefit you?). SCS Short form (SCS-SF) – 12 items. Participants were Self-referred or referred by Medical centres (Timeline: 2014–2017). | Small size. Generalisation of findings is
limited. Self-report measures and only one qualitative question.
Some general information (e.g. missing information on
reimbursement), demographics and stats are
missing/unclear. Ethical approved study. Participants benefitted from the programme and engaged in trainings, social and physical activity. Dog ownership did not have a negative effect among participants. | ✓ | ✓ | ✓ |
| Bravo et al. (2019) | USA, Virginia, Chesapeake. | Formative research/Cross-sectional | Veterans injured in combat members of the
Combat Wounded Coalition – a non-profit organisation
(Online). N = 163 Caucasian = 74% Male = 96% Age = 46 years Education: College or over = 74% Unemployed/retired = 48% Army = 45% Deployments = 78% PTSD = 51% | Assess if combat wounded Veterans would be willing to participate to mindfulness-based treatment (in general, or online or at the VA) to help them cope with emotional and physical discomfort. Additionally, the study explores several variables (e.g. SC, social support, current MH, prior MH care, etc.) that could predict willingness. | 30 minutes online self-report
survey. Recruitment via e-mail to members. SCS-SF – 12 items. | Cross-section study, analysing
correlations, so causal inferences limited. Some missing data
(including demographics) and un-clarity (e.g. how many participants
would practice mindfulness). Generalisation of findings is limited.
Data gathered from a self-reported questionnaire, responses not
validated against official records or clinical
diagnoses. Participants offered a $10 Amazon gift card (61.8% opted for the gift card). Compensation values participants time and effort, but may also influence responses/participation. Study approved by the board. Options on how to receive mindfulness treatment showed flexibility of the study and met individual/personal choices. | × | × | ✓ |
| Collinge et al. (2012) | USA, Vermont, Burlington, and Oregon, Eugene. | Phase 1 feasibility pilot study. Mixed methods. | Dyads: National Guard Veterans &
partners (Home). N = 41 Caucasian = 90% Dyads: Male & Female = 93% & 95% Age Veteran = 34 years Age partner = 29 years Education: College or over = 71% Unemployed/retired = N/A Army = N/A Deployments = 100% PTSD = at risk (%N/A) | To develop and evaluate “Mission Reconnect” (MR) an 8 weeks self-directed programme of integrative therapies to support reintegration, well-being and resilience Post-Deployment. | Repeated self-report measures and
qualitative data. Monthly online questionnaires and Weekly reports during the programme. Two 90 minutes’ follow-up focus groups at the end of the programme. Compassion Love Scale – Close to Other version 21 items and the SCS – 26 items. | Small sample size. Generalisation of
findings is limited. Lack of control group. Some missing data and un-clarity (including demographics). Data gathered from a self-report measures. The frequency of use of the intervention (frequently or infrequently) was not controlled for. Due to external circumstances (deployment) some dyads had to postpone participating during the 8 weeks. Participants were compensated with $20 for weekly report and $50 attendance at focus group interviews (this may influence their answers and their continual participation, however it also values participants, time and effort). Study approved by the board. Flexibility of the study to the participant needs (use of the intervention as much as they liked/needed). The use of the intervention at home, that avoided travelling efforts/cost and reduces exposure to MH stigma (oneself as in need of MH care). The involvement of partners not only veterans, which may have increased adherence. | × | ✓ | ✓ |
| Dahm et al.(2015) | USA, Texas, Waco and North Carolina, Durham. | Cross-Sectional and correlational study | Veterans that were deployed to Iraq or
Afghanistan and who had been exposed to one or more traumatic events
(Healthcare centre). N = 115 Caucasian = 57% Male = 83% Age = 37 years Education = N/A Unemployed/retired = N/A Army = N/A Deployments = N/A PTSD = 42% | Examine the association of mindfulness and self-compassion with PTSD symptom severity and functional disability. | Structural clinical interview (conducted
by professionals) and Self-report questionnaires. Recruited via staff, advertisement in sites and direct mailing. SCS – 26 items. | Cross-section study, analysing
correlations, so causal inferences limited. Generalisation of
findings is limited. Some missing data (including demographics).
Data gathered from self-report measures. SC as a broader construct
– included mindfulness as a core element. Financial compensation values participants, time and effort but may also influence responses/participation. Study approved by the VA healthcare board. | ✓ | × | × |
| Eicher et al. (2013) | USA, Indianapolis, Indiana. | Cross-Sectional study | Participants that had a confirmed
diagnosis of Schizophrenia or a Schizoaffective disorder and were in
a stable phase of the illness and were enrolled in another study in
a Midwestern VA medical centre on metacognition (VA medical centre
or community mental health). N = 88 (Part recruited from a VA medical centre) Caucasian = 47% (African American = 52%) Male = 86% Age = 50 years Education = (level) 13 years Unemployed/retired = N/A Army = N/A Deployments = N/A PTSD = N/A Schizophrenia = 58% Schizoaffective disorder = 42% Lifetime Hospitalization = 8 (with the first occurring at the average age of 27) | Explore the relationship between self-compassion and symptoms and insights in individuals with schizophrenia. | Clinical diagnostic interview (conducted
by professionals), followed by the verification of their diagnosis,
a screening questionnaire and the administration of symptoms
interviews and neuro-cognitive and self-report questionnaires (by
trained researchers). Recruited via another study in a Midwestern VA medical centre or community mental health. SCS – 26 items. | Cross-section study, so causal inferences
limited. Generalisation of findings is limited. Some missing data
(including demographic and military details, such as on how many
participants were veterans). Data gathered from self-report
measures. Social desirability issues. Financial compensation information was missing. Study approved by the institutional board. | ✓ | ✓ | × |
| Forkus et al. (2019a) | USA, New Jersey (RI). However, been an Amazon survey could include data from different states | Cross-Sectional and correlational study | Veterans that were deployed to Iraq or
Afghanistan (Online). N = 203 Caucasian = 74% Male = 77% Age = 35 years Education = N/A Unemployed/retired = N/A Army = 52% Deployments = N/A PTSD = at risk (%N/A) | Examine the relationship between morally injurious experiences and mental (i.e., PTSD, Depression) and behavioural (i.e., Alcohol, Drugs, DSH) health outcomes, and the potential protective moderating role of SC in this relationship. | Amazon MTurk platform – Online
Questionnaires. Recruitment via Amazon advertising. SCS – 26 items. | Cross-section study, analysing
correlations, so causal inferences limited. Generalisation of
findings is limited. Some missing data (including demographics).
Data gathered from self-report measures. Unclear, whether
participants most stressful deployment-related experience recorded
was related to morally injurious event. More research needed, self-compassion may not have the same protective role for behavioural health outcomes. Prospective and longitudinal studies may show a better understanding of these outcomes. Compensation ($2.00 for participation) values participants time and effort, but may also influence responses. Study approved by the board. | ✓ | × | × |
| Forkus et al. (2019b) | USA, New Jersey (RI). However, been an Amazon survey could include data from different states. | Cross-Sectional and correlational study (Part of Forkus et al., 2019a) | Veterans that were deployed to Iraq or
Afghanistan (Online). N = 203 Caucasian = 72% Male = 77% Age = 35 years Education = N/A Unemployed/retired = N/A Army = 52% Deployments = N/A PTSD = at risk (%N/A) | Examine whether SC and fear of SC, separately mediated the association between PTSD and Alcohol, in Veterans. | Amazon MTurk platform – Online
Questionnaires. Recruitment via Amazon advertising. SCS – 26 items and Fear of SC – 15 items. | See above strengths/limitations details
for the Forkus et al., 2019a
study. First study to examine SC and fear of SC in relation to PTSD and alcohol misuse. Study approved by the board. | ✓ | × | × |
| Held and Owens (2015) | USA, South-eastern regions. Tennessee and Missouri, St. Louis. | Pilot study (with 2 randomised groups) | Homeless male veterans with a six-grade
reading level, living in housing facilities – Volunteers
(Transitional housing facilities). N = 27 (13 in the SC training group and 14 in the Stress Inoculation group) Caucasian = 81% Male = 77% Age = 51 years Education: College or over = 45% Unemployed = 78% Army = 56% Deployments = 49% PTSD = at risk (%N/A) Alcohol misuse = 67% | Examine the effects of a 4 week self-administered SC training on trauma-related guilt and PTSD (using a workbook) compared to a Stress Inoculation group. | Training intervention – randomised
to either the SC training or the Stress Inoculation
group. Pre-, mid-, and post-intervention assessments. Recruitment via advertisement on site. SCS – 26 items. | Small sample size. Generalisation of
findings is limited. Lack of a control group. The SC group lacked a
true mindfulness exercise (even though mindfulness is considered one
of the three core elements of SC), this may have had an impact on
the overall results. Self-report measures. Significant withdrawal
(43% of sample) and reasons for not continuing were not properly
recorded (yet some participants left the transitional housing
facilities). Provides limited evidence. Highly probable participants
were receiving other therapies/services and/or medication and this
was not recorded and may have confounded the results. Other
confounding variables is that participants were allowed to miss
3-hour meetings in their transitional houses (reasons and frequency
were not recorded). Difficult to determine if findings can be
attributed to completing workbook. In addition, even though research
assistants checked if exercises in workbook where completed, no way
of confirming if participants practiced exercises as
instructed. Compensation ($20 gift card if they signed up to study) values participants time and effort, but may also influence responses. Study approved by the University board. First study to examine SC in homeless veterans. | × | ✓ | × |
| Hiraoka et al. (2015) | USA, Central Texas, Waco and North Carolina, Durham. | Correlational and Longitudinal | VA Registered Veterans that were deployed
to Iraq or Afghanistan and who had been exposed to one or more
traumatic events during deployment, meeting the DSM-IV-R criterion-A
for PTSD (Veterans Healthcare centre). N = 115 Caucasian = 57% Male = 83% Age = 35 years Education = N/A Unemployed/retired = N/A Army = 86% Deployments = N/A PTSD = 42% | To examine the concurrent and prospective associations between SC and PTSD symptom severity, after accounting for level of combat exposure. To explore the relationships between SC and aspects of combat exposure, and trauma-related guilt. | Semi structured clinical interview
conducted by professionals and self-report and retrospective
measures. All were conducted at baseline and at 12 months’
follow-up. Recruited through direct mailing, advertising at enrolment sites, and clinical staff. SCS – 26 items. | Generalisation of findings is limited.
Some missing data/information (including demographics and
compensation). Data gathered from self-report measures. Another
limitation is that the impact of treatment via the VA healthcare for
PTSD during the study is unknown and may have influence follow up
findings. Depression symptoms were not measured (although there are
similarities with some symptoms). Strengths of this study is the longitudinal component (the opportunity to exam impact of SC on PTSD symptoms over time) and the consideration of combat exposure. Validated tools used for measures. Study approved by the board. Further research required on the role of SC for treatment of PTSD is required (e.g., risk samples, determine the extent to which low SC may represent a risk factor). | ✓ | × | × |
| Kahn et al. (2016) | USA, 4 regions: California, Texas, North Carolina, New York. | RCT (Phase 2 of the Collinge et al., 2012 study). | Dyads of Veteran-Partners, in which the
veteran had a history of deployment in a post-9/11 combat
operation. Most were Iraq and Afghanistan Veterans of America Members (MR – home). N = 160 dyads (40 participants each group: 181 veterans and 139 partners), 21 dyads were both veterans Caucasian = 50% Male Veterans = 81% Female Partners = 93% Age = N/A Education: College or over = 82% Unemployed/retired = N/A Army = 56% Deployments = 100% PTSD = 29% of the Veterans | 16 weeks “Mission Reconnect”
(MR) self-directed programme evaluation of use, satisfaction and
effects on mental health outcomes and pain levels, associated with
post-deployment readjustment. Explanatory data on the presence of Moral injury. | 4 randomised groups: (1) MR alone, (2)
MR+PREP, (3) PREP alone, (4) waitlist control. PREP – was the
evidence-based comparator programme. Web-based application, followed by a telephone interview and an introductory meeting. 3 times survey measurements at the launch meeting, at 8 weeks and at 16 weeks and 8 weekly reports in the first weeks. The MR groups: Web-based app & message practice. The PREP groups – attended a 3 days’ retreat with PREP trained professionals. Recruitment via Iraq and Afghanistan Veterans of America website, social media, targeted emails in four metropolitan areas. SCS – 26 items. | MR is a programme/resource for users not
using formal services (see previous study: Collinge et al., 2012). Generalisation of
findings is limited. Lack of enquiry about prior use of mediation,
complementary or alternative therapies. No inclusion or exclusion
criteria for specific MH or physical problems, or on single
veterans, so this needs to be assessed in further research. Study
may have excluded potential participants who could not attend
in-person launch meeting. Program videos and audio instructions did
not include captions or transcripts, and would exclude veterans with
hearing problems, this needs to be considered in future research.
Longer follow up (i.e., 12 months) may show continued benefits for
well-being. Conflict of interest (MR programme is owned and
distributed by Mission Reconnect LLC, founded by Dr Kahn and Dr
Collinge to make the programme widely available). Received a pre-load debit card for compensation, which values participants time and effort, but may also influence responses. Card automatically funded via the data collection website when reports and surveys were submitted ($40 for each survey, $20 after each weekly report). Strengths of this study is the RCT design. Study approved by the board. Partner relationship may enhance sustained use of self-directed interventions. | × | ✓ | ✓ |
| Kelley et al. (2019) | USA, Virginia, Norfolk. | Explanatory/Cross-Sectional (Sub-study of Bravo et al., 2019). | Combat wound Veterans, experiencing one or
more deployment – members of the Combat Wounded Coalition
(online). N = 189 Caucasian = 74% Male = 97% Age = 43 years Living in Virginia (12%) or Texas (15%) Education = N/A Unemployed/retired = N/A Army = 46% & Marines = 25% Deployments = 86% (90 days or more) PTSD = 29% of the Veterans Service-connected disability = 93% Received a purple heart = 86% | Examine moderators of associations between self- and other-directed moral injury (inner conflict between beliefs/values) and suicidality. | Study analysing models. Online survey – see Bravo et al. (2019). Recruitment via announcements from the Combat Wounded Coalition members. SCS-SF – 12 items. | See strengths/limitations from Bravo et
al. (2019) study.
Cross-section study, so causal inferences limited. Generalisation of
findings is limited (e.g. willingness to remember and report moral
injury experiences and suicidality). Other variables and MH illness
are not examined and may contribute to suicidality. Further research
is needed to better clarify association between SC elements, moral
injury and suicidality, with other validated tools. Study was approved by the board. Compensation ($10 amazon gift card for completing the study) values participants time and effort, but may also influence responses. Despite this, the study expends the understanding on risks and protective factors related to moral injury and suicidality. | ✓ | × | × |
| Kerney et al. (2013) | USA, Washington, Seattle. | Pilot longitudinal study (non-randomised design). | Veterans with PTSD (large urban VA
hospital and home). N = 42 Caucasian = 83% Male = 58% Age = 54 years Education: College or over = 62% Christian = 60% Unemployed/retired = 67% Army = N/A Deployments = N/A PTSD = 100% Housing = own/rent (86%), homeless (7%) In a committed relation = 38% | Examine the feasibility and effects of a loving-kindness meditation course for Veterans with PTSD. Examine if SC would mediate symptoms of PTSD and depression. | 12-weeks loving-kindness meditation course
(a practice to enhance feelings of kindness and compassion) as
adjunct to usual care. Self-report measures at baseline, at 12-weeks and at a 3 months’ follow-up. Self-referral or referred via a health care provider (only enrolment notes were reviewed prior study acceptance). SCS – 26 items. X2 versions of Compassion Love Scale – 21 items. X1 version Compassion friends/family. X2 version Compassion humanity in general. | Small sample. Generalisation of findings
is limited. No control group, which precludes a causal association
between participation in the mediation and changes observed in
outcome measures, further research (e.g., RCT) would address this
limitation. Self-reported measures. Improvements maybe confounded by
regression to the mean, natural history of a disorder and
participation in a class rather than specific effects ok
Loving-kindness mediation. Selection bias, due to self-referrals.
88% of the participants received other forms of MH care, which could
influence the outcomes. The duration of the follow-up was short,
longer follow-ups are needed. No structured psychiatric
interview or other formal assessment was not performed prior to enrolment in the study. No monetary compensation. Study approved by the board & VA hospital (registered trial). High compliance indicates good acceptability. More research is needed to explore if Loving-kindness mediation has potential as an adjunct to usual care for veterans with PTSD. | ✓ | ✓ | ✓ |
| Kerney et al. (2014) | USA, Washington, Seattle. | Pilot trial longitudinal study
(non-randomised design). Sub-study of Kerney et al., 2013. | Veterans with PTSD (large urban VA
hospital and home). N = 42 Caucasian = 83% Male = 60% (female 40%) Age = 54 years Education: College or over = 62% Christian = 60% Unemployed/retired = 67% Army = N/A Deployments = N/A PTSD = 100% Housing = own/rent (86%), homeless (7%) In a committed relation = 38% | To assess whether participation in a
loving-kindness mediation course for veterans with PTSD is
associated with improved positive emotions, decentering, and
personal resources. | Part of the Kerney et al. (2013) previous
pilot study – See details above. 12-weeks course (a practice to enhance feelings of kindness and compassion) as adjunct to usual care. Veterans were assessed at baseline, after the course, and 3 months later (6 months from baseline). Measures were chosen as an initial investigation of the broaden-and-build theory of positive emotions (hypothesizing that enhanced positive emotions, attentional broadening, and built personal resources would occur following participation in the course). SCS – 26 items not analysed/reported in the present study, however was measured in the above linked study (see Kerney et al., 2013). | See strengths/limitations from Kerney et
al. (2013) study. Small study. Generalisation of findings is
limited. Lack of control group. Preclude conclusions regarding a
causal association between LKM practice and the changes seen overtime. Participants continued to receive usual care from their medical and MH providers during the study. No assessment of temporal changes. Study approved by the board. Further investigation of the course for veterans with PTSD is warranted. | ✓ | ✓ | × |
| Klich (2016) | USA, Georgia. | Case study (Clinical setting) | A Veteran and his
wife. N = 2 (1 male Veteran and a Female spouse) Caucasian = N/A Age = N/A Education = N/A Unemployed/retired = N/A Army = N/A Deployments = N/A PTSD = N/A | Exploring unique factors and benefits involved in the clinical treatment of SC strategies within a Mindfulness-based Biofeedback treatment protocol. | Mindfulness-based Biofeedback instruments
were used for training and developing adaptive coping
strategies (e.g., Coherence as a measure of harmonious synchronization among various systems in the body, such as the heart rhythms, respiratory system, and blood pressure). | Case study design limitations. Cannot be
generalised. Limited in scope to one individual veteran and his wife
and the view of the clinician/author. No compensation (therapy sessions). No mention of study approved by a board. Gives an insight into how the use of SC-based strategies. Involves partner. | × | ✓ | ✓ |
| Meyer et al. (2018) | USA, Texas, Waco. | Correlational and Multiphase – parent study (Longitudinal) | Iraq/Afghanistan Veterans registered for
healthcare (VA Medical facility) and exposed to one or more
potentially traumatic events that met the DSM-IV criteria for
PTSD. N = 117 (97 in Time 2) Caucasian = 58% Male = 84% Age = 37 years Education = N/A Unemployed/retired = N/A Army = 95% Deployments = 76% (Iraq and Afghanistan) PTSD = 62% | Examining the factors underpinning third wave behavioural interventions and impacting on readjustment following warzone service, and their clinical usage. By firstly modelling relations among proposed mechanisms (e.g. SC, mindfulness and psychological flexibility) of change in clinical practice in third wave behavioural therapies; and secondly testing if these mechanisms predicted QoL accounting for PTSD symptom severity. | Neuropsychiatric interview conducted by
professionals followed by several self-report measurements in
multiple time-points, at the medical centre. The disability and QoL
measures were repeated at 1-year follow-up during an in-person
assessment by 83% (N = 97 participants at time
2). Correlations followed by factor analysis to model relations and hierarchical regression analysis for the prediction of QoL at Time 2. Recruited via advertisements in enrolment sites clinical staff, and direct mailing. SCS – 26 items | Generalisation of findings is limited.
Some missing data (including demographics) and unclear information.
Self-report measurement completed at medical
centre. Interviewers by Master level technicians or licensed psychologists who completed comprehensive a assessment and training. Comprehensive test of impact on disability and QoL in veterans with PTSD, using multiple time points, and 2 a year a part, while accounting for PTSD. Mini International Neuropsychiatric Interview used to screen for excluded diagnoses of psychotic or bipolar disorders based on DSM-IV, and six validated measurement scales were used (e.g., DSM-IV clinical PTSD scale). Study approved by the board. Participants received financial compensation for participating, which values participants time and effort, but may also influence responses. | ✓ | × | × |
| Meyer et al. (2019) | USA, Texas, Waco. | Longitudinal study and empirical correlation analysis (Parent study) | Veterans registered for healthcare with
PTSD who were combat deployed post 9/11 and were exposed to one or
more traumatic event during their service -Iraq/Afghanistan war (VA
medical facility). N = 107 Caucasian = 59% Male = 84% Age = 37 years Education = N/A Unemployed/retired = N/A Army = 86% Deployments = yes (N/A%) PTSD = 64% | Understanding the recovery process and potential intervention targets by examining the factors (i.e. all the contributors of the mindfulness awareness variables: SC, mindfulness and psychological flexibility) associated with change in PTSD symptoms over time, impacting readjustment following warzone service. | Testing models. Clinical interview administered by professionals followed by self-report measures (in private offices in the VA facility) measured at baseline and at 1-year follow-up. Recruited in parent longitudinal study, and via advertisements in enrolment sites clinical staff, and direct mailing. SCS – 26 items. | Generalisation of findings is limited.
Constructs of some of the variables have been criticised. Lifetime
worst PTSD was assessed retrospectively. No assessment of treatment
involvement. Missing data was low. Study was approved by board. Longitudinal aspect is one of the strengths of the study as well as the use of a clinical diagnostic interview to assess PTSD symptom severity across time, as well as the use of other psychometrically measures. | ✓ | × | × |
| Rabon et al. (2019) | USA, South Carolina, Columbia; Tennessee, Johnson City; North Carolina, Charlotte; Texas, Austin; UK Sheffield. | Cross-Sectional and correlational study | Any USA veteran, fluent in English and
with internet access (Online). N = 541 Caucasian = 85% Male = 69% Age = 50 years Education = N/A Unemployed/retired = N/A Army = 17% (38% reported been from all branches of the military) Deployments = 68% PTSD = 61% | Examine the relation between SC and suicide risk and the moderating effects of depression, PTSD symptoms, anger, shame, and thwarted interpersonal needs. | Online self-report
survey. Recruited via online advertising, invitation to national veterans’ organisations and veterans’ national social media pages including military-focused pages. SCS Short form (SCS-SF) – 12 items. | The use of cross-sectional data precludes
examination of causal relationships. Explanatory power of the model
was limited. Generalisation of findings is limited (even if the
study controlled for demographic variables). Convenient sample,
recruitment online. The study did not assess diagnostic categories,
used self-report measures and subclinical symptomology. Future
research should focus also on measures that directly focus on
trauma, and recommend mixed methodology, prospective, longitudinal
studies to investigate and explore risk and protective factors for
suicide and the protective role of SC. Compensated with a raffle entry to win an Amazon gift card. This values participants time and effort, but may also influence responses. Institutional Review Board approval. The ability for SC may provide a proactive coping strategy in times of crisis, reducing suicide risk for veterans. | ✓ | × | × |
Table 3
Studies Showing Association Between SC and Mental and Physical Health Factors (PTSD, Disability, Morally Injurious Events, Depression, DSH, and Alcohol).
| CITATION | FINDINGS EXPLORED: Associated Factors | ||||||||
|---|---|---|---|---|---|---|---|---|---|
| PTSD | DISABILITY | MORALLY INJURIOUS EVENTS & RELATED FEELINGS | DEPRESSION | DSH OR SUICIDE | SCHIZOPHRENIA SCHIZOAFFECTIVE DISORDERS | ALCOHOL AND DRUGS | |||
| 1 | Bergen-Cico et al. (2018) | Within the intervention group there was a significant reduction in the scores of the questionnaire measuring PTSD symptoms at follow-up (p = .03). The score decline mean was just below the 5-point change in the scale that is considered threshold for determining whether the intervention had clinical significance. Within the control group there was a moderate increase in PTSD scores, however these changes were no significant. Between group differences showed moderate effect size –.28. The intervention programme significantly predicted changes in PTSD scores at follow-up (p = .01). There were no changes for the control group. | × | × | × | × | × | × | |
| 4 | Dahm et al. (2015) | Mindfulness and SC were each uniquely,
negatively associated with PTSD symptom severity. After accounting for mindfulness, SC accounted for unique variance in PTSD symptom severity (f2 = .25; medium ES). The combined association of mindfulness and SC with disability over and above PTSD was large (f2 = .41). | After accounting for PTSD symptom severity, mindfulness and SC were each uniquely negatively associated with functional disability. After accounting for mindfulness, SC accounted for unique variance in disability (f2 = .13; small ES). | ×× | × | × | × | × | |
| 5 | Eicher et al. (2013) | × | × | × | × | × | Higher SC scores were associated with lower scores on the Positive and Negative Psychopathology Syndrome Scale (in the positive, excitement, and emotional discomfort symptom sub-scales) in addition to poorer insight (self-reflectiveness, self-certainty). | × | |
| 6 | Forkus et al. (2019a) | SC significantly moderated the
relationship between exposure to morally injurious experiences and
PTSD. Individuals high in SC (vs. low) had significantly fewer of
negative MH symptoms after exposure to these events, including fewer
PTSD symptoms. Morally injurious experiences were associated with PTSD when participants were low, t _ 10.07, p _ .001, and high, t _ 5.60, p _ .001, in SC, although the latter relation was weaker. The main and interactive associations of morally injurious experiences and SC predicted PTSD. | × | Morally injurious events were significantly negatively related to SC, r _ _.21, p _ .001. | SC significantly moderated the
relationship between exposure to morally injurious events and
depression severity. Individuals high in SC (vs. low) had
significantly fewer of negative MH symptoms after exposure to these
events, including fewer depression symptoms. The main and
interactive associations of morally injurious experiences and SC
also predicted depression. Morally injurious experiences were associated with depression when participants were low, t _ 9.18, p _ .001, and high, t _ 4.33, p _ .001, in SC, although the latter relation was weaker | SC significantly moderated the
relationship between exposure to morally injurious experiences and
DSH versatility. Individuals high in SC (vs. low) had significantly
fewer of negative MH symptoms after exposure to these events,
including lower DSH versatility. The main and interactive associations of morally injurious experiences and SC predicted DSH versatility. Morally injurious experiences were associated with DSH versatility when participants were low, t _ 4.14, p _ .001, but not high, t _ .56, p _ .577, in SC. Conversely, morally injurious experiences and SC were significant predictors of DSH history. However, the interaction of morally injurious experiences and SC did not predict DSH history | × | Morally injurious experiences and SC were significant predictors of alcohol and drug misuse. However, the interaction of morally injurious experiences and SC did not predict alcohol or drug misuse. | |
| 7 | Forkus et al. (2019b) | Both SC and fear of SC significantly explained the association between PTSD symptoms and alcohol misuse. Furthermore, fear of SC explained this relation after adjusting for levels of SC. Greater PTSD symptoms were associated with greater fears of SC, which was associated with greater alcohol misuse. However, fear of SC explained the PTSD-alcohol misuse, even when controlling for levels of SC, suggesting that fear of self-compassion’s role in this relation is distinct and does not simply reflect levels of SC. | × | × | × | × | × | Both SC and fear of SC significantly explained the association between PTSD symptoms and alcohol misuse. Greater PTSD symptoms were associated with greater fears of SC, which was associated with greater alcohol misuse | |
| 9 | Hiraoka et al. (2015) | SC was negatively associated with
associated with each of the three DSM-IV PTSD
symptom clusters at baseline (after accounting for combat exposure;
β = –.59; p < .001; R2 = .34; f2 = .67; large effect) and at 12-month follow-up (after accounting for combat exposure and baseline PTSD symptoms; β = –.24; p = .008; R2 =.03; f2 =.08; small effect). SC was negatively associated with trauma-related guilt at baseline and follow-up. Results suggested that SC may influence the degree of chronicity of PTSD symptoms among Iraq and Afghanistan war veterans. As such, increasing SC may be beneficial. Findings also indicate that the association between SC and PTSD is maintained over time, and that SC was not as strongly related to trauma-related guilt. | × | The overall association between SC and level of combat exposure was not strong as expected based on the literature on moral injury. | × | × | × | × | |
| 11 | Kelley et al. (2019) | × | × | Both self- and other-directed moral injury
strongly associated with suicidality, and moderately negatively
associated with the 3 SC subscales: self-kindness, common humanity
and mindfulness. Social connectedness, moderately positively
associated with negative SC elements (self-judgment,
over-identification). However, the 3 SC subscales did not significantly moderate the self- or other-directed moral injury-suicidality link. | × | × | × | × | |
| 12 | Kerney et al. (2013) | Change in SC, significantly mediated changes in PTSD symptoms between baseline and post-loving-kindness meditation, and between baseline and the 3 months’ follow-up. | × | × | Change in SC mediated changes in depression scores (PROMIS) between baseline and post-loving kindness meditation, and between baseline and the 3 months follow-up. | × | × | × | |
| 13 | Kerney et al. (2014) | PTSD is linked with negative emotions,
significant increases in unactivated pleasant (d =
0.73), but not activated pleasant, emotions were found over time
during the loving-kindness mediation course in veterans with PTSD.
Activated and unactivated unpleasant emotions decreased over time
(d = –.69 and –.53, respectively).
There were also increases in environmental mastery (d = .61), personal growth (d = .54), purpose in life (d = .71), self-acceptance (d = .68), and decentering (d = .96) at 3-month follow-up. Also, improvements in social support increased at 3-month follow-up (medium effect size). Thus, overall, positive emotions increased, and enhancement of personal resources occurred over time. Overall, these findings, in combination with the prior 2013 findings (increases in mindfulness and SC along with reductions in PTSD symptoms and depression) following participation in the course provide support for further investigation of LKM as an intervention designed to serve as an adjunct to established interventions. | × | × | × | × | × | × | |
| 15 | Meyers et al. (2018) | All study variables were moderately
correlated with each other (all p <
.01). PTSD symptom severity at time 1 was a significant predicted of disability at time 2, but not QoL. Overall mindfulness, SC and psychological flexibility, as a single factor (mindful awareness) predicted disability and QoL after accounting for PTSD symptom severity. | Analyses indicated a common factor
“mindful awareness” underlay the SCS, and that had
stronger relationships to QoL, relative to PTSD. Mindful attitudes factor at time 1 predicted > QoL and < disability at time 2. Increase levels of “Mindful awareness influence levels of disability and QOL over time. | × | × | × | × | × | |
| 16 | Meyers et al. (2019) | Each construct predicted PTSD recovery when tested individually. When tested simultaneously, SC (but not mindfulness or psychological flexibility) predicted PTSD recovery. | × | × | × | × | × | × | |
| 17 | Rabon et al. (2019) | SC had a large negative association with
the proposed moderating variables of PTSD symptoms, anger, shame,
thwarted belongingness, and perceived burdensomeness. We did not
find a moderating effect of PTSD on the link between SC and suicide;
however, a trend was observed. Contrary to expectations, the link between SC and suicidal ideation did not change significantly as a function of the level of PTSD symptoms, although a review of results indicates significance at moderate-to-high levels of PTSD symptomology. | × | Linkage between SC and suicidal behaviour
in the sample was moderated by distress-evoking risk factors,
including depression, anger, shame, and thwarted interpersonal
needs, such that, as level of risk severity increases the inverse
association between SC and suicidal behaviour is
strengthened. When examining emotional factors, the interactions between anger and SC (p = .02) and between shame and SC (p = .001) each independently explained a significant increase in the variance explained in suicidal behavior. | SC had a large negative association with
the proposed moderating variables of depressive symptoms, anger,
shame, thwarted belongingness, and perceived
burdensomeness. When examining psychopathological factors as moderators of the relation between SC and suicidal behavior, the interaction term between SC and depressive symptoms explained a significant increase in the variance in suicidal behavior (p = .00), such that at higher levels of depressive symptoms (above M = 9.28) the beneficial impact of SC on suicidal behavior was enhanced. It appears that when individuals experience significant depressive symptoms such as feelings of sadness, hopelessness, and worthlessness, SC may be of particular utility. | SC had a moderate negative association
with the outcome of suicidal behaviour. PTS, Depression, Anger, shame, thwarted belongingness, and perceived burdensomeness. had moderate to large positive associations with suicidal behaviour. The beneficial effect of SC on suicidal behavior was more salient at higher levels of both anger (above M = 5.01) and shame (above M = 3.95). When examining interpersonal factors, both the interaction between SC and perceived burdensomeness (p = .03) and between SC and thwarted belongingness (p = < .00) explained significant increases in the variance explained in suicidal behavior. Moreover, the positive impact of SC on suicidal behavior became more prominent at higher levels of perceived burdensomeness (above M = 15.38) and thwarted belongingness (above M = 30.50). | × | × | |
Table 4
Studies Describing Improvements in Mental and Physical Health Outcomes, Wellbeing, Acceptability of SC Education.
| CITATION | FINDINGS EXPLORED | |||||
|---|---|---|---|---|---|---|
| IMPROVEMENTS IN … | EDUCATION AND ACCEPTABILITY | |||||
| SELF-COMPASSION | MENTAL HEALTH (MH) (E.G., PTSD DEPRESSION, SCHIZOPHRENIA, ALCOHOL) | PHYSICAL HEALTH (PH) (E.G., PAIN, SLEEP) | WELLBEING (E.G., QOL, STRESS, SOCIAL) | |||
| 1 | Bergen-Cico et al. (2018) | At follow-up, within the intervention
group increases in the overall SC scores were significant
(p = .02). the strongest changes were in SC and self-judgement. In all outcome variables there were no changes in the control group. | Within the intervention group there was a
significant reduction in the scores of the questionnaire measuring
PTSD symptoms at follow-up (p = .03). The score
decline mean was just below the 5-point change in the scale that is
considered threshold for determining whether the intervention had
clinical significance. Within the control group there was a moderate
increase in PTSD scores, however these changes were no significant.
Between group differences showed moderate effect size –.28.
The intervention programme significantly predicted changes in PTSD
scores at follow-up (p = .01). There were no
changes for the control group. Qualitative data supported and reinforced these quantitative findings, such as the identified themes of improved MH and emotional wellbeing (44%, N = 14), PTSD symptoms management (12%, N = 4). | × | Within the intervention group there were
significant reductions at follow-up for all the outcome measures
(p < .05): perceived stress
(p = .02), self-judgement (p =
.01), isolation (p = .02). Between group differences showed moderate effect sizes in all these outcome variables (perceived stress –.60; self-judgement –.90; isolation –.64; SC .37). At follow-up, the intervention programme significantly predicted reductions in perceived stress (p ≤ .00) and self-judgement scores (p = .00), and predicted increases in SC scores (p ≤ .00). There were no changes in the control group for these outcome variables. However, the intervention did not predict reductions (no main effect) in isolation scores over time. Qualitative data supported and reinforced these quantitative findings. Identified themes were decreased isolation (47%, N = 14), improved emotional well-being (44%, N = 14), renewed sense of safety and purpose including the opportunity to apply service skills (35%, N = 12), increased physical activity (6%, N = 2), and unconditional acceptance and companionship. | Acceptability: not directly measured, yet
the authors report that of the 64 participants who enrolled in the
programme 90% enrolled in the study (N = 60; 12
individuals were excluded from analysis due to incomplete data). Of
those included in the study all returned the qualitative
survey. In the qualitative survey some participants reported a sense of accomplishment, purpose and satisfaction, especially in the application of service skills. |
| 2 | Bravo et al. (2019) | × | × | × | × | Acceptability: In general participants
were willing to part-take. Especially if they reported use of a VA
service for MH (either prior or current). However, participants with higher SC were less willing (they also reported less distress and fewer MH). Whereas, participants with problems in multiple health domains and lower SC were most likely to express interest in treatment (as likely represent a very high need group). |
| 3 | Collinge et al. (2012) | Significant improvement in SC measured via the SCS, but not in the Love scale. | Significant reduction in standardised measures of PTSD and depression and in anxiety, especially following massage. | Significant reduction in pain and physical tension, following massage. | Significant longitudinal reduction in
irritability and worry, following massage. Couple strengthening. | Acceptability: Dyads showed compliance and
fidelity in the recommended utilisation of the
activities. Education Participant reported finding the programme useful and beneficial for managing stress, and easy to practice in a variety of setting (e.g., home, work, vehicle). |
| 5 | Eicher et al. (2013) | × | Relationships between SC and several factors of the Positive and Negative Syndrome Scale (psychopathology) were found. These included positive symptoms, excitement, and emotional discomfort. As scores on the SCS increased, scores on these symptom scales decreased. An unexpected result was that there appeared to be no relationship between SC and negative symptoms. | × | Analysis of the sub-scales (self-reflectiveness and self-certainty) indicates that those with high self-reflectiveness also have increased self-judgment, isolation, and over-identification. Additional findings highlighted that those with higher awareness of illness also had significantly higher levels of self-judgment, isolation, and over-identification, which supports the idea that individuals may endorse self-stigma. | × |
| 8 | Held and Owens (2015) | Overall, levels of SC increased for
participants in both groups over the course of 4 weeks training.
Although participants’ SC Increased abilities were not greater in the stress inoculation group. SC training was also not inferior to the control intervention. Practicing either SC or deep breathing and other relaxation exercises for 4-weeks d increase SC abilities. | Stress inoculation training appeared to be
slightly more effective than the SC workbook. Over the course of the
4-week intervention, veterans’ trauma-related guilt cognitions
reduced significantly for the entire sample. For participants in the
SC intervention, trauma-related guilt cognitions increased slightly
from pre- to mid-intervention. A drastic reduction in trauma-related
guilt cognitions was observed between the mid- and post-intervention
assessments (p < .001, d =
4.399). No significant changes in PTSD severity over time were associated with either treatment condition. In only 4 weeks these changes demonstrate the effectiveness of SC as a possible intervention trauma-related guilt or support intervention to existing treatments for PTSD, especially for people who are extremely self-critical. | × | × | × |
| 10 | Kahn et al. (2016) | Significant improvement was seen at 8 and 16 weeks in SC for participants assigned to MR arms. | Significant improvements were seen at 8 and 16 weeks in measures of PTSD, depression, for participants assigned to MR arms. In addition, significant reductions in self-reported levels of anxiety, and depression were associated with use of partner massage. | Significant improvements were seen at 8 and 16 weeks in measures of sleep quality, for participants assigned to MR arms. Additionally, significant reductions in self-reported levels of pain associated with use of partner massage. | Significant improvements were seen at 8 and 16 weeks in measures of perceived stress and resilience, for participants assigned to MR arms. In addition, significant reductions in self-reported levels of tension, and irritability were associated with use of partner massage. | Acceptability: High user-satisfaction
rates. Both veterans and partners were able to learn and make
sustained use of a range of wellness practices taught in the MR
programme. MR usage low but stable (average in the first 8 weeks was
of 2.5 hours per week: 17 uses of non-massage practices and 1.4 of
massages, modest reduction in the following 16 weeks towards 1hour
per week for veterans, whereas a slight increase was found for
partners) Education: The use of the MR programme appears to be an accessible, low-cost approach that supports well-being and reduces multiple symptoms among Post-9/11 veterans and their partners. Home-based, self-directed interventions may be of particular service to veterans who are distant from, averse to, or prohibited by schedule from using professional services. Leveraging the partner relationship may enhance sustained use of self-directed interventions for this population. |
| 12 | Kerney et al. (2013) | Compared to baseline, measures obtained after the loving-kindness meditation course demonstrated increased in SC (large effect size) and mindfulness skills (medium to large effect size). | A large effect size was found for
reduction in PTSD symptoms 3-months post loving-kindness meditation
(d = –0.89), and a medium effect size was
found for reduction in depressive symptoms at 3-months follow-up
(d = –0.49). Evidence showed that f SC mediated reductions in PTSD symptoms and depression. | × | × | High user acceptability. Compliance (86%)
and attendance (74%) was high even if participant were not
compensated. Education: Overall the course was seen as safe and acceptable by veterans with PTSD. |
| 13 | Kerney et al. (2014) | × | Significant increases in unactivated
pleasant (d = 0.73), but not activated pleasant,
emotions were found over time. Activated and unactivated unpleasant
emotions decreased over time (d = –.69 and
–.53, respectively). Overall, positive emotions increased, and enhancement of personal resources occurred over time. These findings, in combination with the prior 2013 findings (increases in mindfulness and SC along with reductions in PTSD symptoms and depression) following participation in the course provide support for further investigation of LKM as an intervention designed to serve as an adjunct to established interventions. | × | There were also increases in environmental mastery (d = .61), personal growth (d = .54), purpose in life (d = .71), self-acceptance (d = .68), and decentering (d= .96) at 3-month follow-up. Also, improvements in social support increased at 3-month follow-up (medium effect size). | × |
| 14 | Klich (2016) | Increase in SC components (i.e., reduction of self-deprecation, of self-judgment). | Clinical and user reported notable
improvements in hyper-alertness, emotional health for him and
others. Reduction of escalation of anger, fear, mood fluctuations, and overall emotional dysregulation and discomfort. | Clinical and user reported notable improvements in hyper-alertness (greater comfort) and physical discomfort such as pain. | Clinical and user reported greater comfort. Reduction of judgment of others (increased tolerance). | Acceptability: Clinician reports an
initial resistance to the training. Following that initial
resistance, due to explanation, reflection, practice and veteran
specific characteristic, the clinician reports a consistent use from
both patients. Education: Clinician reports that SC and mindfulness-based strategies can be a powerful adjunct to biofeedback treatment with veterans. They are feasible, useful and successful strategies that can be readily incorporated into biofeedback treatment, without necessitating Complex long-term psychotherapy. |