Theory and practice of compassion

Gilbert, a pioneer of Western compassion research, developed CFT as an integrative, multidisciplinary and process-based approach, underpinned on Buddhist views and several schools of psychotherapy [2,15,16]. CFT was developed to help people with high levels of shame and self-criticism, who were struggling to derive benefits from standard therapeutic interventions. People with pathogenic levels of shame and self-criticism typically come from insecure, negligent or traumatic backgrounds, and often fear seeking compassion and affiliation. This ‘fear of compassion’, is found to be one of the biggest inhibitors to practising compassion towards the self and others [2]. CFT attempts to suppress these inhibitors, and develop compassion using three directional flows, namely, compassion to others (CTO), compassion from others (CFO), and compassion to the self (self-compassion: SC).

Western studies integrating CFT and other compassion-based practices have reported psychological benefits, with evident decreases in depression, anxiety, self-harm and several other psychological presentations [17–19]. These practices have also shown a transcultural effect in improving well-being in Eastern Buddhist societies such as Japan [20], Western non-Buddhist communities [21], as well as in Middle Eastern and Muslim societies [22].

Cultural influence

One’s cultural background plays a vital role in shaping compassion, and these cultural dimensions influence their tendency to show SC and CTO [1]. Research has explored how SC manifests across different cultures. For example, an individual’s functioning, including the extent to which they can develop SC, is congruent with the cultural and societal values they share with their community [23]. Furthermore, Birkett [24] attributed differences between the levels of compassion, to the beliefs and religious practices affiliated to each country, rather than a simple East-West cultural contrast. To date, most compassion studies have been limited to Western countries [25] and even where studies exploring compassion have made cultural comparisons, this has been limited to a few countries [26]. This signifies the need for more diverse cross-cultural research.

As many compassion practices stem from Buddhist principles [27], and Buddhism is mainly practised in Asian traditions, one would expect Asian Buddhist followers to exhibit higher levels of compassion. Furthermore, it appears fair to expect people in Asian interdependent countries where people’s decisions are very much influenced by others in their society, to be more compassionate due to high levels of social interconnectedness, caring, and social conformity shared between one another [26]. However, studies have actually found the opposite result, with people in Asian interdependent societies such as Japan (where Buddhism is practised as a main religion), having higher levels of self-criticism than people in the Western world [28]. In consideration of these findings, Kitayama and Uchida [29] suggested that self-criticism, is often prevalent in emotionally interdependent and densely knit Asian societies. Therefore, levels of SC could be expected to be lower among those in Asian cultures, as self-criticism is a key inhibitor of SC [26]. Social pressure to conform with social norms and values might then hinder one’s SC. Thus, it is important to consider cultural and religious backgrounds, as well as one’s upbringing, into account when understanding the interplay of factors that may impact upon compassion [26].

Sri Lanka is a South Asian multi-ethnic country, where Buddhism is practised by 69% of the population [10,30]. Although the Sri Lankan community is heavily influenced by the teaching of Buddha, the incorporation of Buddhist teaching into psychotherapy and education remain unexploited [10,30] and are yet to be incorporated into the academic curricular of psychological teachings in Sri Lanka [31]. Applying Buddhist practices such as mindfulness and compassion into psychotherapy is also problematic in Sri Lanka, as the lack of knowledge in integrating Buddhist influenced psychotherapy has restricted mental health professionals from accepting such therapeutic methods. This is mainly due to the social view of meditation and Buddhist practices as spiritual practice rather than a psychotherapeutic approach [10].

Rationale for the present study

With Sri Lanka being a largely Buddhist influenced, collectivistic and interdependent society where social dominance, comparison, and criticism influences one’s identity and behaviour [32], it seems fair to propose that implementing compassion based practices may enhance the well-being of Sri Lankan people. However, while compassion interventions conducted in Asia appear to be minimum, to date, there has been no published research exploring compassion in Sri Lanka from a psychological view, let alone implementing compassion-based practices.

This study, therefore, aimed to explore the views and lived experiences of compassion in Sri Lankan students using the three flows of compassion; SC, CTO, and CFO, with a particular emphasis on their perceived inhibitors and facilitators.

Design and participants

The scientific account of compassion greatly depends on the understanding of individuals’ subjective experiences [33]. Thus, a qualitative approach was determined suitable to understand participants’ subjective experiences of compassion in the present study. Although it is critical to conduct qualitative studies to fully understand the challenges that mental health problems pose to experiencing compassion and to uncover potential inhibitors that wider cultural discourses create [34], qualitative research exploring compassion among community populations remain at an infancy stage [34]. Therefore, this study used a qualitative design to gain a realistic and detailed personal account into how Sri Lankan students view and make sense of their experiences with compassion. As IPA provides rich and insightful data, Smith et al. [35] recommend that 4–10 participants are sufficient for a professional study. They also emphasised on the importance of adapting an in-depth semi-structured interview approach as the most suitable method to elicit meaningful qualitative data.

Therefore, 10 Sri Lankan participants (3 males, 7 females), aged between 19–46 years (M = 26.1, SD = 8.0) were recruited via a purposive sampling method on a first-come first serve basis. Participants’ religious faith varied from Buddhism (n = 3), Catholicism (n = 1), Christianity (n = 2), Hinduism (n = 1), Islam (n = 2), and Atheism (n = 1). They were recruited from an undergraduate psychology course in Sri Lanka and participants declared that they had not learnt about compassion in their course.

Interview structure

A semi-structured interview guide was created aiming to understand participants’ views of the concepts of compassion and their experiences of SC, CTO, and CFO. Questions also sought to understand participants’ interpretations of the motives behind a person offering and receiving compassion, and the inhibitors and facilitators that participants encountered in doing so. Additionally to the structured interview questions, probing questions were asked when necessary. See Table 1 for a list of questions asked.

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Table 1. Interview questions.

https://doi.org/10.1371/journal.pone.0260475.t001

Procedure

This study was approved by the Ethics committee of the University of Southampton. Participants’ informed consent to partake and the interviews to be audio recorded was obtained prior to starting the study. All names reported in the Results section are pseudonyms used to protect participants’ identity. Pilot interviews were conducted with two participants from the sample, in order to check the feasibility of the interview guide and to observe whether the questions sampled the areas of interest. As the pilot did not show the need to change the questions, interview guide was not refined, and the pilot data were added to the final analysis. Interviews lasted around 20–30 minutes on average.

Data analysis

All audio-recorded interviews were manually transcribed verbatim, and subjected to Interpretative Phenomenological Analysis (IPA: [35,36]). IPA is a reflexive, transparent approach, which provides a thorough understanding of individual accounts with meaningful interpretations of their relationships to the world and others. The inductive nature of IPA, which is not based on predetermined hypotheses, facilitated the emergence of unpredicted themes [36]. Reid and colleagues [37] emphasised the importance of using IPA in areas that significantly lack previous literature. As the authors were not aware of any psychological research conducted on compassion in Sri Lanka, IPA was considered an appropriate method.

Analysis involved reading the transcripts multiple times to allow the primary researcher to familiarise with the interview content and fully immerse in the narrative. Each transcript contained two wide margins, with the significant meanings written on the left-hand margin and emerging themes on the right-hand margin. Next, the descriptive, linguistic and conceptual comments for quotes were made throughout the transcripts to elicit the themes. Preliminary themes were then developed, amended, and refined. Each theme was summarised and allocated a participant number with an identifiable verbatim quote. In order to confirm the validity of the interpretations, themes were analysed with recurrent reference to the original text and where appropriate, these themes were clustered together based on relevance to originate the superordinate and subordinate themes. This process was repeated until all the superordinate themes and subordinate themes were developed.

Superordinate theme: What compassion means to me

Participants discussed their understanding about compassion and what it meant to them. Compassion was needed the most in tough times and participants viewed it as an innate ability to express a sympathetic consideration towards one’s suffering. However, many participants found it easier to show CTO than towards themselves. Some participants also found accepting CFO challenging. This superordinate theme elicited two subordinate themes: sympathetic consideration towards suffering, and self and others: it is not the same.

Superordinate theme: What I make of it

This superordinate theme discusses participants’ overall experience of engaging in the three flows of compassion. To many, this was a healing and positive experience, which motivated them to continue seeking and offering compassion, whereas for others, the experience was rather negative. Experience was mostly positive when participants viewed the compassion received and given as genuine, whereas the compassion perceived as fake or obligatory was experienced negatively, causing exhaustion.

Superordinate theme: Compassion through facilitators and inhibitors

Participants also discussed what factors they believed facilitated their experiences of compassion and the factors that inhibited it. Most participants signified the importance of their religion and culture in shaping compassion. Some of them however, elucidated how one’s religion and culture could restrict their compassion only to those who belong to the same religion and culture, and could act as an inhibitor towards showing CTO who belong to out-groups. On the other hand, all participants indicted society and the stigma surrounding certain social constructs and norms as their biggest inhibitor to compassion.

What compassion means to me

Compassion is known as a sensitivity to suffering in oneself and others, with a motivation to alleviate and prevent it [1]. Gilbert [38,39] outlined some key competencies involved in compassion, including the motivation to care, tolerance of negative emotions, sympathetic concerns, and non-judgemental and empathetic understanding. Although participants had not previously learnt about compassion in their psychology course, everyone shared a similar view to Western definitions whilst actively recalling memories of previous compassionate engagements. Their recalled experiences with compassion implied that they were well aware of its impact on increasing well-being and reducing suffering. Participants described compassion as not just being sensitive towards suffering, but also having the motivation to relieve that suffering. When asked to describe their understanding of compassion as a construct, they shared a similar understanding to Western explanations, and expressed genuine sympathetic considerations towards people’s problems, motivation to alleviate suffering, and kind and loving feelings as attributes of compassion. Compassion is viewed as stepping out of one’s typical frame of position and perceiving the world from a standpoint of another [40]. In support, many participants identified the act of showing compassion as a process that requires not only sympathetic considerations towards suffering, but also a conscious effort to achieve.

Participants then described self-compassion as compassion given towards the self. Their views of SC was in line with that of Neff [41], who defined SC as being kind and non-judgmental towards oneself and their own suffering or failure, while intending to alleviate that suffering rather than being harsh towards the self or avoidant of that suffering. Overall, it appeared that despite the absolute lack of compassion research conducted in Sri Lanka, interviews of the present study indicated that Sri Lankan students would possibly benefit from compassion-based practices as they shared a good knowledge of compassion as a construct and of its benefits in increasing their psychological well-being.

What I make of it?

Despite being fully aware of the concept and its benefits, most participants however reported feeling as if they struggled to develop SC although they found it easier to give CTO. To many, ‘guilt’ obstructed SC and incited self-blame and criticism instead. Although many psychological models emphasise that humans are primarily guided on self-interest [42], studies signify that humans are more likely to use harsh language towards themselves rather than to a loved one, or even a stranger in that regard [41,43]. Participants’ statements such as ‘I’m wasting my life’ (Mathew), and ‘I was ugly and fat’ (Fatima) further confirmed this. Furthermore, studies emphasise that some people who are extremely compassionate to others have a tendency to be harsh towards themselves even when things are out of their control [41]. People generally have a different way of viewing others when compared to how they view themselves [19] and become self-critical when they fail to achieve what they want, self-inflicting pain [44]. On the other hand, studies have found that females have slightly lower SC and higher CTO than men [45], due to females’ natural propensity towards nurturing and compassionate care than men [46]. This gender difference may have also affected the present study, as 7 out of 10 participants were females. Further quantitative and mixed method studies could be conducted to explore the possible differences of gender, age and other demographic factors on the varying levels of compassion.

Participants also enjoyed giving CTO and receiving CFO when they believed it was offered genuinely. In the interviews, they expressed that they could sense when someone was being real, and recognised when the compassion felt superficial. In such cases, it appeared to participants that the compassion that was offered, was done so with a sense of obligation, and was perceived as forced. Heshan explained “I think it’s because I help them, not because they want me to be happy”, igniting a powerful understanding of the true motive behind CFO. From an evolutionary perspective, compassion is not always seen as unconditional due to its propensity towards cost-benefit outcomes [47]. The reciprocity norm [48] suggests that people generally feel obliged to reciprocate help when they have received favours from others. This transactional behaviour raises a question for future research to consider, with regards to how genuine this type of compassionate giving is, or if people who feel obliged to offer CTO really want to relieve the suffering of others. Catarino and colleagues [49] attributed this perceived difference to ‘genuine compassion’, which is the genuine concern for others’ needs and the motivation to help them [2], and ‘submissive compassion’, the caring that develops for self-advancing or defensive needs in order to be liked by others or to avoid rejection. In this study, most participants felt genuine compassion for others, while they implied that the compassion they received from some people might have been submissive.

However, when the motivation was genuine, participants believed that it benefited both the recipient and the giver of compassion. They stressed that people who had experienced similar life events could find comfort in offering CTO. This is consistent with previous research. For example, Catarino et al. [49] established that giving CTO positively influences one’s own well-being. Studies have also found positive relationships between CTO and life-satisfaction [37], prosocial behaviour [40], self-esteem, self-awareness, and negative relationships between CTO and depression [49]. In addition, the phenomena of giving CTO have led to increased feelings of connectedness, social support and trust [50].

Whilst many participants found the experience of receiving and offering compassion to be pleasant, this was not the outcome for some others. Nelu felt exhausted from showing CTO, although she felt compelled to do this. Fears, blocks and resistances of compassion [51] can often hinder compassion. Being overwhelmed by distress can generate a sense of fear, while lack of understanding of compassion or environmental and external difficulties can lead to blocks. People also resist compassion when they do not want to be compassionate due to exhaustion, previous negative experiences and for other reasons. This implies that compassion offered with obligation (submissive compassion) may not feel as satisfactory as genuine compassion, which would then be reflected in the experience of the recipient.

Despite the perceived benefits, compassion can lead to avoidance or fear reactions in some individuals, especially among those with high self-criticism [15]. Gilbert [15] found that for some people, the experience associated with CFO can generate grief feelings of wanting but not getting the love and care from loved ones, which can increase the awareness of an inner loneliness. In such situations therefore, if the experience of receiving CFO is unfamiliar, people would dissociate or avoid the CFO. CFO is an under-researched area and, it would be interesting for future research to explore whether the discrepancy between believing participants’ own compassion to be genuine and CFO to be submissive, is due to participants’ own fear reactions, and if this was their reason for avoiding CFO.

In support, Fatima and Mathew discussed how maintaining a negative self-image pushed them away from seeking CFO. Most participants exhibited problems with overthinking, anxiety and rumination, implying a link between these traits and low self-compassion. Overthinking, anxiety and rumination lead to low self-esteem, which in turn guides people to be their own worst self-critics [52]. This is supported by previous cross-cultural research, which emphasised that people in Asian collectivistic backgrounds indicated higher self-criticism and rumination than those in the West [53,54]. Self-criticism in collectivistic cultures is considered as a facilitator of self-improvement that helps to perpetuate social harmony [55,56]. Thus, participants’ experiences with low SC and reluctance to seek CFO might have had a cultural impact.

Compassion through facilitators and inhibitors

Although experiences and recollections of memories varied, all participants shared a set of factors that enabled their compassion and others that hindered it. Despite participants following different religions, almost everyone believed that religion taught them to be compassionate. Studies have found that religion plays a major role in the majority of the Sri Lankan society especially when determining self-identity [57]. This is consistent with other studies that religious identification is the strongest constituent of one’s self-identity [58]. Although compassion is central to the Buddhist teaching, studies have found that compassion is taught and practiced in many other religions, including Christianity [59] and Islam [22]. Deliberating on the links between compassion in Buddhism and Islam, Shah-Kazemi [60] demonstrated that compassion is inseparable from love in both religions and that the level of loving compassion defines the core of one’s humanity. Successful application of compassionate practices among non-Buddhist, Western communalities [26], and Middle Eastern Muslim countries [22], imply the transcultural applicability of compassion practice.

All participants discussed the idea of a collectivistic culture that encourages its members to be there for one another during tough times. These cultures and their values often shape human behaviours and thought processes [61]. Values are socially accepted concepts that are set to help achieve motivational goals such as well-being and social interaction among groups [62]. Tradition is one of these values that requires obligation, respect and acceptance of the norms that one’s culture or religion postulates. Gilbert et al. [63] predicted that cultural elements such as social norms might influence SC, while Neff et al. [26] suggested that SC might be at least partially culturally determined. Particularly, people in Asian, Buddhist influenced societies may practice compassion more naturally, given that SC and CTO is central in the Buddhist worldview [26]. In fact, in Buddhist societies such as Thailand, failure is seen as an opportunity for self-improvement, while Buddhist compassion has influenced ethics of daily living such as child rearing [64].

People are more likely to show compassion towards those who share similar values, beliefs, preferences, actions and physical characteristics with them [65]. According to evolutionary theories, compassion is subjective to evolutionary demands, leading people to be more compassionate towards kin and possible reciprocators of compassion than to those with whom they are unacquainted and non-kin [66]. Although culture helps people identify and unite within their social group, they can encourage people to negatively evaluate those who do not comply with these values [62]. Radhi, a participant of the present study identified this disparity and explained how society, culture and religion could inhibit compassion as opposed to being a facilitator. She further emphasised how these entities manipulate the level of compassion one should show to others, based on the in-group outgroup diversion. By forming groups and societies, social dominance leads people to identify their groups as superior to other groups and, as a result, act in non-compassionate ways to outgroups [67]. Furthermore, obedience to authority, having to abide by group norms and the pressure of fitting in have diminished people’s ability to show CTO [68].

Contrary to the aforementioned Asian Buddhist influence on compassion, some studies have found that people in such collectivistic societies exhibit a narrower trust radius, meaning a narrower width of the circle of people they trust, when compared to people in individualistic societies. This is due to collectivistic societies being more discriminatory and limiting of trust towards those in an out-group when compared to those in an in-group [69]. The lack of trust may also explain why participants viewed society as an inhibitor towards experiencing CTO as well as CFO. As previously detailed, the very definition of tradition itself highlights the need for ‘obligation’ and, Heshan in his interview emphasised how Sri Lankans are limited in their understanding and acceptance of people due to the ‘so called frame of tradition’. Participants’ understanding of this disparity raises the question whether culture and religion actually influence people to be more compassionate or, whether they hinder one’s compassion, signifying the void for further exploratory research.

Another inhibitor participants identified was the stigma and lack of awareness in the Sri Lankan society surrounding the topic of mental illness. Mathew emphasised how his mother wanted him to ‘just get over’ his depression, when he disclosed his struggles with depression to his mother. Many Sri Lankan families try to hide mental illness of family members from the society to avoid stigma and discrimination, as mental illness is seen to restrict peoples’ chances at employment and marriage [70]. Fear of stigma was seen as the biggest obstacles to seeking professional help and, even when help was sought, studies indicated that there is minimum reintegration into families following psychiatric treatment in Sri Lanka [71]. Negative stigmatising views from others could create self-stigmatising thoughts in people, which consequently result in social withdrawal [61]. Such individuals become increasingly sensitive to threat and less adherent to self-soothing actions [27]. In the present study, Sonali described how society views depression as ‘being weak’ leading people to conceal mental illnesses. Studies also showed that Sri Lankan children are raised to fear shame and are ridiculed by the society if social norms such as norms of sexual modesty and approved behaviour are subverted. Fear of being ridiculed by the society was evident in this study as participants discussed being called overconfident and criticised for showing SC and CTO.

Consequences were a lot more severe when participants were misunderstood or judged by their own family, especially parents. Gilbert [38] emphasised that the attachment system from significant others acts as a foundation for developing capacities for compassion. Thus, the lack of care in early relationships may lead people to feel underserving of love and fear compassion [63]. Fear of compassion manifests in negative self-evaluations resulting in detachment from society [41]. In the current study, participants with negative self-perceptions and weak attachments with significant others were reluctant to seek help, or, according to them, ‘be a burden’ on others. In a non-compassionate self-perception, people view themselves as underserving and others as deserving of compassion, creating a fabricated sense of separation from the rest of humankind. Self-critics often feel inadequate and believe that they are the only ones facing failure. This irrational belief that everyone else is perfect, makes them isolate themselves from others [44]. This is one of the main challenges for psychotherapy, as people fearful of compassion tend to be avoidant or not disclose personal struggles hoping to escape receiving CFO [39]. Thus, it is apparent that participants’ self-criticism may have stemmed from unappreciative, insincere significant others, in this case, parents and family.

Taken together, findings indicate that Sri Lankan students’ views and lived experiences of compassion reflect those discussed in the Western psychological models. These findings are not entirely surprising due to compassion-based practices such as the Compassion Focused Therapy [39], being at least partly influenced by Eastern and Buddhist practices. Findings therefore, suggest that the Western therapeutic models and practices of cultivating compassion and SC, along with the recognition of fears, blocks and resistances may also be of use to the Sri Lankan population.