Living with cancer typically affects many aspects of a person’s life, including one’s physical, mental, and social well-being. Physical effects of the illness and treatment, such as fatigue, can impact a persons’ quality of life and diminish opportunities to participate in activities and roles that make life meaningful (Janda et al., 2000; Ann et al., 2015). Adjustment to cancer involves various processes of adaptation as one is managing, learning from and accommodating all the life changes incited by the diagnosis (Brennan, 2001). People with cancer are at an increased risk for experiencing mental distress, including anxiety and depression (Zabora et al., 2001; Trindade et al., 2018). An additional challenge in the adjustment process is that many people with cancer tend to be critical of their bodies, their lifestyle behaviors, their personality traits and how they are managing their illness and its consequences (Bennett et al., 2005; Przezdziecki et al., 2013; Callebaut et al., 2017).

Self-criticism can be described as a self-orientation that entails harsh self-scrutiny, negative self-evaluation and an excessive concern with personal failure (see Lueke and Skeel, 2017). Self-criticism can be a way to try to correct or improve the self, or to persecute the self for failures (Gilbert and Procter, 2006). This can present as explicit self-critical cognitions, but also as feelings of guilt, shame, or anger: these internalized defense strategies and resulting emotions often get fused (Gilbert and Procter, 2006). In clinical and non-clinical populations, self-criticism is associated with depressive symptoms (Warren et al., 2016), loneliness (Wiseman, 2005), and seeking less social support (Blalock et al., 1995).

Little is known about the experience and impact of self-criticism specifically in the context of cancer. It is assumed that in the face of a cancer diagnosis, people naturally try to make sense of the event by giving meaning to how and why it happened, or why the treatment is (not) progressing in a certain way. This process may involve guilt, shame, self-blame, and self-critical cognitions (Callebaut et al., 2017). One crossectional study found that high self-criticism is significantly associated with high distress in women with breast cancer (Campos et al., 2012). Furthermore, in a systematic review of self-blame in people with physical conditions, it was found that between 18 and 39% of people with cancer experience self-blame (Callebaut et al., 2017). Although self-criticism does not always concern causal attributions of the illness onset, it does seem to appear more in people with diagnoses strongly related to lifestyle-based risk factors (e.g., lung cancer) (Callebaut et al., 2017). On top of these self-condemning experiences, self-criticism often goes together with difficulties in generating reassuring and kind feelings toward oneself, i.e., difficulties in being self-compassionate (Gilbert, 2009).

In contrast to self-criticism, self-compassion can be described as an internal resource that enables responding to difficulties with kindness and wise, caring action. Self-compassion creates a context of relating to oneself that supports effective emotion regulation and social connection (Neff, 2013). While research on self-compassion in people with cancer is still in the early stages, more and more studies show that higher self-compassion in people with cancer is significantly associated with lower depression (Pinto-Gouveia et al., 2014; Todorov et al., 2019; Zhu et al., 2019), anxiety (Todorov et al., 2019; Zhu et al., 2019), and distress (Pinto-Gouveia et al., 2014; Todorov et al., 2019), lower body-image distress (Todorov et al., 2019), higher treatment adherence (Sirois and Hirsch, 2019), and higher resilience (Alizadeh et al., 2018). Evidence from intervention studies further demonstrates the relevance of self-compassion, as a recent review shows that training self-compassion skills via compassion-based interventions can yield reductions in anxiety, depression and self-criticism in people with cancer (Austin et al., 2020).

A limitation of existing research on self-compassion in cancer patients is the almost exclusive use of quantitative methods, e.g., correlational and intervention studies using self-report questionnaires to assess self-compassion. Although valuable in showing how self-compassion relates to patients’ outcomes such as distress and providing evidence for the efficacy of compassion-based interventions, these studies cannot shed led on cancer patients’ experiences of self-criticism and self-compassion. Having more insight into this may inform researchers and health care professionals whether and how compassion-based interventions should be adapted to the context of the cancer patient. In the aforementioned review by Austin et al. (2020), none of the compassion-based interventions were tailored to the distinct experiences of self-criticism and self-compassion or specific needs regarding compassion-based interventions of people with cancer. Only in one qualitative study by Lathren et al. (2018), experiences with an online Mindful Self-Compassion (MSC) group intervention of young adult cancer survivors were investigated. The participants expressed that training self-compassion helped them to address peer isolation, e.g., by becoming more mindful of the support already present in their environment and by learning to become a source of support for themselves. In addition, training self-compassion enabled the young adults to become kinder and more accepting instead of critical toward physical limitations and to experience gratitude for their working body parts. While these results indicate some interesting themes that are relevant for understanding experiences of self-compassion and benefits of compassion-based interventions in cancer patients, they do not address experiences of self-criticism and self-compassion of people with cancer of all ages and in various contexts. In general, in the field of self-compassion, there is a lack of qualitative research, with so far only two other qualitative studies on the experiences of self-criticism and self-compassion in adult clinical or non-clinical (non-cancer) populations (Pauley and McPherson, 2010; Halamová et al., 2018). These studies show that participants describe both emotional and action-oriented aspects of self-compassion. Participants describe self-compassion as meaningful, offering benefits such as an increased sense of calm, while also expressing unfamiliarity with the concept and perceived challenges such as high self-criticism (Pauley and McPherson, 2010; Halamová et al., 2018). Given the sparsity of qualitative studies, also in the context of cancer, there is a need for further qualitative research. The current qualitative study aims to explore in what ways people with cancer experience self-criticism and self-compassion, after prompting them with minimal and untailored self-criticism and self-compassion exercises to facilitate reflection on these often unfamiliar concepts. Such insights will increase our understanding of self-criticism and self-compassion in the process of adjusting to cancer and may inform future development and evaluation of theory, scales and (self-) compassion interventions.

This study was approved by the Ethical Committee BMS of the University of Twente. A multimethod qualitative study design was used to study experiences of people with cancer regarding self-criticism and self-compassion. A semi-structured interview approach enabled an in-depth exploration of personal experiences and meaning (Carter and Henderson, 2005). Individual interviews were corroborated with group interviews in order to increase data richness. Specifically, group interviews can supplement the in-depth personal accounts of individual interviews with data emerging from group interactions about similarities and differences in experiences (Lambert and Loiselle, 2008). Individual and group interviews were conducted simultaneously and non-hierarchically, and thus were not informed by either outcome during the data collection phase.

This is the first qualitative study that investigated ways in which adults with cancer are self-critical and self-compassionate in relation to their diagnosis and illness. All participants were able to describe ways of being self-critical as well as being self-compassionate post-diagnosis, often reporting being self-critical in some areas (e.g., about lashing out at others) and being self-compassionate in other areas (e.g., by taking rest).

Four themes describing ways of being self-critical were identified: being harsh or strict with yourself, feeling guilty or angry, feeling useless or like a burden, feeling ashamed and not wanting to show weakness. Being harsh or strict with yourself is a theme that has been identified by Neff (2013) as the opposite of self-kindness and is also a facet assessed by the Self-Compassion Scale (Neff, 2016). However, the other themes brought up by patients have not gotten much attention in existing self-compassion scales and literature. Interestingly, when looking beyond the literature on self-compassion and expanding to literature on coping with cancer, some resemblance with our results can be noted, particularly regarding the experience of feeling useless or like a burden (Refsgaard and Frederiksen, 2013). It is possible that this entails a form of self-criticism more specific to people with cancer or perhaps long-term physical conditions in general, brought on by an inability to perform various social roles and by being dependent upon others. Another way in which self-criticism may express itself in people with long-term physical conditions, is that stigma regarding diagnoses strongly related to lifestyle-based risk factors (e.g., lung cancer) may become internalized by patients in the form of harshness or guilt, even when they did not engage in these harmful lifestyle behaviors themselves (Else-Quest et al., 2009; Marlow et al., 2010). Further research is warranted to investigate the experience of these types of self-criticism in people with cancer and other long-term physical conditions, and the extent to which these experiences are similar to or different from other populations.

Six themes describing ways to be self-compassionate were identified: being mild to yourself, guarding your boundaries, accepting the illness and limitations, maintaining a positive perspective, connecting to others and taking responsibility for your health. Self-compassion as experienced by people with cancer thus encompasses coming to terms with the situation, resting, setting boundaries and lowering expectations (“doing less”), while also taking active steps to take care of oneself by focusing on positive aspects of life, sharing with others and engaging in healthy behaviors (“acting more”). Similarly, theoretical definitions of self-compassion describe dimensions of noticing and being with suffering, as well as acting to alleviate suffering (Gilbert, 2014; Neff and Germer, 2018) as corroborated by the few qualitative studies of self-compassion in other adult populations (Pauley and McPherson, 2010; Halamová et al., 2018). Thus, although self-compassion is sometimes publicly (mis)understood as overly soft or accepting (Gilbert et al., 2019), our results concur that self-compassion requires courage and wisdom to make beneficial, albeit difficult, decisions. In that way self-compassion contributes both to recovery (e.g., by taking rest) and sustainability and growth (e.g., by redefining priorities post-diagnosis) aspects of resilience in the adaptation process (Austin et al., in press).

Some elements of theoretical approaches to self-compassion can be recognized in our results. For example, being mind to yourself resembles an aspect of self-compassion identified by Neff (2013) as self-kindness. However, our other themes are not measured by Neff’s Self-Compassion Scale (SCS), and these have mainly been overlooked by previous quantitative research on self-compassion. We suggest that this is because our findings particularly shed light on a more practical, daily life experience of self-compassion (e.g., specific emotions, behaviors and cognitions)—something that earlier (more conceptual) qualitative studies of self-compassion in adult populations have also not addressed (Pauley and McPherson, 2010; Halamová et al., 2018). Our findings thereby help to bridge the gap between theoretical constructs and lived experience. This connection may be useful in the development or adaptation of compassion-based interventions for people with cancer, making the concept of self-compassion more relatable to this target population and hopefully increasing intervention success. Indeed, in our own development of a mobile self-compassion self-help training for people with cancer (Austin et al., 2020) the themes found in this study are embedded as topics to be addressed in the training. For example, “taking responsibility for your health” as an intervention topic addresses the difference between self-compassion and self-indulgence (e.g., undergoing treatments that may be unpleasant at first but that reduce suffering in the long-term), as well as practicing compassionate self-correction and goal setting (e.g., practicing understanding when a health behavior goal is not met, and then supporting yourself by adjusting the goal or facilitating circumstances that make it more obtainable). While initial responses to the intervention are positive, only future research can tell how this applied approach to self-compassion will be perceived. Furthermore, our findings raise an interesting question about whether available instruments that measure (trait) self-compassion (e.g., the Self-Compassion Scale, Neff, 2016) align with the more practical descriptions of self-compassion found in this study, or whether more practical, tailored instruments could be of added predictive value. For example, the themes of the current study could translate to cancer-specific questionnaire items (e.g., an item for “guarding your boundaries” could be: “When coping with the limitations resulting from my illness, I indicated my boundaries to others.,” and an item for “feeling useless or like a burden” could be: “In relation to my illness, I feel guilty about being a burden to others”).

Research shows that self-compassion is inversely associated with self-criticism (Zhang et al., 2019). As Neff (2013) posits, self-criticism asks whether you are good enough, while self-compassion asks what is good for you. In our results, self-criticism and self-compassion sometimes presented as opposite responses, where for example self-criticism entailed not accepting your mistakes, and self-compassion entailed being understanding toward your mistakes. At other times this dynamic was more complex, for example when self-compassion was experienced as setting social boundaries and not being available to others, while self-criticism was experienced as feeling guilty for not being available to others. Indeed, what is experienced as self-compassion or self-criticism depends on what is needed to alleviate suffering in any given situation. Self-compassion can be seen as an alternative to self-criticism, wherein compassionate self-correction instead of self-criticism is practiced in response to failures or difficulties (Gilbert, 2010; Hulsbergen and Bohlmeijer, 2015). However, more research is needed to clarify how self-criticism and self-compassion relate, i.e., as two unipolar constructs or as opposite ends of the same spectrum. Intervention research indicates that when self-compassion is trained, a self-compassionate response becomes more available and a self-critical response may become less appropriate (Gilbert, 2010). Most compassion-based interventions target both self-criticism and self-compassion, and experienced benefits of less isolation/more connection and more acceptance toward physical limitations have been reported post-intervention (Lathren et al., 2018; Austin et al., 2021). Noteworthy, in our study the difference between self-criticism and compassionate self-correction was not always clear to participants, with self-criticism occasionally being described as something valuable and constructive. At times it was challenging to determine whether this indicated a meaningful difference in self-to-self relating or merely a difference in semantics. After the initial interviews, we began to clarify this by asking (more) follow-up questions regarding intentions preceding the “self-criticism” and feelings resulting from the “self-criticism.” We suggest that this is something to take into account and allot sufficient time for in future research of perceived self-criticism and self-compassion.

This study was strengthened by the integration of two different qualitative methods, which allowed for a more comprehensive investigation of experienced self-criticism and self-compassion in people with cancer. Similar to the study by Lambert and Loiselle (2008), we noticed that an individual interview typically offered a more linear perspective of antecedents and context of self-critical or self-compassionate experiences, while in group discussions participants were triggered by each other’s experience to remember similar examples, offering less detail but more spontaneity and breadth—despite the similarity in topics. The integration of different qualitative methods can indeed offer a more comprehensive view of complex experiences (Frank et al., 2019), although pitfalls such as assigning hierarchy to findings from different methods should be avoided (Lambert and Loiselle, 2008). Another strength of this study was that the use of self-compassion exercises prior to the interviews enabled participants to reflect on their experiences of self-criticism and self-compassion in the context of their daily lives. The exercises were kept brief and untailored for this purpose, which facilitated prompting experiences without a main focus on an intervention process. Given that most participants were not yet familiar with self-compassion, we believe that this was successful in increasing data richness. Nevertheless, it should be noted that this approach may have steered the results to some extent, since we did not capture the perspective of a “naïve” patient that a health care professional would most likely encounter in clinical practice. Conducting interviews prior to and after engaging with exercises could shed more light on this perspective. Noteworthy, a limitation of this study is that 5 out of the 26 participants were diagnosed a long time ago (8–10 years), and their experiences of self-criticism and self-compassion in relation to their diagnosis and illness may be clouded by other, more recent, life experiences. Furthermore, while compared to other studies our sample was quite balanced in terms of gender, the majority of participants had a theoretical education, were married/in a relationship and were from a non-migration background. In addition, breast cancer was by far the most common diagnosis. Therefore it is unclear whether our findings apply to other groups of cancer patients, such as people with a vocational education, for whom rates of self-compassion have been found to be lower than for people with a theoretical education (López et al., 2018).

In sum, our multimethod qualitative study described experiences of self-criticism and self-compassion in people with cancer in relation to their diagnosis and illness. Four themes describing ways of being self-critical were identified: being harsh or strict with yourself, feeling guilty or angry, feeling useless or like a burden, feeling ashamed and not wanting to show weakness. While existing research focuses more on experienced guilt, shame and anger, being harsh or strict with yourself and feeling useless or like a burden warrant further attention. More research is needed to investigate these and other specific ways in which people with cancer are self-critical, and how they are similar to or different from other (illness) populations. Six themes describing ways to be self-compassionate were identified: being mild to yourself, guarding your boundaries, accepting the illness and limitations, maintaining a positive perspective, connecting to others and taking responsibility for your health. Elements of theoretical approaches to self-compassion can be recognized in our results, including dimensions of “being with” as well as “acting to alleviate” suffering. However, our findings particularly offer insight into the practical and daily life experiences of self-compassion, with may prove to be helpful in the further development of theory, scales and interventions.

The datasets presented in this article are not readily available because of the sensitive nature of this research (interview transcripts are not available for sharing). Requests to access the datasets should be directed to corresponding author.

The studies involving human participants were reviewed and approved by the Ethical Committee BMS of the University of Twente. The patients/participants provided their written informed consent to participate in this study.

JA and CD performed the material preparation, supervision of individual interviewers, and data analysis. JA wrote the first draft of the manuscript. All authors commented on previous versions of the manuscript, read and approved the final manuscript, and contributed to the study conception and design.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.