Compassion Focused Therapy offers therapists new options.
Dennis Tirch Ph.D
Compassion is currently being studied and used as an evidence based ingredient in effective psychotherapy more than ever before. This might not seem surprising, given that practicing compassion has been at the center of emotional healing in global wisdom traditions for at least 2,600 years. Empathy and emotional validation have been identified as some of the most important components of psychotherapy effectiveness for decades. However, compassion, as a process in itself, has only recently come to be seen as a core focus of psychotherapeutic work. A growing body of research continues to demonstrate how cultivating our compassionate minds can help us to alleviate and prevent a range of psychological problems, including anxiety and shame (Tirch and Gilbert, 2014). Rather than being a soft option, the deliberate activation of our compassion system can generate the courage and psychological flexibility we need to face life’s challenges, and step forward into lives of meaning, purpose and vitality.
Paul Gilbert (2009) has drawn upon developmental psychology, affective neuroscience, Buddhist practical philosophy, and evolutionary theory to develop a comprehensive form of experiential behavior therapy known as Compassion Focused Therapy (CFT). Gilbert describes compassion as a multifaceted process that has evolved from the caregiver mentality found in human parental care and child rearing. As such, compassion includes a number of emotional, cognitive, and motivational elements involved in the ability to create opportunities for growth and change with warmth and care. CFT involves training and enhancing this evolved capacity for compassion.
Gilbert defines the essence of compassion as “a basic kindness, with deep awareness of the suffering of oneself and of other living things, coupled with the wish and effort to relieve it” (2009, p. xiii). This definition involves two central dimensions of compassion. The first is known as the psychology of engagement and involves sensitivity to and awareness of the presence of suffering and its causes. The second dimension is known as the psychology of alleviation and constitutes both the motivation and the commitment to take actual steps to alleviate the suffering we encounter (Gilbert and Choden, 2013).
Over the last few years, the research base for compassion psychology generally and CFT specifically has been growing at a remarkable rate, with a rapid increase in the number of research and clinical publications addressing compassion. For example, the last ten years have seen a major upsurge in exploration into the benefits of cultivating compassion, especially through imagery practice (Fehr, Sprecher, and Underwood, 2008). Neuroscience and imaging research has demonstrated that practices of imagining compassion for others produce changes in the frontal cortex, the immune system, and overall well-being (Lutz et al., 2008). Notably, one study (Hutcherson, Seppala, and Gross, 2008) found that even just a brief loving-kindness meditation increased feelings of social connectedness and affiliation toward strangers.
Several compassion-focused intervention components have been found to enhance psychotherapy outcomes, and to serve as mediator variables in outcomes. For example, one study (Schanche, Stiles, McCullough, Svartberg, and Nielsen, 2011) found that self-compassion was an important mediator of reduction in negative emotions associated with personality disorders. In a study of the effectiveness of mindfulness-based cognitive therapy for depression (Kuyken et al., 2010), researchers found that self-compassion was a significant mediator between mindfulness and recovery. In fact, in a meta-analysis of research concerning both clinical and nonclinical settings, compassion-focused interventions were found to be significantly effective (Hofmann et al., 2011).
CFT is also seeing increasing empirical supported through outcome research. An early clinical trial involving a group of people with chronic mental health problems who were attending a day hospital (Gilbert and Procter, 2006) found that CFT significantly reduced self-criticism, shame, sense of inferiority, depression, and anxiety. In other outcome research, CFT has been found to be significantly effective for the treatment of personality disorders (Lucre and Corten, 2012), eating disorders (Gale, Gilbert, Read, and Goss, 2012), psychosis (Braehler, Harper, and Gilbert, 2012) and in people presenting to community mental health teams (Judge, Cleghorn, McEwan, and Gilbert, 2012). As CFT continues to become more widely disseminated and growing numbers of clinicians and researchers acquire understanding and skill in its methods and philosophy, increasing outcome research will further test the model, leading to innovation and improvement.
The following brief tips can help psychotherapists begin to appreciate how useful a compassion focus can be in practicing ACT, CBT or, in fact, any form of psychotherapy. Furthermore, we can see how remembering to practice compassion for ourselves might help to restore the energy and attention we bring to our work, of sharing compassion with our clients. Feel free to experiement with the following:
1. “It is not your fault…”
From a perspective of compassion, we remember how much of the pain and suffering in life is not of our choosing, and couldn’t really be our fault. In CFT we practice the “wisdom of no-blame” which means that taking responsibility for the direction you choose in life is essential, while languishing in shame, social fears and self-blame seldom leads to effective action. We know we didn’t choose our place in the genetic lottery. We didn’t choose to have a tricky human brain that is set up with a hair-trigger threat detection system and confusing loops of thoughts and actions. We didn’t choose our parents, our childhood or the myriad of social circumstances of life. By realizing that much of what we suffer with is simply not our fault, we can begin to activate compassion for ourselves and others, as we contact and engage with the tragedies of life.
2. Holding ourselves and others in warmth and kindness
When humans are in the presence of warmth, acceptance and affiliative emotions, we are likely to be at our most flexible, empathic, responsive and healthiest mode of operation. From the day we are born and throughout our lives the presence of kindess, support and emotional strength will have powerful impacts on every aspect of our health and behavior. In CFT, we use methods drawn from ancient visualization practices, and also modern techniques drawn from method acting to create the conditions and context that can allow for the experience of compassion. So, when we practice compassion for ourselves and others, we remember to slow down, to have a warm and caring expression on our face, and to use open and centered body language. Adopting a slow pace of our breathing and a warm tone of voice, we do all that we can to invite an experience of compassion. Images that evoke compassion are also used to bring us into contact with our compassionate mind. Can you imagine the most elegant cognitive reframe shouted at you with a cruel voice, such as a depressed client telling themselves, “The evidence doesn’t add up that you are a loser, so stop being so stupid about everything and suck it up and deal with life!” Perhaps even worse, can you imagine the condeming inner monologue of a mindfulness practitioner saying something like, “You’re not supposed to be judgemental about judging your thoughts! My God, you are terrible at this!” No matter how clever the content of our minds may seem to be, an emotional tone of acceptance, kindess and compasion is an essential ingredient to our experience of well-being.
3. Practicing compassion as a flow
We all can feel distressed in our work as psychotherapists, when we repeatedly encounter the suffering of others, which activates sympathetic emotional pain that we experience within our own minds, hearts and brains. Practicing deliberate, consistent compassion for ourselves and for others can help us to prevent empathic distress fatigue, and can build our inner architecture of compassionate strength. When you find yourself feeling that your reservoir of empathy, wisdom and warmth is slightly drained, deliberately breathe in compassionate intentions for yourself. As you exhale, direct compassionate intentions towards your client. This can be done silently, secretly, and consistently. As we breathe in, we wish for our suffering to cease and for ourselves to find peace and happiness. As we breathe out, we wish for our clients suffering to cease also, and we wish them happiness, wellness and an end to needless struggles. When this simple gesture becomes a therapist’s habit, they can quickly activate affiliative emotions to help them work towards their own compassionate mission of alleviating and preventing the suffering that they find in themselves and in others.
Dennis Tirch, Ph.D., is a compassion-focused psychologist, the author of The Compassionate Mind Guide to Overcoming Anxiety, and a faculty member at Weill Cornell Medical College.
Paul Gilbert, Ph.D., is currently a professor of clinical psychology at the University of Derby in the United Kingdom, and director of the Mental Health Research Unit at Derbyshire Mental Health Trust.
Compassion Focused Therapy For Dummies
You can work through a never-ending list of things you could do to improve your wellbeing. Getting more sleep, taking regular exercise, eating a healthier diet, developing a positive mental attitude and drinking less alcohol are just some of the things you may benefit from. Advice comes from the TV, newspapers, self-help books, friends, relatives, colleagues, healthcare professionals and even the chats we have with ourselves! But it’s hard to motivate ourselves to make helpful changes. It’s even harder to maintain them.
Compassion Focused Therapy (CFT) is here to help. This approach offers life-changing insights into our amazing capacities and also the challenges we face in our everyday lives. By understanding ourselves, we become motivated to act out of true care for our wellbeing. This changes the relationship we have with ourselves and others. Practicing CFT won’t mean you suddenly turn into a ‘perfect’version of yourself. It does however mean that you become more aware of the choices you have and you’re motivated to make ones that are more helpful to you. And yes, you find plenty of advice in here to guide you on your way too!
About This Book
Compassion Focused Therapy For Dummies contains a wealth of important information that can help you to understand yourself, and others, better. It also introduces you to practices that you can integrate into your everyday life, minute by minute, hour by hour, day by day…. I’ve used as little jargon and off-putting technical terms as possible, and so you don’t need to approach this book with a background knowledge of psychology. Simply put, if you’re in possession of a human brain and you’d like to discover more about CFT, this book is written for you.
That said, two factors may motivate you to continue developing your understanding of CFT once you finish this book: CFT is rooted in a scientific understanding of what it is to be human. As such, the approach constantly evolves to reflect the science. In the same way as it’s helpful to keep up with advancing technology, it’s also good to keep up with advancing our understanding of ourselves. We humans are highly complex.
This book simply doesn’t have the room to do CFT complete justice –not if you want to be able to lift it up! When you finish reading, you may want to move on to explore the comprehensive work of Paul Gilbert (the originator of the CFT approach), his colleagues and collaborators.
Foolish Assumptions In writing this book
I’ve had to make a few assumptions about you. I’ve assumed that: You’re interested in improving your wellbeing. You appreciate that CFT is based on an incredible amount of research –but you don’t necessarily want to plough through it all! You realise that I’ve had to make some tough decisions about what to include and what to leave out. Hopefully most of the choices I’ve made are right (but thankfully I won’t criticise myself if I’ve made a mistake; I hope you don’t either!). You recognise that I’m not trying to pass CFT off as my own creation. Instead, I set out to describe the work of Paul Gilbert and colleagues (of whom I am privileged to be one).
You may be selective about which parts of the book you read. As such, I’ve written this book in a way that allows each chapter to ‘stand alone’ so that you can pick and choose the content you want to read, and when you want to read it. You’re prepared to give new things a go! If you’re a therapist or studying CFT, I also assume that you recognise the importance of learning the approach ‘from the inside out’, and as such that you’ll work through the book with this in mind.
Beyond the Book
In addition to the material in this book, I also provide a free access-anywhere Cheat Sheet that offers some helpful reminders about the many benefits of CFT. To get this Cheat Sheet, simply go to http://www.dummies.com and search for ‘Compassion Focused Therapy For Dummies Cheat Sheet’ in the Search box.
Where to Go from Here
If you’re new to CFT, you may find it helpful to start with Chapter 1 before you decide how to tackle the rest of the chapters (you may even decide that you want to read the book from start to finish –but you don’t have to take that approach, as you find plenty of helpful cross-references to other useful chapters as you work through each chapter).
However you decide to begin, do this at a pace to suit both your understanding and emotional experience. If you have some experience of CFT, you may choose to skip to a particular topic due to a need or question you may have. If this is the case, use the table of contents and the index to help you find your way to the required information. Regardless of how you find your way around this book, I hope you appreciate the journey.
Finally, CFT aims to assist you to develop a compassionate understanding and relationship with yourself and others. If you find the approach helpful, it’s likely to become a way of life. To support your journey, you can access a number of courses to assist you. These course can also connect you with a wider group of people. You can find suitable courses advertised on a range of websites, including http://www.compassionatemind.co.uk, http://www.compassioninmind.co.uk and http://www.compassionatewellbeing.co.uk.
Getting Started with Compassion Focused Therapy
IN THIS PART Discover what CFT is all about and how it can be helpful. Explore what compassion is, including the skills and attributes of compassion. Find out about the challenges we face and how our minds are organised.
Introducing Compassion Focused Therapy
IN THIS CHAPTER
– Understanding how Compassion Focused Therapy works
– Discovering the benefits of compassion
– Exploring the effects of shame and self-criticism
– Beginning your journey
– Reaching out to others with compassion
People are more similar than different. We’re all born into a set of circumstances that we don’t choose, and in possession of a phenomenal yet very tricky brain. We’re all trying to get by, doing the best we can. The sooner we wake up to this reality the better.
Compassion Focused Therapy (CFT) is here to help. This approach aims to liberate you from shame and self-criticism, replacing these feelings with more helpful ways of relating to yourself. It helps you to choose the type of person you want to be and to develop ways to make this choice a reality. In this chapter, I introduce you to CFT, offering you an understanding of how it works and helping you to understand the benefits. I also point out the steps you may take along the way as you work with the information in this book. Finally, I take a moment to help you connect to the wider community around you as you begin this journey.
CFT advocates that you don’t rush to ‘learn’ about the approach but instead allow space to experience and ‘feel’ it. So take your time with this book as you apply it to your life, and really discover the benefits.
Getting to Grips with Compassion Focused Therapy
CFT was founded by UK clinical psychologist Paul Gilbert, OBE.
The name of the approach was chosen to represent three important aspects:
Compassion, in its simplest yet potentially most powerful definition, involves a sensitivity to our own, and other people’s, distress, plus a motivation to prevent or alleviate this distress. As such, it has two vital components. One involves engaging with suffering while the other involves doing something about it. Chapter 2 delves into the ins and outs of compassion in more detail.
Focused means that we actively develop and apply compassion to ourselves. It also involves accepting and experiencing compassion from and for others.
Therapy is a term to describe the processes and techniques used to address an issue or difficulty.
CFT looks to social, developmental and evolutionary psychology and neuroscience to help us understand how our minds develop and work, and the problems we encounter. This scientific understanding (of ourselves and others) calls into question our experiences of shame and self-criticism and helps us to develop the motivation to make helpful changes in our lives.
CFT utilises a range of Eastern and Western methods to enhance our wellbeing. Attention training, mindfulness and imagery combine with techniques used in Cognitive Behavioural Therapy (CBT), and Person Centred, Gestalt and Narrative therapies (to name but a few), resulting in a powerful mix of strategies that can help you become the version of yourself you wish to be.
CFT is often referred to as part of a ‘third-wave’ of cognitive behavioural therapy because it incorporates a number of CBT techniques. However, CFT derives from an evolutionary model (which you find out more about in Chapters 3, 4 and 5) and it uses techniques from many other therapies that have been found to be of benefit. As such, CFT builds upon and integrates with other therapies. As therapies become more rooted in science, we may see increasing overlap rather than diversification.
Compassion can involve kindness and warmth, but it also takes strength and courage to engage with suffering and to do something about it. CFT is by no means the easy or ‘fluffy’ option. Head to Chapter 6 to address some of the myths associated with compassion.
You may be reading this book because you want to find out more about this form of therapy. Alternatively, you may want to develop your compassionate mind and compassionate self out of care for your own wellbeing. The why or your motivation for reading this book has a big effect on the experience and, potentially, the outcome. Personally, I hope that whatever your motivation, you consider applying the approach to yourself in order that you can learn it ‘from the inside out’.
Defining common terms
You may find that some of the terms used in CFT are new to you. Here are a few common terms that I use throughout this book, along with an explanation of what they mean:
Common humanity: This refers to the fact that, as human beings, we all face difficulties and struggles. We’re more alike than different, and this realisation brings with it a sense of belonging to the human family.
Tricky brain: Our highly complex brains can cause us problems. For example, our capacity to think about the future and the past makes us prone to worry and rumination, while our inbuilt tendency to work out our place in a hierarchy can have a huge impact on our mood and self-esteem. In CFT, we use the term tricky brain to recognise our brain’s complexity and the problems this complexity can lead to. We consider our tricky brain in more detail in Chapter 3.
Compassionate mind: This is simply an aspect of our mind. It comes with a set of attributes and skills that are useful for us to cultivate (I introduce these attributes and skills in Chapter 2). This frame of mind is highly important for our wellbeing, relationships and communities. But just as we have a compassionate mind, we also have a competitive and threat-focused mind –which is highly useful, if not a necessity, at certain times (Chapter 4 takes a look at our threat-focused mind).
Compassionate mind training: This describes specific activities designed to develop compassionate attributes and skills, particularly those that influence and help us to regulate emotions. Attention training and mindfulness are used as a means to prepare us for this work, and we look at these practices in Part 3.
Compassionate self: This is the embodiment of your compassionate mind. It’s a whole mind and body experience. Your compassionate self incorporates your compassionate mind but also moves and interacts with the world.
Compassionate self cultivation: Your compassionate self is an identity that you can embody, cultivate and enhance. Compassionate self cultivation describes the range of activities that help you develop your compassionate self. Head to Chapter 10 for more on the cultivation of your compassionate self.
Engagement in the compassionate mind training and compassionate self cultivation activities provided in this book is often referred to as ‘physiotherapy for the brain’, as their use has been found to literally change the brain! Compassionate mind training and compassionate self cultivation are integral to CFT, but there’s so much more to CFT.
For many, getting to a point at which you can see the relevance and benefits of compassionate mind training and compassionate self cultivation, and overcome blocks and barriers to compassion, is the most significant aspect of your compassionate journey.
Exercises: These are activities for you to try. Sometimes they help to illustrate a point or provide a useful insight. Other exercises can give you an idea of what helps you to develop and maintain your compassionate mind.
Practice: Once you’re aware of which exercises are helpful to you, you can then incorporate these into your everyday life. Regular use of these exercises becomes your practice.
Observing the origins of CFT
CFT is closely tied to advances in our understanding of the mind and, because scientific advances never stop, the therapy continues to adapt and change based upon it. Much of this book focuses on sharing the science to help develop a compassionate understanding of yourself and a sense of connection with fellow travellers on this mortal coil.
CFT is also born out of a number of clinical observations:
– People demonstrating high levels of shame and self-criticism often struggle with standard psychological therapies. For example, using CBT, many find that they’re not reassured by the generation or discovery of alternative beliefs and views and that this doesn’t result in changes to the way they feel. Individuals may say ‘Logically, I know I’m not bad/not to blame, but I still feel it’ and ‘I know it’s unlikely that things will go wrong, but I still feel terrible’.
– What we say to ourselves is important, but how we say it is even more important.
Ever called yourself ‘idiot’ in a light-hearted and jovial manner? You probably did so without feeling any negative effects. But, have you ever called yourself an idiot in a harsh and judgemental manner? You probably felt much worse on that occasion, perhaps resulting in an urge to withdraw or isolate yourself.
Consider phrases such as, ‘look on the bright side’ or ‘count your blessings’.
Sometimes these phrases can be said in a life-affirming way, but using a condescending, frustrated or angry tone represents a whole different ball game. This helps illustrate that your emotional tone is important. Therapy can result in improvement in mood, self-esteem, sense of control and achievement, alongside a reduction in difficulties.
However, life events can trigger relapse. How we relate to ourselves, especially when life doesn’t go the way we hope, is pivotal to our ongoing wellbeing. Post therapy, many people report that they never disclosed to their therapist the things that caused them the most distress. This resulted from their sense of shame and the way they believed others (the therapist) would feel about them.
In addition to this, consider how many people simply don’t seek help at all because they fear what others think. People struggle to feel loved, valued, safe or content if they’ve never experienced these feelings. For some people, these feelings are alien concepts and, most of all, alien experiences, difficult to generate by discussion alone. As such, it’s important to develop the emotional resources and skills to deal with difficult emotions without turning to alcohol, food, drugs, work, excessive exercise or particular fixations.
– Most of us struggle with emotions such as anger, anxiety and vulnerability, but many also find positive emotions extremely difficult, even frightening. For some people, care, kindness, love and intimacy are terrifying, and to be avoided.
– People experiencing depression often worry that something bad will happen when their mood lifts.
– Likewise, feelings of connection and trust often stir up feelings of isolation and rejection, and a fear of loss.
These difficulties can interfere with the goals we set ourselves unless we address them.
CFT is an accumulation of years of research, clinical insights and teachings drawn from a broad range of areas. Much of this research and study is summarised and published in scientific papers, textbooks and self-help books by Paul Gilbert and colleagues. A number of websites also provide additional resources. You can find details of these in the Appendix. This book provides you with a starting point for your CFT journey and offers a framework upon which you can hang your future CFT practice –use these resources to develop your practice further.
TAKING A COMPASSIONATELY THERAPEUTIC APPROACH
It has long been established that compassionate, respectful and supportive relationships are key to our wellbeing and integral to effective psychotherapies. A key goal of many therapies is the development of a better relationship with yourself. However, different therapies place emphasis on different methods to account for and produce change, for example: CBT focuses primarily (but not exclusively) on the link between thoughts, feelings and behaviours and helps you generate new thoughts and behaviours in order to change your feelings. Interpersonal therapy focuses on your relationships and how they affect you. Psychodynamic therapy aims to bring the unconscious mind into consciousness, helping you to experience and understand your true feelings in order to resolve them.
In contrast, CFT begins with your experience of compassion from your therapist (in person or through books like this one). This relationship with your therapist is pivotal. It then focuses on the personal development and cultivation of compassion to help you to make beneficial choices for yourself and for others.
With this in mind, this book contains quite a bit of me –as an author, as a psychologist and, most of all, as a human being who struggles too. I hope that the bits of me enhance your experience of reading the words I have chosen to write for you.
Making the Case for Compassion
If we view compassion as ‘a sensitivity to our own and other people’s distress plus a motivation to prevent or alleviate it’, we can easily appreciate the many individual, group and societal benefits to developing and maintaining compassion in our lives. It makes intuitive sense and it’s the reason why compassion has been a central component of many religious and spiritual traditions across the centuries.
Research studies support the benefits of bringing compassion into your life. Higher levels of compassion are associated with fewer psychological difficulties. Compassion enhances our social relationships and emotional wellbeing: it alters our neurophysiology in a positive way and can even strengthen our immune systems. Research also suggests that CFT can be successfully used to address difficulties associated with eating, trauma, mood and psychosis.
However, for me, you can observe the power of the CFT approach in training clinicians. As they discover this approach to help their clients, they often report that the application of CFT in their personal lives can be transformative, leading many clinicians to develop and maintain their own personal practice. I believe that personal practice is vital for any clinician. I attribute much of my wellbeing and my ability to engage with other people’s suffering to the application of this approach in my life.
SO I’LL NEVER FEEL BAD AGAIN?
CFT won’t rid you of life’s difficulties. You won’t find yourself day after day serenely swanning around, impervious to life’s difficulties. We practise compassion because life is hard. Compassion can assist us to make helpful choices and, when ready, create a space in which we can work through strong emotions, and grieve for things we’ve lost and wish had been different. With compassion, we relate to our anger, anxiety and sadness with kindness, warmth and non-judgement. This allows us to consider the reasons such emotions are there, work through them and face the issues they are alerting us to. The development and cultivation of compassion isn’t a quick fix. It’s a way of living our lives.
Understanding the Effects of Shame and Self-Criticism
Shame and self-criticism are common blocks to wellbeing, and CFT is designed to overcome them. The following sections help you consider how shame and self-criticism can affect you and what you can do to address and overcome these issues.
The isolating nature of shame
Shame is an excruciatingly difficult psychological state. The term comes from the Indo-European word ‘sham’meaning ‘to hide’, and, as such, the experience of shame is isolating. When we feel shame, we feel bad about ourselves. We believe others judge us as inadequate, inferior or incompetent.
The next exercise helps you to explore the nature of shame and how it may affect you.
Begin by finding a place you can sit for a short time that is free of distractions. Allow yourself to settle for a few moments. It may help to lower your gaze or close your eyes during the exercise. Bring to mind a time when you felt ashamed (nothing too distressing, but something you feel okay to revisit briefly). Allow the experience to occupy your mind for a few moments.
Slowly ask yourself the following questions, allowing time after each question to properly explore your experience:
– How (and where) does shame feel as a sensation in your body?
– What thoughts go through your mind about yourself?
– What do you think other people thought/would think or make of you if they knew this about you?
– What emotions do you feel? What does it make you want to do?
Allow the experience to fade from your mind’s eye. Recall a time you’ve felt content or happy, perhaps on your own or with someone else, and let this memory fill your mind and body.
Depending upon the situation you brought to mind, a sense of anxiety, disgust or anger may have come to the fore. You may feel exposed, flawed, inadequate, disconnected or bad. Maybe you experience the urge to curl up, hide or run away, or perhaps feelings of anger and injustice leave you with the urge to defend yourself or confront someone.
Often, shame results in a feeling of disconnection. We don’t like ourselves (or a part of ourselves) and we don’t want to experience closeness to others because this may result in rejection. Our head goes down and we want to creep away. In addition, shame can affect our bodily sensations, maybe leading to tension, nausea or hotness. When you combine these negative views of yourself with predicted negative views from others, you create a very difficult concoction of experiences.
Shame brings with it a range of difficult experiences. Strong physical sensations, thoughts and images are just some of them. Emotions such as anxiety, sadness and anger can race through you as you feel the urge to withdraw, isolate or defend yourself.
Some of the things we feel shame about include:
– Our body (for example, its shape, or our facial features, hair or skin)
– Our body in action (for example, when sweating, urinating, defecating, burping, shaking, walking or running)
– Our health (for example, illnesses, infections, diseases or genetic conditions)
– Our mind (for example, our thoughts, including any intrusive images in our heads, our impulses, forgetfulness and our psychological health)
– Our emotions (for example, anxiety, anger, disgust, sadness, jealousy or envy)
– Our behaviour (for example, things we’ve said and the way we’ve said them, our use of alcohol and drugs, our compulsions, our eating patterns, or our tendency to avoid other people)
– Our environment (for example, our house, neighbourhood, car or bedroom)
– Other people (for example, our friends, family, cultural or religious group, or community)
Exploring why we feel shame
Human beings are social animals and need the protection, kindness and caring of others. Our brains are social organs. We like to feel valued, accepted and wanted by those around us in order to feel safe. There’s no shame in this. These needs represent a deep-rooted part of us that’s been highly significant in our evolution and survival. Shame begins in how you feel you live in the mind of another –and it is a social regulator. In other words, we’re programmed to try to work out, ‘What are they thinking about or feeling toward me?’, ‘Do they like me?’ and ‘Who can I trust?’
Just to add a further layer of complexity, we also try to work out, ‘Do I like myself or this aspect of me?’ and ‘Can I trust myself?’ If we perceive rejection from our social group or reject an aspect of ourselves, shame can be the result.
Although difficult to experience, shame can trigger us to make helpful changes and others to come to our aid in order to soothe the difficulties we experience. But what happens if we feel shame about things we are unable to change (such as our appearance, an aspect of our personality or our culture)? What happens if shame is attached to historical events that we blame ourselves for and can do nothing about? What happens when nobody comes to our assistance or we’re unable to accept the help offered to us?
Dr. Mary Welford, Consultant Clinical Psychologist, lives and works in the South West of England. She is a founding member of the Compassionate Mind Foundation, Chair to the charity from 2009-2015 and authored the Compassionate Mind Guide to Building Self Confidence.
Compassion Focused Therapy For Dummies
by Mary Welford
get it at Amazon.com
COMPASSION FOCUSED THERAPY
Research into the beneficial effect of developing compassion has advanced enormously in the last ten years, with the development of inner compassion being an important therapeutic focus and goal.
This book explains how Compassion Focused Therapy (CFT)—a process of developing compassion for the self and others to increase well-being and aid recovery—varies from other forms of Cognitive Behaviour Therapy.
Comprising 30 key points this book explores the founding principles of CFT and outlines the detailed aspects of compassion in the CFT approach. Divided into two parts—Theory and Compassion Practice—this concise book provides a clear guide to the distinctive characteristics of CFT. Compassion Focused Therapy will be a valuable source for students and professionals in training as well as practising therapists who want to learn more about the distinctive features of CFT.
Paul Gilbert is Professor of Clinical Psychology, University of Derby and has been actively involved in research and treating people with shame-based and mood disorders for over 30 years. He is a past President of the British Association for Cognitive and Behavioural Psychotherapy and a fellow of the British Psychological Society and has been developing CFT for twenty years.
THEORY: UNDERSTANDING THE MODEL
1 Some basics
All psychotherapies believe that therapy should be conducted in a compassionate way that is respectful, supportive and generally kind to people (Gilbert, 2007a; Glasser, 2005). Rogers (1957) articulated core aspects of the therapeutic relationship involving positive regard, genuineness and empathy—which can be seen as “compassionate”. More recently, helping people develop self-compassion has received research attention (Gilbert & Procter, 2006; Leary, Tate, Adams, Allen, & Hancock, 2007; Neff, 2003a, 2003b) and become a focus for self-help (Germer, 2009; Gilbert, 2009a, 2009b; Rubin, 1975/ 1998; Salzberg, 1995).
Developing compassion for self and others, as a way to enhance well-being, has also been central to Buddhist practice for the enhancement of well-being for thousands of years (Dalai Lama, 1995; Leighton, 2003; Vessantara, 1993).
After exploring the background principles for developing Compassion Focused Therapy (CFT), Point 16 outlines the detailed aspects of compassion in the CFT approach. We can make a preliminary note, however, that different models of compassion are emerging based on different theories, traditions and research (Fehr, Sprecher, & Underwood, 2009).
The word “compassion” comes from the Latin word compati, which means “to suffer with”. Probably the best-known definition is that of the Dalai Lama who defined compassion as “a sensitivity to the suffering of self and others, with a deep commitment to try to relieve it”, i.e., sensitive attention-awareness plus motivation. In the Buddhist model true compassion arises from insight into the illusory nature of a separate self and the grasping to maintain its boundaries—from what is called an enlightened or awake mind.
Kristin Neff (2003a, 2003b; see http://www.self-compassion.org), a pioneer in the research on self-compassion, derived her model and self-report measures from Theravada Buddhism. Her approach to self-compassion involves three main components:
– 1 being mindful and open to one’s own suffering;
– 2 being kind, and non self-condemning; and
– 3 an awareness of sharing experiences of suffering with others rather than feeling ashamed and alone—an openness to our common humanity.
In contrast, CFT was developed with and for people who have chronic and complex mental-health problems linked to shame and self-criticism, and who often come from difficult (e.g., neglectful or abusive) backgrounds.
The CFT approach to compassion borrows from many Buddhist teachings (especially the roles of sensitivity to and motivation to relieve suffering) but its roots are derived from an evolutionary, neuroscience and social psychology approach, linked to the psychology and neurophysiology of caring—both giving and receiving (Gilbert, 1989, 2000a, 2005a, 2009a). Feeling cared for, accepted and having a sense of belonging and affiliation with others is fundamental to our physiological maturation and well-being (Cozolino, 2007; Siegel, 2001, 2007). These are linked to particular types of positive affect that are associated with well-being (Depue & Morrone-Strupinsky, 2005; Mikulincer & Shaver, 2007; Panksepp, 1998), and a neuro-hormonal profile of increased endorphins and oxytocin (Carter, 1998; Panksepp, 1998).
These calm, peaceful types of positive feelings can be distinguished from those psychomotor activating emotions associated with achievement, excitement and resource seeking (Depue & Morrone-Strupinsky, 2005). Feeling a positive sense of well-being, contentment and safeness, in contrast to feeling excited or achievement focused, can now be distinguished on self-report (Gilbert et al., 2008). In that study, we found that emotions of contentment and safeness were more strongly associated with lower depression, anxiety and stress, than were positive emotions of excitement or feeling energized. So, if there are different types of positive emotions—and there are different brain systems underpinning these positive emotions—then it makes sense that psychotherapists could focus on how to stimulate capacities for the positive emotions associated with calming and well-being.
As we will see, this involves helping clients (become motivated to) develop compassion for themselves, compassion for others and the ability to be sensitive to the compassion from others. There are compassionate (and non-compassionate) ways to engage with painful experiences, frightening feelings or traumatic memories.
CFT is not about avoidance of the painful, or trying to “soothe it away”, but rather is a way of engaging with the painful. In Point 29 we’ll note that many clients are fearful of compassionate feelings from others, and for the self, and it is working with that fear that can constitute the major focus of the work.
A second aspect of the CFT evolutionary approach suggests that self-evaluative systems operate through the same processing systems that we use when evaluating social and interpersonal processes (Gilbert, 1989, 2000a).
So, for example, as behaviourists have long noted, whether we see something sexual or fantasise about something sexual, the sexual arousal system is the same—there aren’t different systems for internal and external stimuli. Similarly, self-criticism and self-compassion can operate through similar brain processes that are stimulated when other people are critical of or compassionate to us. Increasing evidence for this view has come from the study of empathy and mirror neurons (Decety & Jackson, 2004) and our own recent fMRI study on self-criticism and self-compassion (Longe et al., 2010).
CFT is a multimodal therapy that builds on a range of cognitive-behavioural (CBT) and other therapies and interventions.
Hence, it focuses on attention, reasoning and rumination, behaviour, emotions, motives and imagery.
It utilizes: the therapeutic relationship (see below); Socratic dialogues, guided discovery, psycho-education (of the CFT model); structured formulations; thought, emotion, behaviour and “body” monitoring; inference chaining; functional analysis; behavioural experiments; exposure, graded tasks; compassion focused imagery; chair work; enactment of different selves; mindfulness; learning emotional tolerance, learning to understand and cope with emotional complexities and conflicts, making commitments for effort and practice, illuminating safety strategies; mentalizing; expressive (letter) writing, forgiveness, distinguishing shame-criticizing from compassionate self-correction and out-of-session work and guided practice—to name a few! Feeling the change CFT adds distinctive features in its compassion focus and use of compassion imagery to traditional CBT-type approaches.
As with many of the recent developments in therapy, special attention is given to mindfulness in both client and therapist (Siegel, 2010). In the formulation CFT is focused on the affect-regulation model outlined in Point 6, and interventions are used to develop specific patterns of affect regulation, brain states and self-experiences that underpin change processes.
This is particularly important when it comes to working with self-criticism and shame in people from harsh backgrounds. Such individuals may not have experienced much in the way of caring or affiliative behaviour from others and therefore the (soothing) emotion-regulation system is less accessible to them. These are individuals who are likely to say, “I understand the logic of [say] CBT, but I can’t feel any different”. To feel different requires the ability to access affect systems (a specific neurophysiology) that give rise to our feelings of reassurance and safeness. This is a well-known issue in CBT (Leahy, 2001; Stott, 2007; Wills, 2009, p. 57).
Over twenty years ago I explored why “alternative thoughts” were not “experienced” as helpful. This revealed that the emotional tone, and the way that such clients “heard” alternative thoughts in their head, was often analytical, cold, detached or even aggressive. Alternative thoughts to feeling a failure, like: “Come on, the evidence does not support this negative view; remember how much you achieved last week!” will have a very different impact if said to oneself (experienced) aggressively and with irritation than if said slowly and with kindness and warmth. It was the same with exposures or home-works—the way they are done (bullying and forcing oneself verses encouraging and being kind to oneself) can be as important as what is done.
So, it seemed clear that we needed to focus far more on the feelings of alternatives not just the content—indeed, an over focus on content often was not helpful.
So, my first steps into CFT simply tried to encourage clients to imagine a warm, kind voice offering them the alternatives; or working with them in their behavioural tasks. By the time of the second edition of Counselling for Depression (Gilbert, 2000b) a whole focus had become concentrated on “developing inner warmth”(see also Gilbert, 2000a).
So, CFT progressed from doing CBT and emotion work with a compassion (kindness) focus and, then, as the evidence for the model developed and more specific exercises proved helpful, on to CFT.
The therapeutic relationship
The therapeutic relationship plays a key role in CFT (Gilbert, 2007c; Gilbert & Leahy, 2007), paying particular attention to the micro-skills of therapeutic engagement (Ivey & Ivey, 2003), issues of transference/countertransference (Miranda & Andersen, 2007), expression, amplification, inhibition and/or fear of emotion (Elliott, Watson, Goldman, & Greenberg, 2003; Leahy, 2001), shame (Gilbert, 2007c), validation (Leahy, 2005), and mindfulness of the therapist (Siegel, 2010).
When training people from other approaches, particularly CBT, we find that we have to slow them down; to allow spaces, and silences for reflection, and experiencing within the therapy rather than a series of Socratic questions or “target setting”. We teach how to use one’s voice speed and tone, nonverbal communication, the pacing of the therapy, being mindful (Katzow & Safran, 2007; Siegel, 2010) and the reflective process in the service of creating “safeness” to explore, discover, experiment and develop.
Key is to provide emotional contexts where the client can experience (and internalize) therapists as “compassionately alongside them”—no easy task because as we will discuss below (see Point 10) shame often involves clients having emotional experiences (transference) of being misunderstood, getting things wrong, trying to work out what the other person wants them to do and intense aloneness.
The emotional tone in the therapy is created partly by the whole manner and pacing of the therapist and is important in this process of experiencing “togetherness”. CF therapists are sensitive to how clients can actually find it hard to experience “togetherness” or “being cared about”, and wrap themselves in safety strategies of sealing the self off from “the feelings of togetherness and connectedness” (see Point 29; Gilbert, 1997, 2007a, especially Chapters 5 and 6, 2007c). CBT focuses on collaboration, where the therapist and client focus on the problem together—as a team.
CFT also focuses on (mind) “sharing”.
The evolution of sharing (and motives to share), e.g., not only objects but also our thoughts, ideas and feelings, is one of humans’ most important adaptations and we excel at wanting to share. As an especially social species, humans have an innate desire to share—not only material things but also their knowledge, values and the content of their minds—to be known, understood and validated. Thus, issues of motivation to share versus fear of sharing (shame), empathy and theory of mind are important evolved motives and competencies. It is the felt barriers to this “flow of minds” that can be problematic for some people and the way that the therapist “unblocks” this flow that can be therapeutic.
Dialectical Behaviour Therapy (DBT; Linehan, 1993) addresses the key issue of therapy-interfering behaviours. CFT, like any other therapy, needs to be able to set clear boundaries, and use authority as a containing process. Some clients can be “emotional bullies”, threatening the therapist (e.g., with litigation or suicide) and are demanding. Frightened therapists may submit or back off. The client, at some level, is frightened of their own capacity to force others away from them.
For other clients, during painful moments, therapists might try to rescue rather than be silent. So, clarification of the therapeutic relationship is very important. This is why DBT wisely recommends a support group for therapists working with these kinds of clients. Research has shown that compassion can become a genuine part of self-identity but it can also be linked to self-image goals where people are compassionate in order to be liked (Crocker & Canevello, 2008). Compassion focused self-image goals are problematic in many ways.
Researchers are also beginning to explore attachment style and therapeutic relationships with evidence that securely attached therapists develop therapeutic alliances easier and with less problems than therapists with an insecure attachment style (Black, Hardy, Turpin, & Parry, 2005; see also Liotti, 2007). Leahy (2007) has also outlined how the personality and schema organization of the therapist can play a huge role in the therapeutic relationship—for example, autocratic therapists with dependent patients, or dependent therapists with autocratic patients. So, compassion is not about submissive “niceness”—it can be tough, setting boundaries, being honest and not giving clients what they want but what they need. An alcoholic wants another drink—that is not what they need; many people want to avoid pain and may try to do so in a variety of ways—but (kind) clarity, exposure and acceptance may be what actually facilitates change and growth (Siegel, 2010).
Evidence for the benefits of compassion
Although CFT is rooted in an evolutionary, neuro- and psychological science model, it is important to recognize its heavy borrowing from Buddhist influences. For over 2500 years Buddhism has focused on compassion and mindfulness as central to enlightenment and “healing our mind”. While Theravada Buddhism focuses on mindfulness and loving-( friendly)-kindness, Mahayana practices are specifically compassion focused (Leighton, 2003; Vessantara, 1993).
At the end of his life the Buddha said that his main teachings were mindfulness and compassion—to do no harm to self or others. The Buddha outlined an eight-fold path for practice and training one’s mind to avoid harming and promote compassion. This includes: compassionate meditations and imagery, compassionate behaviour, compassionate thinking, compassionate attention, compassionate feeling, compassion speech and compassionate livelihood.
It is these multimodal components that lead to a compassionate mind. We now know that the practice of various aspects of compassion increases well-being and affects brain functioning, especially in areas of emotional regulation (Begley, 2007; Davidson et al., 2003).
The last 10 years have seen a major upsurge in exploring the benefits of cultivating compassion (Fehr et al., 2009). In an early study Rein, Atkinson and McCraty (1995) found that directing people in compassion imagery had positive effects on an indictor of immune functioning (S-IgA) while anger imagery had negative effects. Practices of imagining compassion for others, produce changes in the frontal cortex, immune system and wellbeing (Lutz, Brefczynski-Lewis, Johnstone, & Davidson, 2008). Hutcherson, Seppala and Gross (2008) found that a brief loving-kindness meditation increased feelings of social connectedness and affiliation towards strangers. Fredrickson, Cohn, Coffey, Pek and Finkel (2008) allocated 67 Compuware employees to a loving-kindness meditation group and 72 to waiting-list control.
They found that six 60-minute weekly group sessions with home practice based on a CD of loving kindness meditations (compassion directed to self, then others, then strangers) increased positive emotions, mindfulness, feelings of purpose in life and social support, and decreased illness symptoms. Pace, Negi and Adame (2008) found that compassion meditation (for six weeks) improved immune function and neuroendocrine and behavioural responses to stress. Rockliff, Gilbert, McEwan, Lightman and Glover (2008) found that compassionate imagery increased heart rate variability and reduced cortisol in low self-critics, but not in high self-critics.
In our recent fMRI study we found that self-criticism and self-reassurance to imagined threatening events (e.g., a job rejection) stimulated different brain areas, with self-compassion but not self-criticism stimulating the insula—a brain area associated with empathy (Longe et al., 2010). Viewing sad faces, neutrally or with a compassionate attitude, influences neurophysiological responses to faces (Ji-Woong et al., 2009). In a small uncontrolled study of people with chronic mentalhealth problems, compassion training significantly reduced shame, self-criticism, depression and anxiety (Gilbert & Procter, 2006). Compassion training has also been found to be helpful for psychotic voice hearers (Mayhew & Gilbert, 2008). In a study of group-based CFT for 19 clients in a high-security psychiatric setting, Laithwaite et al. (2009) found “…a large magnitude of change for levels of depression and self-esteem…. A moderate magnitude of change was found for the social comparison scale and general psychopathology, with a small magnitude of change for shame,…. These changes were maintained at 6-week follow-up”(p. 521).
In the field of relationships and well-being, there is now good evidence that caring for others, showing appreciation and gratitude, having empathic and mentalizing skills, does much to build positive relationships, which significantly influence well-being and mental and physical health (Cacioppo, Berston, Sheridan, & McClintock, 2000; Cozolino, 2007, 2008).
There is increasing evidence that the kind of “self” we try to become will influence our well-being and social relationships, and compassionate rather than self-focused self-identities are associated with the better outcomes (Crocker & Canevello, 2008).
Taken together there are good grounds for the further development of and research into CFT.
Neff (2003a, 2003b) has been a pioneer in studies of self-compassion (see pages 3–4). She has shown that self-compassion can be distinguished from self-esteem and predicts some aspects of well-being better than self-esteem (Neff & Vonk, 2009), and that self-compassion aids in coping with academic failure (Neff, Hsieh, & Dejitterat, 2005; Neely, Schallert, Mohammed, Roberts, & Chen, 2009). Compassionate letter writing to oneself, improves coping with life events and reduces depression (Leary et al., 2007).
As noted, however, Neff’s concepts of compassion are different from the evolutionary and attachment-rooted model outlined here and, as yet, there is no agreed definition of compassion—indeed, the word compassion can have slightly (but important) different meanings in different languages. So, here compassion will be defined as a “mind set”, a basic mentality, and explored in detail in Point 16.
2 A personal journey
My interest in developing people’s capacities for compassion and self-compassion was fuelled by a number of issues:
• First, was a long interest in evolutionary approaches to human behaviour, suffering and growth (Gilbert, 1984, 1989, 1995, 2001a, 2001b, 2005a, 2005b, 2007a, 2007b, 2009a). The idea that cognitive systems tap underlying evolved motivation and emotional mechanisms has also been central to Beck’s cognitive approach (Beck, 1987, 1996; Beck, Emery, & Greenberg, 1985), with a special edition dedicated to exploring the evolutionary-cognitive interface (Gilbert, 2002, 2004).
• Second, evolutionary psychology has focused significantly on the issue of altruism and caring (Gilbert, 2005a) with increasing recognition of just how important these have been in our evolution (Bowlby, 1969; Hrdy, 2009) and now are to our physical and psychological development (Cozolino, 2007) and well-being (Cozolino, 2008; Gilbert, 2009a; Siegel, 2007).
• Third, people with chronic mental-health problems often come from backgrounds of high stress and/ or low altruism and caring (Bifulco & Moran, 1998), backgrounds that significantly affect physical and psychological development (Cozolino, 2007; Gerhardt, 2004; Teicher, 2002).
• Fourth, partly as a consequence of these life experiences, people with chronic and complex problems can be especially, deeply troubled by shame and self-criticism and/ or self-hatred and find it enormously difficult to be open to the kindness of others or to be kind to themselves (Gilbert, 1992, 2000a, 2007a, 2007c; Gilbert & Procter, 2006).
• Fifth, as noted on page 6, when using CBT they would typically say, “I can see the logic of alternative thoughts but I still feel X, or Y. I can understand why I wasn’t to blame for my abuse but I still feel I’m to blame”, or, “I still feel there is something bad about me”.
• Sixth, there is increasing awareness that the way clients are able to think about and reflect on the contents of their own minds (e.g., competencies to mentalize in contrast to being alexithymic) has major implications for the process and focus of therapy (Bateman & Fonagy, 2006; Choi-Kain & Gunderson, 2008; Liotti & Gilbert, in press; Liotti & Prunetti, 2010).
• Last, but not least, is a long personal interest in the philosophies and practices of Buddhism—although I do not regard myself as a Buddhist as such. Compassion practices, such as becoming the compassionate self (see Part 2), may create a sense of safeness that aides the development of mindfulness and mentalizing.
In Buddhist psychology compassion “transforms” the mind.
Logic and emotion
It has been known for a long time that logic and emotion can be in conflict. Indeed, since the 1980s research has shown that we have quite different processing systems in our minds.
One is linked to what is called implicit (automatic) processing, which is non-conscious, fast, emotional, requires little effort, is subject to classical conditioning and self-identify functions, and may generate feelings and fantasies even against conscious desires. This is the system which gives that “felt sense of something”.
This can be contrasted with an explicit (controlled) processing system, which is slower, consciously focused, reflective, verbal and effortful (Haidt, 2001; Hassin, Uleman, & Bargh, 2005).
These findings have been usefully formulated for clinical work (e.g., Power & Dalgleish, 1997) with more complex models being offered by Teasdale and Barnard (1993).
But the basic point is that there is no simple connection of cognition to emotion, and there are different neurophysiological systems underpinning them (Panksepp, 1998).
So, one of the problems linking thinking and feeling (“I know it but I don’t feel it”) can be attributed to (different) implicit and explicit systems coming up with different processing strategies and conclusions.
Cognitive, and many other, therapists and psychologists have not helped matters by using the concept of cognition and information processing interchangeably as if they are the same thing. They are not.
Your computer and DNA—indeed every cell in your body—are information processing mechanisms but I don’t think that they have “cognitions”.
This failure to define what is and is not “a cognition” or “cognitive” in contrast to a motive or an emotion has caused difficulties in this area of research.
Various solutions have been offered to work with the problems of feelings not following cognitions or logical reasoning, such as: needing more time to practise; most change is slow and hard work; more exposure to problematic emotions; identifying “roadblocks” and their functions (Leahy, 2001); a need for a particular therapeutic relationship (Wallin, 2007); or developing mindfulness and acceptance (Hayes, Follette, & Linehan, 2004; Liotti & Prunetti, 2010).
CFT offers an additional position
CFT suggests that there can be a fundamental problem in an implicit emotional system that evolved with mammalian and human caring systems and which gives rise to feelings of reassurance, safeness and connectedness (see Point 6).
The inability to access that affect system is what underpins this problem. Indeed, as noted (page 6), some people can cognitively (logically) generate “alternative thoughts” but hear them in their head as cold, detached or aggressive. There is no warmth or encouragement in their alternative thoughts—the emotional tone is more like cold instruction.
I have found that the idea of feeling (inner) kindness and supportiveness as part of generating alternative “thoughts” is an anathema to them. So, they just cannot “feel” their alternative thoughts and images.
Paul Gilbert, Ph.D., is currently a professor of clinical psychology at the University of Derby in the United Kingdom, and director of the Mental Health Research Unit at Derbyshire Mental Health Trust.
Compassion Focused Therapy
by Paul Gilbert
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