The Training Effects of a Mindful Self-Compassion Teacher Program: Pilot Study

INTRODUCTION Korea has the number one suicide rate among OECD countries in recent years (Statistics Korea, 2016). As the society becomes more polarized, there are more conflicts among individuals, and more people with various psychological symptoms are looking for psychiatric hospitals or counseling centers. The media has successively reported events and accidents due to impulse control disorder. Thus, the need for psychological intervention has become stronger than ever. If traditional psychotherapy targets psychiatric patients, Korean society is now increasingly shifting to the prevention of psychological disorders. Recently, there has been a growing demand for stress management programs for the general public who are in the healthy or subclinical range before the onset of psychiatric disorders. Amid this, mindfulness and self-compassion attract attention among clinicians and counselors. Mindfulness brings attention and awareness to momentary experiences with acceptance and non-judgment (Kabat-Zinn, 1994), and selfcompassion refers to treating oneself kindly considering the pain in a moment of struggle (Neff, 2003). Mindfulness-Based Cognitive Therapy (MBCT) (Segal, Williams, & Teasdale, 2013) and Mindfulness-Based Stress Reduction (MBSR) have been actively applied in clinical and non-clinical settings. These programs have proven effective at reducing psychological symptoms and improving wellbeing (Kabat-Zinn, 1994; Niemann, Schmidt, & Walach, 2004; Aalderen, 2012) to aid in more effective depression treatment and prevention of relapse, another factor is considered necessary besides mindfulness, which is a key factor in MBCT and MBSR: self-compassion. Self-compassion is conceptualized as a trait that is inherent in human nature but can be modified or improved through training (Bluth, Gaylord, Campo, Mullarkey, & Hobbs, 2016; Neff & Germer, 2013). From the viewpoint of Buddhist psychology, the typical symptoms of depression can be seen as the energy of frustration, hatred, aggression toward oneself on the side of grief, suicidal impulse, helplessness, anger, worthlessness, and anxiety. Therefore, it seems that the treatment of depression would benefit from the effect of self-compassion meditation as an antidote to aggression and anger toward the self. Depressive patients with high self-criticism, self-loathing, and shame are not strong enough to tolerate and accept each moment as it is or to tolerate it internally. Therefore, self-compassion meditation is needed as training to first send kindness and compassion to the suffering self. In the intervention to improve self-compassion, it appears that optimism, self-efficacy, life satisfaction, and compassion for others are enhanced, while depression, rumination, and stress reactions are reduced (Albertson, Neff, & Dill-Shackleford, 2015; Kelly & Amp; Carter, 2015). When we compare the results of previous studies related to the effects of self-compassion, the higher the level of self-compassion, the less negative thoughts, self-blame, sadness, suicide, and rumination there are (Neff, Kirpatrick, & Rude, 2007). AbstrAct: For the last 10 years or more, mindfulness meditation based on Buddhist practice has been widely spreading in the medical field including psychology in Korea. Until now, if psychological programs based on mindfulness meditation have been applied, recently, attention has been focused on the Mindful Self-Compassion (MSC) program combining mindfulness and self-compassion. There are a few people who have the qualifications and training to conduct this program. In this paper, we discuss our pilot study on a MSC Teacher Training Program developed. 51 participants (41 women, 10 men) were involved in this program. Qualitative thematic analysis confirmed 5 themes and 18 subthemes. Participants reported positive changes in cognition, emotion, professional work, spiritual area, and interpersonal areas after the program. The meaning and the mechanism of this program were discussed.


INTRODUCTION
Korea has the number one suicide rate among OECD countries in recent years (Statistics Korea, 2016). As the society becomes more polarized, there are more conflicts among individuals, and more people with various psychological symptoms are looking for psychiatric hospitals or counseling centers. The media has successively reported events and accidents due to impulse control disorder. Thus, the need for psychological intervention has become stronger than ever. If traditional psychotherapy targets psychiatric patients, Korean society is now increasingly shifting to the prevention of psychological disorders. Recently, there has been a growing demand for stress management programs for the general public who are in the healthy or subclinical range before the onset of psychiatric disorders. Amid this, mindfulness and self-compassion attract attention among clinicians and counselors. Mindfulness brings attention and awareness to momentary experiences with acceptance and non-judgment (Kabat-Zinn, 1994), and selfcompassion refers to treating oneself kindly considering the pain in a moment of struggle (Neff, 2003). Mindfulness-Based Cognitive Therapy (MBCT) (Segal, Williams, & Teasdale, 2013) and Mindfulness-Based Stress Reduction (MBSR) have been actively applied in clinical and non-clinical settings. These programs have proven effective at reducing psychological symptoms and improving wellbeing (Kabat-Zinn, 1994;Niemann, Schmidt, & Walach, 2004;Aalderen, 2012) to aid in more effective depression treatment and prevention of relapse, another factor is considered necessary besides mindfulness, which is a key factor in MBCT and MBSR: self-compassion. Self-compassion is conceptualized as a trait that is inherent in human nature but can be modified or improved through training (Bluth, Gaylord, Campo, Mullarkey, & Hobbs, 2016;Neff & Germer, 2013). From the viewpoint of Buddhist psychology, the typical symptoms of depression can be seen as the energy of frustration, hatred, aggression toward oneself on the side of grief, suicidal impulse, helplessness, anger, worthlessness, and anxiety. Therefore, it seems that the treatment of depression would benefit from the effect of self-compassion meditation as an antidote to aggression and anger toward the self. Depressive patients with high self-criticism, self-loathing, and shame are not strong enough to tolerate and accept each moment as it is or to tolerate it internally. Therefore, self-compassion meditation is needed as training to first send kindness and compassion to the suffering self. In the intervention to improve self-compassion, it appears that optimism, self-efficacy, life satisfaction, and compassion for others are enhanced, while depression, rumination, and stress reactions are reduced (Albertson, Neff, & Dill-Shackleford, 2015;Kelly & Amp;Carter, 2015). When we compare the results of previous studies related to the effects of self-compassion, the higher the level of self-compassion, the less negative thoughts, self-blame, sadness, suicide, and rumination there are (Neff, Kirpatrick, & Rude, 2007).
Self-compassion increases the positive qualities associated with psychological well-being, such as self-acceptance, self-kindness, and mindfulness that contribute to the treatment of depression (Germer, 2009). Thus, the results of previous studies have led to the conclusion that self-compassion meditation is effective at reducing psychological symptoms (MacBeth & Gumley, 2012). Mindfulness and self-compassion are related to psychological adjustment (Khoury et al., 2013;MacBeth & Gumley, 2012;Neff & McGehee, 2010). Programs that enhance mindfulness and self-compassion focus on improving emotional well-being and mental health using mindfulness and self-compassion meditation skills (Shonin, VanGordon, and Griffiths, 2014;Zoogman et al., 2014). Until now, mindfulness and self-compassion have been developed as separate programs, but Germer and Neff (2013) developed an 8-week Mindful Self-Compassion (MSC) program for adults. The MSC program is aimed at resource-building that can solve the problem of pain on its own rather than treatment. It is different from any other existing programs such as MBSR, MBCT, or Compassion-Focused Therapy. Usually, treatment focuses on old wounds, but MSC focuses more on what individuals are currently experiencing, how they relate to it (mindfulness), and how they feel compassionate (self-compassion). Ultimately, the program aims to help the participants themselves become their own mentors in their life journeys (Raab, 2014). The core skills of the MSC program can be summarized in the following three elements: (1) stop (How often do we stop in daily life?), (2) see what happens (mindfulness), and (3) respond to discomfort with kindness (self-compassion). The first element, "stop," has a stronger implication of stopping habitual, automatic responses. In other words, it involves habitually and automatically stopping internal discomfort or difficulty in daily life instead of fighting or fleeing. The second element is the awareness of what is happening inside (mindfulness). The third skill combines a variety of skills that enhance the ability to provide kindness and compassion rather than avoiding or criticizing other people. The MSC program was first introduced in Korea in September 2014 by Germer. Then, in August 2016, the MSC teacher training program was held for the first time in Asia in the Manhae Village of Gangwon Province. Participants were primarily counselors, clinical specialists, social worker, psychiatrist, Buddhist practitioners, and Catholic sisters. The reason this study paid particular attention to the MSC program is that, first, MSC uses the integrated wisdom and compassion practice in terms of cultivating mindfulness, charity, and compassion with the relatively recently developed meditation program. Second, the MSC program is composed of core themes and exercises, so it deals with theory and practice in a balanced way. Third, the main purpose of the MSC program is to use the capacity of wisdom and compassion practically at the moments needed in everyday life. Until now, no research has applied MSC in Korea, and the experience of this program is insufficient among mental health professionals. Therefore, we first want to investigate what the participants in the training will feel about MSC. Additionally, because the participants are almost all health-related workers or professionals, this preliminary study aims to investigate how they can deliver in-depth insights gained from training to future patients or clients who are suffering.
We asked the following specific research questions for this purpose: • What changes will the participants experience after engaging in the MSC teacher training program?
• How will the MSC teacher training program affect the qualities of participants as a future MSC teacher?

Research Participants
There were 51 (10 male and 41 female) participants. They participated in the MSC Teacher Training program for 6 nights and 7 days. A total of 54 participants participated in the study, but only 51 were included in the analysis after excluding three who responded unfaithfully.

Procedure
All participants completed the previous 8-week general MSC course to enter the MSC Teacher Training program. Research was only promoted to those who participated in the program and who agreed to participate in the study. Before the program started, the research assistant explained the purpose of the study. After the program, semi-structured questionnaires were given. To ensure the anonymity of the research, the research assistant assigned arbitrary number to the dataset.

MSC Intervention
The MSC Teacher Training Program was held for 7 days and 6 nights and is a group lesson lasting 3 hours and 30 minutes each morning. The first day lasted 1 hour and 30 minutes from 7:00 pm to 8:30 pm, and the second to the sixth day used the following sequence: 1-hour morning meditation (optional), 1 hour and 30 minutes for morning and afternoon session, a demonstration, 30 minutes of rest, and 30 minutes divided into 3 groups with "teachbacks" sessions. On the third day and the sixth evening, a question-and-answer session was held as a conceptual discussion time from 7:30 to 8:30. On the evening of the fifth day, there was rhythm dance time (optional). On the seventh and last day, morning meditation and morning sessions were conducted. Three MSC Teacher Trainer classes were held by the first author, Yung Sook Song (Seo Kwang Snim); Germer; and MSC-Certified Teachers. The guidebook for the MSC Teacher Training Program is based on the work developed by Germer and Neff (2013) and uses the original English version of MSC. All the guides for American teachers were translated into Korean. The purpose, core skills, and specific elements of the MSC Teacher Training Program are designed to be realized through 8 half-day (approximately 3 and a half hours) sessions. Each session consists of demonstration and teachbacks, and the demonstration training involves 1 hour and 30 minutes of demonstration of techniques to teach MSC components by experienced MSC teacher trainers. Participants learn from the student's point of view and share their direct experiences in small groups (Table 1).

Thematic Analysis
The responses of the participants to the questionnaire were classified by the researchers. The data were analyzed by thematic analysis using models of Braun and Clarke (2006). Braun and Clarke (2006) proposed six steps for the thematic analysis: (1) being familiar with the material, (2), developing initial codes, (5) labeling themes, (6) describing the results. During the data collection, records were made and then considered the ideas and contextual information related to the analysis. Several researchers with different backgrounds were put into initial coding for reliable analysis. The first researcher (Seo Kwang) is a Buddhist who has trained and taught MSC for a long time. The second researcher is a clinical psychologist who has more than 20 years of clinical experience. We both are well aware of mindfulnessrelated programs such as MBCT. The third researcher was a MSC specialist. We also compared the coding of each research member, when we moved to codes to final themes. As we gathered and described the material, we became familiar with the data. Each statement of participants was coded by sentence. Each coding was labeled to describe the content of the selected item and marked if it was determined that it was something interesting or important in relation to the research questions. Thematic analysis was performed manually, one by one, based on what the participants described. We categorized participants' responses, compared them with one another, and modified them based on the viewpoint of each researcher. The researchers concluded that the validity of the results was confirmed by agreeing to a common interpretation of the data.

Thematic Analysis
Thematic analysis identified 5 themes and 18 sub-themes, which were developed from the data ( Table 2). The first, "cognitive change," encompassed 4 sub-themes such as viewpoint about self, viewpoint about others/world, viewpoint about MSC, and cognitive awareness. All participants expressed that they were more open to themselves through MSC and were able to accept themselves as they are. They also reported positive thinking and flexible thinking about others and the world, accepting others as they are, and being able to respect them more. They learned more deeply about MSC and became aware of the habit of judging, making non-judgments, and observing and being aware of their thoughts. The second, "emotional change," had sub-themes such as warm heart/softness, happiness/fullness/gratitude, relaxation/ calmness, and peace of mind. All participants reported that they had become emotionally warm and tender through the MSC and were able to treat themselves and others with a warmer heart. They also reported happiness, fullness, generosity, comfort, peace, security, and inner peace. In the third, "professional work-related change," sub-themes of change as an "MSC teacher," giving help to clients, and "as a person" appeared. In the theme of "professional work," they gained a deeper understanding of the program. As an MSC leader, they reported becoming more confident in helping clients with depression, anxiety, and trauma and advising and counseling them. As individuals, they also made a commitment to continue their personal practice of MSC. In addition to this, they realized that they deeply understood the core values of life.
The fourth theme, "spiritual growth," encompasses 3 themes of "internal growth," "willingness to practice MSC," and "spiritual happiness/blessing." In "spiritual growth" themes, the participants reported becoming spiritually deepened and mature and that they had the will to practice MSC to gain spiritual growth and inner peace. They also said that they felt spiritual fullness, happiness, bliss, thanksgiving, joy, and an inner Creator. In the fifth topic, "interpersonal relationship," 4 sub-themes were "feelings of love for the family," "familiarity with the surrounding people," "compassionate relationship," and "connection/open heart." In the theme of "interpersonal relationships," participants felt love for their family, gratitude for their spouse, and compassion. They also felt more comfortable with the people around them. They reported that they had a compassionate relationship and were willing to give comfort to those in difficult situations.

DISCUSSION
In this study, we conducted qualitative theme analysis of what happened to the 51 people who participated in the MSC leader training course. The theme analysis revealed that, in the first theme of "cognitive change," there were positive changes in perspective on self, others, and the world. Secondly, positive experiences were expressed in the "emotional change" theme. The MSC program emphasized the training of the instructor as well as the regular 8-week introductory course for comfortable and enjoyable training, because it is not self-compassionate to work hard. It is natural that the number of respondents who answered that the comfort, relaxation, and quietness of body and mind were the biggest changes, because the program emphasized selfkindness, universality of human experience, and mindfulness as the three elements of self-compassion (Neff & Germer, 2013). In the third theme, "professional work-related," the part that mentions the necessity of performance and training as well as the desire to utilize MSC better in the future was the most beneficial. It was connected with the fact that there were many respondents to the overall performance and practical experience. In the "spiritual growth" aspect, there was a strong commitment to individual spiritual growth and spiritual journey. This can be interpreted in two ways, which means that the MSC Teacher Training Program is approached as a whole and integrated. We guess that the MSC training program should cultivate the positive qualities of human beings in harmony and balance. Finally, "human relationships" themes showed a harmonious and balanced appearance as well as a general and integrated growth of awareness and consideration of the inner world, mental and physical comfort, self-compassion and compassion for others, and acceptance and love. One thing to look at is the gratitude and compassionate attitude towards the family. As shown in Neff et al., study, it seems that the compassion toward others is better than self-compassion. It is guessed that, in the relationship, participants realized that compassion for the nearest family, the loved ones, was lacking. In addition, as one of the teacher trainers who conducted MSC program in analyzing the collected data, we realized that the compassionate attitude of the leader was an important factor for the participants' positive experience, especially for the embodiment of the comprehension of self-compassion and compassion toward others. Based on these results, in the future, MSC will be applied to people with psychological problems such as self-blame, depression,

Major theme clusters Sub-themes Contents
Cognitive change Viewpoint about self A clear spirit, an extension of vision, a more open-minded look at me, accepting my concern as it is, belief in my needs, belief in love for me, love for me as I am Viewpoint about others/ world Improve adaptability with others, to connect with others, to help people to understand, to expand awareness of people and to change into positive thoughts, to have a more flexible view of others, to think about the universality of humans, a smile toward others, a deeper understanding of the universality of the human condition (suffering), the acceptance of others as they are, the consideration of the other, the identification of others, a more generous view of the world

Viewpoint about MSC
Clarification of the program, experience of internalization of the theory, clear understanding, understanding of inquiry, deepening of understanding, intention of meditation/sharp intention of education, awareness of MSC, internalization through concept of MSC

Cognitive awareness
Awareness of judging habit, observation/awareness of flow of thoughts, Awareness of differences between criticism and rational thinking, not judging, improve the ability of control of thought, awareness of personal needs

Emotional change
Warm heart/softness Softness, a warm heart for oneself and others Happiness/fullness/ gratitude Happiness, fullness, fullness of love, abundance, generosity, appreciation of being supported, gratitude Relaxation/calmness Emotional calm down, relaxation, calmness Peace of mind Comfort, serenity, stability, peace of mind, safety

Professional work
As an MSC leader Building capacity as a leader, helping meditation leadership, increasing self-esteem through program understanding, expanding understanding of MSC, knowing how to explore in detail, and deep understanding of MSC's deep intentions

Giving help to clients
Confidence in being able to help others with trauma/depression/self-injury, finding connections with professional work, learning how to get information about professional work, knowing what to do with the client's feelings/questions, helping with counseling and education, knowing the importance of concentrating fully on the client, knowing how to give feedback, learned resonance technique

Spiritual growth
As a person The way to go forward, the need for training, the importance of individual performance and study, awareness, the need for group training, the reduction of obsession/stress response, the realization of core values of life, the importance of being together with the body and the heart, freedom, the dismantling of the defenses, the discovery of newness Internal growth It provides spiritual deepening, maturity, a little self-experience and practice, the foundation of spiritual pursuits, the belief that it can support balanced internal growth, the feeling of empathy and growth, A feeling of growing while observing and listening to the sound of the internal voice   (Gilbert, 2010;Gilbert & Proctor, 2006;Held et al., 2018;Neff, 2009;Pauley & McPherson, 2010) demonstrate that compassionate mind or compassion meditation have a powerful impact on our body, mind, and relationships. In particular, the element of self-kindness in MSC when we suffer-instead of hurting or ignoring ourselves while denouncing ourselves, instead of treating ourselves with suffering-can bring calmness and comfort by sending kindness, caring, understanding, and support to ourselves. However, most people are tougher on themselves than others, blame themselves, and do serious acts that they never do to others (Neff & Germer, 2013;Neff, 2009Neff, , 2011Neff, , 2011. The element of universal humanity involves perceiving the fact that failure or suffering in life is part of the human experience. Most of us, however, tend to think, when we are struggling or failing in life, that things that should have not happened have happened to us. As a result, it is easy to isolate ourselves by feeling as if we are the only ones suffering. Finally, in self-compassion, the element of mindfulness helps balance negative emotions and thoughts by not suppressing, avoiding, or exaggerating what we feel and avoiding excessive identification (Neff, 2003;Marshall et al., 2015). According to Germer (2009), the higher self-compassion is in college students, the lower the avoidance factor for post-traumatic stress disorder is, because selfcompassion reduces the avoidance response to emotional discomfort and promotes desensitization. It can weaken post-traumatic stress disorder development. Additionally, high levels of selfcompassion decrease willingness to experience sadness and anger, closely related to depressive symptoms, and can connect tough feelings without self-judgment. Researchers (Neff, 2003;Shapira & Mongrain, 2010) reported that people with low self-compassion experience more emotional stress; more easily abuse alcohol, or more easily attempt suicide. According to karmic consciousness in Buddhist psychology, everything we say, act, and think affects our body, mind, and brain from the day we are born until we die. It is said that a person who is angry upsets others, and a depressed person makes others depressed (Feldman & Kuyken, 2011). Likewise, compassion meditation toward others calms the hatred and anger of others, and compassion toward oneself reduces selfreproach and self-hatred. In Buddhist psychology, self-compassion and compassion toward others are among the four attitudes of holiness that contribute to mental well-being. Mindfulness tells us to feel pain with a relaxed awareness, and self-compassion tells us to be kind to ourselves amid that pain (Germer, 2009). Mindfulness asks us what we are experiencing first, and self-compassion asks us what we need. Mindfulness tells us to desensitize to the hard part of life slowly and safely, and self-compassion adds comfort and warmth to the process of desensitization (Song, 2016(Song, , 2018. Another study reports that compassion meditation (self/ other compassion) activates positive emotions, and mindfulness deactivates negative emotions (Gilbert, 2010;Gilbert & Proctor, 2006). Thus, it can be seen that mindfulness and self-compassion meditation (including compassion for others) play complementary roles. As in the practice of Buddhism, wisdom and compassion play complementary roles like the two wings of birds (Song, 2016). Compassion meditation is a very effective treatment that can provide an antidote to various forms of stress reaction, especially depression, anxiety, and post-traumatic stress disorder (Werner et al., 2011;Westphal et al., 2015;Zeller et al., 2015). However, since there is no direct experimental study on the effect of MSC program on the treatment of psychological problems in Korea, we hope to see research papers related to this in the future.

CONCLUSION
Based on these results, limitations of the study and implications for further research are as follows. This study attempted to study the effects of the MSC teacher training program and did not examine the effects of MSC itself. In the future, it is necessary to collect data on the effects of MSC itself on the participants' wellbeing in Korea. In addition, most of the people who participated in the evaluation are healthy mental health professionals who aspire to become MSC teachers in higher education. Therefore, future research will require in-depth research to identify the key elements of change by applying MSC to the clients or patients with psychological symptoms. This study is a preliminary study to see how the MSC TT program affected participants who aspire to become a MSC teacher. In future studies, this program will need to measure how much the participants actually improve their skills as an MSC teacher. Despite these limitations, it was worth investigating how the participants can deliver in-depth insights gained from the program to future clients who are suffering from various stress.