Vol. - No. - - 2011 Journal of Pain and Symptom Management 1

Original Article

Self-Compassion in Patients With PersistentMusculoskeletal Pain: Relationshipof Self-Compassion to Adjustmentto Persistent PainAnava A. Wren, BA, Tamara J. Somers, PhD, Melissa A. Wright, BS,Mark C. Goetz, PhD, Mark R. Leary, PhD, Anne Marie Fras, MD,Billy K. Huh, MD, PhD, Lesco L. Rogers, MD, and Francis J. Keefe, PhDDuke University Medical Center, Durham, North Carolina, USA

Abstract

Context. Self-compassion entails qualities such as kindness and understanding

toward oneself in difficult circumstances and may influence adjustment topersistent pain. Self-compassion may be a particularly influential factor in painadjustment for obese individuals who suffer from persistent pain, as they oftenexperience heightened levels of pain and lower levels of psychological functioning.

Objectives. The purpose of the present study was to examine the relationship ofself-compassion to pain, psychological functioning, pain coping, and disabilityamong patients who have persistent musculoskeletal pain and who are obese.

Methods. Eighty-eight obese patients with persistent pain completed a paper-and-pencil self-report assessment measure before or after their appointment withtheir anesthesiologist.

Results. Hierarchical linear regression analyses demonstrated that even aftercontrolling for important demographic variables, self-compassion was a significantpredictor of negative affect (b¼�0.48, P< 0.001), positive affect (b¼ 0.29,P¼ 0.01), pain catastrophizing (b¼�0.32, P¼ 0.003), and pain disability(b¼�0.24, P< 0.05).

Conclusion. The results of this study indicate that self-compassion may beimportant in explaining the variability in pain adjustment among patients whohave persistent musculoskeletal pain and are obese. J Pain Symptom Manage2011;-:-e-. � 2011 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. Allrights reserved.

Key Words

Self-compassion, pain, obese, persistent musculoskeletal pain, pain adjustment, paincatastrophizing, self-efficacy

Address correspondence to: Francis J. Keefe, PhD, DukeUniversity Medical Center, 2200 W. Main Street,Suite 340, Durham, NC 27705, USA. E-mail:keefe003@mc.duke.edu

Accepted for publication: May 5, 2011.

� 2011 U.S. Cancer Pain Relief CommitteePublished by Elsevier Inc. All rights reserved.

Introduction

Over the past 30 years, numerous studies

have focused on the role of negative psycho-logical variables in patients’ experiences withchronic illness (e.g., rheumatoid arthritis,

0885-3924/$ - see front matterdoi:10.1016/j.jpainsymman.2011.04.014

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AIDS, cardiovascular disease, musculoskeletalpain).1e6 Work within this field has continuallyreemphasized the detrimental role that nega-tive psychological variables (e.g., negative af-fect, catastrophizing) can play in adjustmentto symptom distress and disability, includingpersistent pain.7e15 Although such researchhas continued, there has been a growing inter-est in the role of positive aspects of psycholog-ical adjustment that might influence one’sability to adjust to chronic illnesses and copewith symptoms such as persistent pain.12,16e21

Research has shown that among patients withchronic illnesses (e.g., cancer, arthritis), con-structs such as self-efficacy, acceptance, andoptimism are related to important outcomesincluding pain, psychological distress, anddisability.16,22e26

A potentially important positive constructthat has just begun to receive attention in rela-tion to chronic illness is self-compassion. Self-compassion has been defined as the qualityof being touched by one’s own suffering andfeeling compelled to help alleviate one’s owndifficulties.27 Self-compassion within this con-text is composed of three components: self-kindness vs. self-judgment, common humanityvs. isolation, and mindfulness vs. overidentifi-cation.28 Self-kindness refers to the ability tobe caring and supportive to oneself when deal-ing with a difficult aspect of one’s personalityor life circumstance and avoiding being overlyself-critical. Embodying a sense of commonhumanity involves recognizing that one’sdifficulties are universal and part of a largerhuman experience. Lastly, the quality of mind-fulness refers to the ability to be in the presentmoment with one’s experiences, so as not toignore or overidentify with difficult thoughtsor feelings.

To date, only one study has evaluated self-compassion in a population with chronic illness.In a sample of patients with mixed persistentpain conditions, self-compassion was associatedwith increased acceptance of pain.29 Althoughthis study is important in showing that self-compassion is related to pain acceptance, it didnot examine how self-compassion relates toother important indices of adjustment to persis-tentpain, includingpain, affect, pain catastroph-izing, pain self-efficacy, and pain disability.Research in healthy populations suggests that

individuals who have high self-compassion re-port less negative affect, more positive affect,and higher levels of overall well-being.28,30,31 Inpatients with mood disorders, self-compassionalso has been associated with psychologicalwell-being and better quality of life.32 In sum,research is needed to establish how self-compassion relates toadjustment inpersonshav-ing persistent pain and chronic illness.In this study, we examined the relationship

of self-compassion to measures of pain andpain adjustment in patients with persistentmusculoskeletal pain who were obese. Personswho have persistent pain and who are obeserepresent a particularly appropriate group inwhich to study self-compassion. Persistentpain and obesity are common in many chronicillnesses (e.g., arthritis, diabetes, heartcondition).33e35 Obese persons who live withpersistent pain may face multiple challenges,including dissatisfaction with their bodies,36,37

difficulties maintaining involvement in mean-ingful daily activities,38e41 increased pain,41,42

and psychological distress.7,43e45 Interestingly,clinical observations suggest that there are sub-stantial variations in how obese individuals ad-just to persistent pain. Some obese individualsexperiencing persistent pain lack confidencethat they can manage pain, seem prone to cat-astrophizing, and report high levels of disabil-ity and negative mood.13,39,44 Other obeseindividuals with persistent pain report fewerconfidence problems with regard to theirpain coping skills, mood, and activity levels.26

Self-compassion is potentially a useful con-struct for understanding these variations inhow obese individuals adjust to persistent pain.However, to date, no studies have examined

how self-compassion relates to adjustment topersistent pain in patients who are obese. To ex-amine the role of self-compassion in this popula-tion, several basic questions must be addressed.First, it is important to determine whether self-compassion can be reliably assessed in obesepatients with persistent pain. Secondly, it is nec-essary to examinehow self-compassion relates toobese patients’ reports of the intensity of theirpersistent pain. Thirdly, it is important to assesshow reports of self-compassion relate to mea-sures of psychological functioning (e.g., nega-tive affect, positive affect) and pain coping(e.g., self-efficacy, pain catastrophizing). Finally,

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there is a need to determine whether self-compassion is associated with pain-relateddisability.

The present study examined these questions.Specifically, this study investigated the reliabil-ity of a measure of self-compassion28 and howself-compassion related to indices of adjust-ment to pain (i.e., pain intensity and unpleas-antness, negative and positive affect, painself-efficacy, pain catastrophizing, pain disabil-ity) in a sample of patients who have persistentmusculoskeletal pain and are obese. It washypothesized that higher levels of self-compassion would be associated with lowerlevels of pain intensity and unpleasantness, neg-ative affect, pain catastrophizing, and pain dis-ability, and higher levels of positive affect andpain self-efficacy, even after controlling forimportant demographic and medical variables.

MethodsParticipants and Procedures

The participants in this study were 88 obesepatients with persistentmusculoskeletal pain re-cruited from the Duke Pain and Palliative CareClinic from September 2009 to April 2010. Tobe enrolled in the study, patients had to meetthe following criteria: 1) have persistent muscu-loskeletal back, neck, or leg pain; 2) be olderthan 20 years; 3) have complaints of persistentpain (i.e., pain on most days of the month forat least six months); 4) meet criteria for obesity(bodymass index [BMI]$ 30)46; and 5) be ableto speak, understand, and read English. Everyparticipant provided informed consent priorto participation in the study. The study visitinvolved completing a packet of paper-and-pencil self-report assessmentmeasures in the re-search offices at the Duke Pain and PalliativeCare Clinic. All procedures and protocols wereapproved by the Duke University Medical Cen-ter’s Institutional Review Board.

MeasuresSelf-Compassion. Self-compassion was measuredusing the 26-item Self-Compassion Scale(SCS).28 The SCS assesses three different aspectsof self-compassion: Self-Kindness (e.g., ‘‘I try to beunderstanding and patient toward aspects of mypersonality I don’t like’’) vs. Self-Judgment (e.g.,‘‘I’m disapproving and judgmental about my

ownflaws and inadequacies’’), CommonHuman-ity (e.g., ‘‘I try to see my failings as part of the hu-man condition’’) vs. Isolation (e.g., ‘‘When I thinkabout my inadequacies, it tends to make me feelmore separate and cut off from the rest of theworld’’), and Mindfulness (e.g., ‘‘When some-thing painful happens I try to take a balancedview of the situation’’) vs. Overidentification(e.g., ‘‘When I’m feeling down I tend to obsessand fixate on everything that’s wrong’’). Patientsrate each item on a scale from 1¼ almost neverto 5¼ almost always. Negative items are reversecoded and mean scores on the six subscales areaveraged to produce an overall self-compassionscore. Research indicates the SCS has an appro-priate factor structure and that a single factor of‘‘self-compassion’’ can explain the intercorrela-tions among the six facets.47 The SCS has demon-strated good internal consistency, concurrentvalidity, convergent validity, discriminate validity,internal consistency, and test-retest reliability.28,47

Pain. Pain intensity and pain unpleasantnessweremeasured with 0e100 mm visual analoguescales. Participants were asked to indicate theiraverage level of pain intensity experiencedthat day by marking along a 100-mm line. Pa-tients then followed the same procedure andmarked their average level of pain unpleasant-ness for the day along a second 100-mm line.Pain visual analogue scales are commonly usedin pain research48 and many studies have sup-ported their reliability, validity, and sensitiv-ity.49,50 Pain intensity and pain unpleasantnesswere measured separately to examine both thesensory-discriminative (intensity) and affective-cognitive (unpleasantness) dimensions ofpain.51,52 Pain intensity measures the strengthof the pain experience, whereas pain unpleas-antness assesses how disturbing the pain experi-ence is to an individual. Previous studies havesupported the distinction between these twodimensions of pain.51,52

Psychological Functioning. Psychological func-tioning was measured with the 20-item Positiveand Negative Affect Scale.53 Patients indicatethe degree of their positive and negative affec-tive states (e.g., excited, distressed, scared, in-spired) by rating items from 1¼ very slightlyor not at all to 5¼ extremely. Scores for bothnegative affect and positive affect are averaged,yielding two indices of affect. A high score on

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positive affect reflects enthusiasm, energy, andalertness, whereas a high score on negativeaffect reflects distress and aversive mood states.The Positive and Negative Affect Scale has dem-onstrated good internal consistency in samplesof patients with persistent pain.54,55 Both scalesof this measure have demonstrated good reli-ability among patients with other persistentpain conditions (i.e., rheumatoid arthritis;Cronbach’s alpha ¼ 0.82e0.92).54 In this sam-ple, internal consistency was high (a¼ 0.87).

Pain Self-Efficacy. Self-efficacy for persistentpain was measured using the 22-item ChronicPain Self-Efficacy Scale.56 This scale consistsof three subscales: self-efficacy for pain con-trol, self-efficacy for physical function, andself-efficacy for coping with symptoms. Theself-efficacy for pain control subscale consistsof five items that ask patients to indicate howcertain they are that they can decrease theirpain and reduce its interference in their dailylives. The self-efficacy for physical functionsubscale is made up of nine items that ask pa-tients to indicate how certain they are that theycan perform specific physical activities. Theself-efficacy for coping with symptoms subscaleincludes eight items that assess patients’ cer-tainty that they can control and cope with theirpain-related symptoms. Patients are asked tocircle the number that best corresponds withtheir certainty on a 10-point scale, ranging in10-point increments from 10 (very uncertain)to 100 (very certain). Scores on the threesubscales are averaged to create a total painself-efficacy score. Higher scores representstronger self-efficacy for pain. All three sub-scales have demonstrated good internal reli-ability in persistent pain populations (i.e.,musculoskeletal pain, primary low back pain;Cronbach’s alpha¼ 0.87e0.9056), as they didin this sample (a¼ 0.82e0.93). The internalreliability of the total pain self-efficacy scorewas high: a¼ 0.92.

Pain Catastrophizing. Pain catastrophizing wasmeasured using the brief two-item version ofthe catastrophizing subscale of the CopingStrategies Questionnaire.57 The two itemswere as follows: ‘‘It is terrible and I feel it’snever going to get any better’’ and ‘‘I feel Ican’t stand it anymore.’’ Patients were asked

to indicate how often they experienced eachitem on a seven-point scale, where 0¼ neverand 6¼ always. In this study population, theinternal reliability of the catastrophizing sub-scale was a¼ 0.72.

Pain Disability. Pain-related disability was mea-sured with the Pain Disability Index (PDI).58

The PDI is a seven-item scale that measuresthe degree of a patient’s disability within sevenlife domains (i.e., family/home responsibilities,occupation, social activity, recreation, sexualbehavior, self-care, life-support activity). Pa-tients rated each item on an 11-point scale,where 0¼ no disability and 10¼ total disability.The PDI score is calculated by summing allseven items. A maximum score of 70 indicatesthe highest level of disability. Item 4 (work-related disability) was dropped in the meanscore analysis because of its potential for covari-ation with an important demographic variableassessing work-related disability (financial com-pensation for pain). This measure has demon-strated good reliability and validity withinpersistent pain populations.58,59 In this sample,the PDI showed good internal consistency(Cronbach’s alpha¼ 0.83).

Demographics. Demographic informationabout age, sex, ethnicity, education, partnerstatus, and financial compensation for painwas collected by self-report. Gender was coded0 for males and 1 for females; ethnicity wascoded 0 for Caucasian Americans and 1 forother ethnicities; education was coded from1 to 6, with each number representing an in-creasing level of education (e.g., high schoolgraduate, completed some college, collegegraduate); marital status was coded 0 for notmarried and 1 for married or living with a sig-nificant other; receiving financial compensa-tion for pain (i.e., disability status) was coded0 for patients not receiving financial compen-sation and 1 for patients receiving financialcompensation.

Medical Variables. Height and weight infor-mation was collected using a standard medi-cal office scale. The data were used tocalculate patients’ BMIs. Relative body weightis defined by BMI, which is calculated by di-viding a patient’s weight (in kg) by their

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height (in m2). BMI is considered a bettermeasure of adiposity than weight-for-heighttables.60 The duration of participants’ muscu-loskeletal pain was collected via a self-reportquestion that asked patients to report thenumber of years they had experienced pain.This question is commonly used in studiesof patients with various persistent painconditions.61,62

Table 1Demographics

Variable Mean (SD) % (n)

Age 53.93 (9.65)BMI 37.35 (6.92)Years of pain 11.79 (10.23)

SexFemale 71.6 (88)

EthnicityAfrican American 40.9 (36)Caucasian American 55.7 (49)American Indian/Alaska

Native1.1 (1)

Other 2.3 (2)

Highest educationSome high school or less 8.0 (7)High school graduate 17.0 (15)Some college 39.7 (35)College graduate or

higher35.3 (31)

Partner statusNever married 13.6 (10)Married/living with

significant other59.1 (52)

Divorced 21.6 (19)Widowed 5.7 (5)

Financial compensation for painReceiving financial

compensation45.5 (40)

Not Receiving financial compensation 54.5 (48)Self-compassion 19.37 (4.12)Pain intensity 65.95 (26.16)Pain unpleasantness 63.61 (25.14)PANAS negative 1.75 (0.85)PANAS positive 2.79 (0.89)Pain self-efficacy 43.17 (16.42)Pain catastrophizing 6.65 (2.96)Pain disability 35.89 (11.41)

SD¼ standard deviation; BMI¼ body mass index; PANAS¼ Posi-tive and Negative Affect Scale.Note: Descriptive statistics for demographic and medical variables,self-compassion, and outcome measures.

Data AnalysisDescriptive statistics were calculated for

demographic variables (i.e., age, sex, ethnic-ity, education, partner status, financial com-pensation for pain), medical variables (i.e.,BMI, years of pain), and measures of self-compassion, pain intensity, pain unpleasant-ness, negative affect, positive affect, painself-efficacy, pain catastrophizing, and paindisability. To answer the first aim of this study,internal reliability was calculated for the SCSusing Cronbach’s alpha. Correlational analy-ses and hierarchical linear regression (HLR)analyses were conducted to answer the re-maining aims of the study. First, correlationswere run to examine how the demographicvariables (i.e., age, sex, ethnicity, education,partner status, financial compensation forpain) and medical variables (i.e., BMI, yearsof pain) related to self-compassion and theoutcome variables (i.e., pain intensity andunpleasantness, negative and positive affect,pain self-efficacy, pain catastrophizing, paindisability) to determine what variables tocontrol for in the HLR analyses. Correlationalanalyses also were conducted to determinethe association between self-compassion andthe outcome variables (i.e., pain intensityand unpleasantness, negative and positiveaffect, pain self-efficacy, pain catastrophizing,pain disability). Finally, HLR was used toexamine the association between self-compassion and the outcome variables aftercontrolling for relevant demographic vari-ables. In each HLR, demographic variables(i.e., age, financial compensation for pain, ed-ucation) were entered in Step 1 and self-compassion in Step 2. (A second set of HLRanalyses also were conducted that controlledfor pain intensity in Step 2, and thenentered self-compassion in Step 3. These didnot impact significant study results.)

ResultsDescriptive Analyses

Patients’ medical and demographic charac-teristics are displayed in Table 1. The averageBMI of patients was 37.35 (standard deviation[SD]¼ 6.92); all patients met criteria for obe-sity.25 The average duration of pain was 11.79years (SD¼ 10.23). The average age of patientsin the sample was 53.93 years (SD¼ 9.65);71.6% were female. Ethnicity self-reports indi-cated that 55.7% of patients were CaucasianAmerican, 40.9% were African American,1.1% were American Indian/Alaska Native,and 2.3% identified as another ethnicity. Mar-ital status data showed that 59.1% were

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married or living with a significant other,21.6% were divorced, 13.6% were never mar-ried, and 5.7% were widowed. With regard toeducational history, 8.0% of patients reportedattending some high school, 17.0% reportedcompleting high school, 39.7% reported at-tending some college, and 35.3% reportedcompleting college or further education.Lastly, 45.5% of patients reported receiving fi-nancial compensation for pain (i.e., disabilitystatus).

Reliability of the SCSThe internal reliability of the SCS in this

sample was a¼ 0.93. This indicates the scalewas highly internally consistent.

Correlations of Demographic and MedicalVariables to Self-Compassion, and Measures ofPain and Adjustment to Pain

Correlational analyses were conducted to ex-amine the relation of demographic andmedicalvariables to self-compassion and measures ofpain and adjustment to pain. Results revealedthat age was significantly correlated with self-compassion (r¼ 0.31, P< 0.01) and pain cata-strophizing (r¼�0.39, P< 0.01), with olderpatients reporting more self-compassion andless pain catastrophizing. In addition, financialcompensation for pain was significantly associ-ated with self-compassion (r¼�0.25, P<0.05), positive affect (r¼�0.23, P< 0.05), painself-efficacy (r¼�0.25, P< 0.05), and pain dis-ability (r¼ 0.33, P< 0.01). Patients who re-ported receiving financial compensation forpain showed lower levels of self-compassion, pos-itive affect, and pain self-efficacy, and higherlevels of pain disability. Education level was sig-nificantly correlated with negative affect(r¼�0.38, P< 0.01), with patients who hada higher education level reporting less negativeaffect. There were no significant associations be-tweenmedical variables (i.e., BMI, years of pain)and self-compassion or measures of pain adjust-ment (i.e., pain intensity and unpleasantness,negative and positive affect, pain self-efficacy,pain catastrophizing, pain disability). Based onthe significant correlations reported above(P< 0.05), age, financial compensation forpain, and education were all controlled for inthe HLR.

Correlations of Self-Compassion to Measures ofPain and Adjustment to PainCorrelational analyses found that self-

compassionwas significantly associatedwithneg-ative affect (r¼�0.52, P< 0.01), positive affect(r¼ 0.31, P< 0.01), pain self-efficacy (r¼ 0.25,P< 0.05), pain catastrophizing (r¼�0.40, P <0.01), and pain disability (r¼�0.29, P< 0.01).Patients experiencing higher levels of self-compassion reported less negative affect, paincatastrophizing, and pain disability, and higherlevels of positive affect and pain self-efficacy.Self-compassionwasnot found tobe significantlyrelated to pain intensity (r¼�0.18, P¼ 0.11) orpain unpleasantness (r¼�0.10, P¼ 0.36).

Hierarchical Linear RegressionHLR analyses are summarized in Table 2.

HLRwas conducted to examine the unique con-tribution of self-compassion to pain intensity,pain unpleasantness, negative affect, positive af-fect, pain self-efficacy, pain catastrophizing, andpain disability after controlling for significantdemographic variables.

Pain Intensity and Pain Unpleasantness. Theoverall model for pain intensity was not signifi-cant (F(4, 76)¼ 0.92; P¼ 0.46) and the overallmodel forpainunpleasantnesswasnot significant(F(4, 76)¼ 0.51; P¼ 0.73). Self-compassion wasnot a significant independent predictor of painintensity (b¼�0.16, t¼�1.32, P¼ 0.19) orpain unpleasantness (b¼�0.06, t¼�0.48,P¼ 0.64).

Psychological Functioning. The overall modelexamining negative affect was significant (F(4,77)¼ 10.16; P< 0.001) with demographic vari-ables (i.e., age, financial compensation forpain, education) accounting for 15% of the var-iance in negative affect. Self-compassion ac-counted for an additional 20% of variance innegative affect over and above demographicvariables. Self-compassion was a significant in-dependent predictor of negative affect(b¼�0.48, t¼�4.81, P< 0.001). Patientswho reported higher levels of self-compassionreported lower levels of negative affect.The overall model examining positive affect

was also significant (F(4, 77)¼ 3.37; P< 0.05),with demographic variables (i.e., age, financialcompensation for pain, education) accounting

Table 2HLR Analyses of Self-Compassion and Outcome Variables of Interest (n¼ 81)

Step and Variables

Statistics by Step Statistics by Variable

Total R2 R2 Change Final Std. b t P

Outcome Negative affect1. Age 0.01 0.09 0.93

Financial compensation for pain 0.02 0.24 0.82Education 0.15 0.15 �0.30 �2.69 0.01

2. Self-compassion 0.35 0.20 �0.48 �4.81 <0.001

Outcome Positive affect1. Age �0.01 �0.05 0.96

Financial compensation for pain �0.21 �1.86 0.07Education 0.08 0.08 �0.17 �1.57 0.12

2. Self-compassion 0.15 0.07 0.29 2.53 0.01

Outcome Pain catastrophizing1. Age �0.32 �2.92 0.01

Financial compensation for pain �0.04 �0.40 0.69Education 0.16 0.16 0.05 0.43 0.67

2. Self-compassion 0.25 0.09 �0.32 �3.02 0.003

Outcome Pain disability1. Age 0.03 0.27 0.79

Financial compensation for pain 0.32 2.86 0.01Education 0.12 0.12 0.08 0.71 0.48

2. Self-compassion 0.17 0.05 �0.24 �2.13 0.04

Outcome Pain self-efficacy1. Age 0.10 0.85 0.40

Financial compensation for pain �0.23 �2.06 0.04Education 0.14 0.14 0.12 1.09 0.28

2. Self-compassion 0.16 0.02 0.14 1.28 0.21

Outcome Pain intensity1. Age �0.01 �0.02 0.98

Financial compensation for pain 0.12 1.01 0.32Education 0.02 0.02 0.05 0.41 0.68

2. Self-compassion 0.04 0.02 �0.16 �1.32 0.19

Outcome Pain unpleasantness1. Age �0.12 �0.93 0.35

Financial compensation for pain 0.05 0.39 0.70Education 0.02 0.02 0.02 0.16 0.88

2. Self-compassion 0.03 0.01 �0.06 �0.48 0.64

Note: Hierarchical Linear Regression (HLR) analyses examining association between self-compassion and outcome measures after controlling forrelevant demographic variables.

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for 8% of the variance in positive affect. Self-compassion accounted for an additional 7%of the variance in positive affect over andabove demographic variables. Self-compassionwas a significant independent predictor ofpositive affect (b¼ 0.29, t¼ 2.53, P< 0.05). Pa-tients who reported higher levels of self-compassion reported higher levels of positiveaffect.

Pain Self-Efficacy. The overall model wassignificant (F(4, 77)¼ 3.70; P< 0.05), with de-mographic variables (i.e., age, financial compen-sation for pain, education) accounting for 14%of the variance in pain self-efficacy. Self-

compassion was not a significant independentpredictor of pain self-efficacy (b¼ 0.14, t¼ 1.28,P¼ 0.21).

Pain Catastrophizing. The overall model wassignificant (F(4, 76)¼ 6.22; P< 0.001), withdemographic variables (i.e., age, financialcompensation for pain, education) accountingfor 16% of the variance in pain catastrophiz-ing. Self-compassion accounted for an addi-tional 9% of the variance over and abovedemographic variables. Self-compassion wasa significant independent predictor of paincatastrophizing (b¼�0.32, t¼�3.02, P<0.01). Patients who reported higher levels of

8 Vol. - No. - - 2011Wren et al.

self-compassion reported lower levels of paincatastrophizing.

Pain Disability. The overall model wassignificant (F(4, 77)¼ 3.86; P< 0.01), with de-mographic variables (i.e., age, financial com-pensation for pain, education) accounting for12% of the variance in pain disability. Self-compassion accounted for an additional 5% ofvariation in pain disability over and above thedemographic variables. Self-compassion wasa significant independent predictor of pain dis-ability (b¼�0.24, t¼�2.13, P< 0.05). Patientswho reported higher levels of self-compassionreported lower levels of pain disability.

DiscussionTo our knowledge, this is the first study to

examine the construct of self-compassion ina sample of patients with persistent musculo-skeletal pain who are obese. The results dem-onstrated that self-compassion could bereliably assessed in a sample of patients whohave persistent musculoskeletal pain and whoare obese. Variations in patients’ levels ofself-compassion were associated with impor-tant indices of psychological functioning (i.e.,negative affect, positive affect), pain coping(i.e., pain self-efficacy, pain catastrophizing),and pain disability. It was found that patientswho reported higher levels of self-compassionhad lower levels of negative affect, pain cata-strophizing, and pain disability, and higherlevels of positive affect and pain self-efficacy.

One of the most noteworthy findings of thisstudy was that higher levels of self-compassionwere associated with better psychological func-tioning, specifically lower levels of negativeaffect and higher levels of positive affect. Self-compassion explained a significant proportionof the variance in negative affect (20%), evenafter accounting for the impact of importantdemographic variables (i.e., age, financialcompensation for pain, education). This isan especially important result as negative affectis highly prevalent among populations withmusculoskeletal pain7,43 and obesity,45 andhas been associated with pain onset and exac-erbation.43 Additionally, negative affect hasbeen shown to influence other functioningand quality-of-life factors among patients with

persistent pain and obesity,63e66 and amongother populations with chronic illness (e.g.,cancer, arthritis).67e69

Secondly, self-compassion explained a signif-icant proportion of variance in positive affect.This is important because recent work has sug-gested that positive affect may serve as a buffer-ing function to health problems associatedwith negative emotions70 in patients withpersistent pain conditions. Fredrickson70 pro-poses that positive affect may have an ‘‘undo-ing effect’’ on the negative physiologicaleffects of negative emotions. Positive affect,therefore, could be operating as a protectivepsychological factor in persons with persistentpain. This suggests that it may be important toexamine the role of self-compassion in influ-encing other important psychological variables(e.g., optimism, well-being). Self-compassion’sassociation with important psychological pro-cesses may be key to understanding how thisconstruct can positively affect patient healthand functioning. Prior research on positive af-fect also suggests that it may be important toexamine the role of self-compassion in influ-encing physiological outcomes related to psy-chological processes such as negative affect(e.g., cardiovascular reactivity, cortisol) amongpersons having persistent pain or chronicillness.Our findings suggest that when patients with

chronic illnesses (e.g., suffering from persistentpain) have more self-compassion, they may en-gage in less pain catastrophizing. Specifically,this study demonstrated that patients with per-sistent musculoskeletal pain who are obesehad higher levels of self-compassion and weremuch less likely to appraise their pain in anoverly negative fashion (i.e., pain catastrophiz-ing). The fact that self-compassion explaineda significant proportion of variance in pain cat-astrophizing (9%) is particularly interestinggiven that pain catastrophizing is one of thebest predictors of lower psychological function-ing and physical disability in patients with per-sistent pain.71 Recent work has indicated thatindividuals who tend to catastrophize abouttheir pain are likely to engage in behaviorsthat communicate their pain and distress toothers and serve to elicit attention and concernfromothers.72,73 Self-compassionmay buffer in-dividuals from such negative pain coping strat-egies because of their perspective that one’s

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pain condition is a common human experienceand their greater sense of social connected-ness,28 both of which likely result in a decreasedtendency to catastrophize about pain (i.e., ten-dency to ruminate about, magnify, and feelhelpless about their pain).

Finally, in the present study, self-compassionexplained a significant proportion of variancein pain disability (i.e., the degree to whichpain interferes with patients’ daily activities).One explanation for this association betweenself-compassion and pain disability may be thatinherent in the construct of self-compassion isthe notion of self-acceptance.28,30,74 Individualswho are more self-compassionate are prone toadopt an accepting stance toward all aspects ofoneself and one’s life,30 including negativeevents such as pain conditions. Past researchon acceptance among patients with persistentpain has shown that pain acceptance is associ-ated with better adjustment.75 Thus, self-compassion in the context of persistent pain,or any chronic illness, may increase patients’ability to have a mindful and accepting attitudetoward their day-to-day limitations, withoutignoring or fixating on them. In effect, self-compassion may be affecting disability by en-abling persons with persistent pain to be moreaccepting of their emotional experiences re-lated to disability, while still maintaining en-gagement in meaningful day-to-day activities.

The results of this study support the hypoth-esis that self-compassion is positively associatedwith patient health and functioning amonga sample of patients with chronic illness (i.e.,persistent pain, obesity). To date, the vast ma-jority of research on self-compassion has beenconducted in healthy samples and has shownthat individuals with higher self-compassionhave less negative affect, more positive affect,and higher levels of physical and psychologicalwell-being.28,30,31 Recently, researchers have be-gun studying self-compassion among popula-tions diagnosed with anxiety and depressivedisorders, finding that self-compassion is alsoassociated with enhanced psychological well-being and quality of life and decreased anxietyand depression.32 The results of the presentstudy, coupled with those of a recent studyshowing that self-compassion is related toincreased pain acceptance,29 suggests that self-compassion may be related to better adjust-ment in persons with persistent pain. In sum,

past research and the present study suggestthat in nonclinical and clinical samples self-compassion can be related to improved physicaland psychological well-being.28e32

This study has several limitations. First, be-cause of the cross-sectional nature of the study,the observed results can only be interpretedin terms of associations. Thus, it is unclearwhether self-compassion leads to better painadjustment or vice versa. Future experimentalstudies could provide insight into the causal re-lationships between self-compassion and painadjustment. For example, controlled studiescould be conducted in a laboratory settingwhere self-compassion could be manipulatedand the effects on key outcomes systematicallyassessed (e.g., positive affect, negative affect,pain catastrophizing). In addition, the presentstudy relied on self-report measures. Futurestudies investigating the relationship betweenself-compassion and pain adjustment shouldconsider integrating self-report measureswith direct measures, such as functional per-formance and observations of pain-relatedbehaviors. Lastly, because the sample was pre-dominantly middle-aged (mean¼ 53.93; SD¼9.65) and female (71.6%), results cannot begeneralized to the more general populationof obese patients having persistent musculo-skeletal pain.

An interesting future direction for researchwould be to examine the effects of psychosocialpainmanagement interventions that specificallyfocus on the cultivation of self-compassion. Al-though no controlled studies have directlytested such an intervention, controlled studiesof mindfulness-based and meditation-basedinterventions have addressed certain elementsof self-compassion (e.g., increasing awarenessand acceptance) and have shown positive re-sults. In one randomized controlled study,Shapiro et al.76 found that a mindfulness-based stress reduction program significantlyincreased self-compassion levels among partici-pants, which were found to mediate reductionsin stress associated with the mindfulness-basedstress reduction program. In another controlledstudy, a loving kindness-based meditation inter-vention that addressed elements of self-compassion produced decreases in pain amongpatients with persistent low back pain and im-provements in indices of psychological func-tioning (i.e., anxiety, anger).17 Such results

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indicate the importance of researching the rela-tionship between self-compassion and painadjustment within a longer-term, intervention-focused paradigm.

Taken together, the findings of this study sug-gest that self-compassion appears to be mean-ingfully related to adjustment to persistentpain in patients with persistent musculoskeletalconditions who are obese. Patients in thissample with higher levels of self-compassionwere found to report better psychological func-tioning (i.e., lower negative affect, higher posi-tive affect), more adaptive pain coping (i.e.,higher pain self-efficacy, lower pain catastroph-izing), and lower levels of pain disability. Thesefindings highlight the importance of examin-ing the role of positive factors, such as self-compassion, in the adjustment to chronicillnesses.

Disclosures and AcknowledgmentsThis research was funded by the Pain Pre-

vention and Treatment Research Program(Duke University Medical Center) and didnot receive outside funding sources. Thereare no conflicts of interest.

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