|"Compassion without wisdom, argues Manu Bazzano, does not address the delusional nature of mental distress, and neuroscience risks explaining away the complexity of being human"|
Research suggests that teaching people to develop self-compassion can reduce shame and self-criticism, as well as lead to improvements in other psychiatric symptoms
Promoting wellbeing through compassion
It’s hard to think of any talking therapy that doesn’t assume the importance of practising with compassion, and at the very least we are all familiar with Rogers’ core conditions of unconditional positive regard, empathy and congruence. Equally, it’s hard to imagine a therapist not motivated by a caring, kindness and sympathy for the suffering of her clients. But it’s only recently that the specific qualities of compassion are gaining attention in the literature, and even becoming an area of study in their own right.
What exactly is compassion and can we have it for ourselves as well as others? Can it have therapeutic properties? If so, can we be taught how and when to practise it? Compassion focused therapy (CFT) has made more than a start at addressing these questions, and while its pioneers continue to gather outcome data in order to extend its reach and levels of understanding, it already offers a valuable integration of a number of familiar ideas.
Paul Gilbert is Professor of Clinical Psychology at the University of Derby and Fellow of the British Psychological Society. He has been working with, and researching, shame-related processes in mood disorders for over three decades. Over the last 15 years his work has looked at compassion as an antidote to shame and self-criticism and a focus for therapeutic intervention. CFT has since appeared on the therapeutic map, in particular in the territories of CBT-type approaches (with an addition last year to Windy Dryden’s CBT Distinctive Features series).
Gilbert’s interest in CFT grew out of a number of observations from his work with people with complex mental health difficulties, who often come from neglectful, abusive or emotionally insecure backgrounds. Typically they would experience a high level of shame and self-criticism. Working with a CBT model, he noted that while some could engage well with the cognitive and behavioural tasks involved, the outcomes could still be poor. A typical response might be, ‘I understand the logic of the alternative thoughts suggested, but they don’t help me feel any better’ – a ‘cognitive-emotion mismatch’ in psychological terms.
This encouraged Gilbert to explore how it is we can feel reassured and relieved by the ‘helpful’ cognitions that CBT suggests, which involved considering the emotional sources of reassurance along with the associated importance of attachment and affiliation. More recently, his work has taken advantage of neuroscience and he has recently described CFT as an ‘integrated and multimodal approach that draws on evolutionary, social, developmental and Buddhist ideas, along with the latest findings of neuroscience’.1 Being ‘multimodal’, it builds on a range of cognitive behavioural and other therapies and interventions (the list of the latter is very long). However, Gilbert is passionate about the importance of integrating science. ‘The science of mind tells us so much now,’ he says. ‘We know that attachment, the therapeutic relationship and unconscious processes are absolutely crucial. If psychotherapy began today, we’d be in a far better position with it all.’
The affiliative system
So CFT is not a discrete therapy as such, but offers another approach to working or organising ideas for practitioners of all theoretical backgrounds who are presented with the trans-diagnostic issue of shame and self-criticism. A key idea rests on findings that suggest we have at least three types of emotion regulation systems: the threat detection and protection focused; the drive and excitement focused; and the contentment, soothing and affiliative focused (see the ‘three circle model’). Research has also shown that the latter has significantly developed with the evolution of attachment behaviour.1 Indeed, we intuitively know that kindness and support of others helps to soothe away threats and restore a sense of safeness. As Gilbert explains, ‘The affiliative system was designed as a threat regulator. We want to go to our nearest and dearest when under threat, because we have an intuitive wisdom that the kindness of others is what helps and what soothes us.’
Neurobiology also suggests that our affiliative emotions operate through specific endorphin and oxytocin systems and self-focused kindness and caring may operate similarly. Both of these systems are distinct from those activated by threat. So feelings of safeness and soothing don’t come about from the mere absence of threat. Equally, if we can reduce threat, it doesn’t mean that the calming and reassuring properties of the affiliative systems are automatically activated. These three discrete systems are also shown to have important effects on other abilities, such as our capacity for attention, tolerating distress and mentalising. They are also very powerfully physiologically organising.
CFT organises its formulations and ideas around these three systems and sets out to re-balance them, but in particular, Gilbert explains, ‘Whatever you do in CFT, you have to get the affiliative system going as a key to regulate the others. CFT takes the view that this system is poorly accessible in people with high shame and self-criticism – for them, the “threat” system dominates their inner and outer worlds’. The therapist will make the ‘three circle model’ explicit at this stage, and the collaborative nature of the work is echoed in making a ‘shared formulation’.
CFT in practice
Chris Irons is a clinical psychologist who works for a mental health team in East London and was supervised by Gilbert. ‘I have been using CFT as my overarching model clinically for about six years with a broad base of clients including severe and chronic depression, trauma and enduring mental health problems. Sometimes just working with the formulation alone can be very powerful and it can be fascinating to see how patients depict the sizes of the circles with pen and paper – with the “threat circle” being huge, the drive system small, and the soothing system a tiny dot.’
This early phase also includes the therapist validating fears and painful experiences and making sense of safety behaviours and core beliefs – personal history is recognised as crucial. Early life experiences that may have sensitised a client’s threat system (eg being bullied) and emotional memories can lead to ‘safety strategies’ that can end up lowering self-esteem and increasing a vulnerability to depression and anxiety (eg appeasing or avoidance behaviour). Normal defensive emotions may also be feared (eg the bullied child fears expressing rage) and fear of emotion is important to explore. Gilbert’s current research focus is fear of positive emotion, noting in his work people who think ‘if I am happy today, something bad will happen tomorrow’.
The development of self-criticism can unfold through a process of fear of the powerful other and the need to self-monitor to avoid stirring their anger. Gilbert explains: ‘It’s about identifying the complex functions of the critic as a safety strategy. History is full of self-deprecation and efforts to appease and sacrifice to powerful gods because we are frightened of them, but we also want them to protect us. If we step on a twig that disturbs a sleeping lion, we tell ourselves off. In both cases we blame ourselves because our own behaviour is the only possible source of control.’ Gilbert uses plenty of metaphor and storytelling in his work. ‘These can be playful and even wonderful fun,’ he says. ‘We continue to learn from our clients about what works and what doesn’t.’
He goes on to emphasise the importance of making all the work in CFT explicit, not just the formulation, partly as a reflection of the collaboration. ‘CFT makes it explicit that trauma memories can open up complex feelings, including shame and that can make the therapeutic relationship difficult. We need to take responsibility for a brain we never chose; it’s absolutely not our fault. Therapy can have the idea that we have to “dig in” to something that is “wrong” with us. CFT assumes nothing has gone “wrong”, but we are saddled with an old brain and a new brain, along with how life has shaped us. The key is to have plenty of discussion, with a calming and soothing orientation, that we are all in life together.’
The it’s-not-your-fault focus is a huge part of all the work, during and after the formulation; it is well developed in dialectical behavioural therapy and trauma work too. It also means, as Gilbert says, that ‘we never tell the patients we are going to take something away from them – we tell them that self-criticism and shame have served functions and are highly defensive. We don’t dismantle safety behaviours until alternatives are in place. We all blame ourselves when things go wrong. Lots of time is spent “normalising” and de-shaming emotional responses, and distinguishing taking responsibility from condemning and blaming behaviours’. The latter involves taking time to explore the differences between shame and guilt – with Gilbert noting the lack of research on learning to tolerate guilt.2
CFT hypothesises that if people can then begin to shift their sense of there being something bad about them, they will be better equipped to develop improved emotional regulation and a positive sense of self. Developing a ‘compassionate self’ becomes the next task, Gilbert says, ‘enabling us to prepare and engage with ourselves with a calm and peaceful mind’.
An evolutionary approach
Specific qualities, forms and foci of compassion have been espoused for centuries, especially by Buddhism. Derived from the Latin compatior (to suffer with), compassion was once defined by the Dalai Lama as ‘a sensitivity to the suffering of self and others, with a deep commitment to try to relieve it’. CFT, however, bases its model on an evolutionary approach to psychological functioning, as Gilbert says: ‘Compassionate motives and competencies are linked to evolved brain systems that underpin altruism, attachment and affiliative behaviours.’3
CFT defines specific attributes and skills of compassion that can be embodied by the therapist while using interventions that aim to help patients develop them in relation to themselves. This means the therapist has to work hard at self-compassion too. Defined attributes include a care for wellbeing, sensitivity, sympathy, distress tolerance, empathy, and a stance of non-judgment. The skills of compassion involve creating feelings of warmth, kindness and support in the work. Therapists should always be concerned to explore whether patients are trying to force (or even bully) themselves to change, rather than being supportive and encouraging in their efforts.
‘The work is about orientating the patient to a compassionate self-identity,’ Gilbert says. ‘Compassionate behaviour often involves courage – such as developing the courage to leave an abusive partner. We sometimes underestimate the importance of facilitating courage in our patients, but it is much more likely to arise in the context of a compassionate therapeutic relationship and internal supportive sense of self.’
Compassionate mind training
While CFT refers to the process, compassionate mind training (CMT) refers to the exercises and practices in CFT, but can also be used alone for anyone wanting to develop their compassion. There’s a large focus on imagery, such as exercises imagining compassion flowing out from the patient to others, along with flowing inwards to themselves (from others and from the self). Interventions familiar to CBT or emotion-focused work may be used, along with others – including letter writing, chair work, graded tasks, mindfulness, Socratic dialogues and re-scripting. Whichever it is, the focus must be to find ways in which the patient can experience them as kind, supportive and encouraging. As Gilbert summarises, ‘creating emotional hits via creating experiences’ is what matters.
Irons, like Gilbert, adapts his CFT approach to the needs and resources of his patients – there is no ‘set’ way of working. ‘I have used it in individual work and with groups on the acute inpatient ward – it’s a very adaptive model. Sometimes we’d never know how long someone was on the ward, and it may be that we’d only work so far as a formulation. Others I may work with for a year or so. I have also just begun to use it with couples, helping them to understand each other’s threat systems.’
His work over the years appears to validate CFT’s rationale: ‘My experience of using CBT with high levels of distress is that patients can struggle with a head-heart lag – they may understand different ways of thinking, but they don’t feel better as result. Again and again clients talk about CFT allowing connections on an emotional level. Profound emotional shifts can emerge from having empathy for themselves for the first time. Often, many report on the fear of connecting emotionally in this way, but they have an intuition that sticking with it will be helpful.’
Research continues to explore the value of bringing compassionate mind concepts to a range of therapies, but some preliminary studies suggest that teaching people to develop self-compassion can reduce shame and self-criticism, as well as lead to improvements in other psychiatric symptoms. These include depression and anxiety in patients with long-term mental health problems, psychotic voices hearers, and in improving depression and reducing shame in clients in a high-security psychiatric setting.3 The hugely resourceful Compassionate Mind Foundation website tells us of research grants in the waiting.
CFT for eating disorders
Eating disorders (ED) is one clinical area where CFT seems to be developing distinctly and a recently published clinical audit of treatment outcome suggests its outcomes are at least comparable, if not better, than standard CBT and CBT-E.3 Spearheaded by Kenneth Goss (an old student of Gilbert and author of The Compassionate Mind Guide to Beating Overeating), he heads the Eating Disorder Service at Gulson Hospital, Coventry and has been progressively introducing CFT interventions into a standard CBT programme for eating disorders since 2002. He now describes CFT for Eating Disorders (CFT-E) as ‘a transdiagnostic approach, specifically to address affect regulation difficulties, shame, self-directed hostility and pride in ED behaviour’.3
CFT-E looks more structured than CFT alone, and is designed with specific stages to help the patient develop an understanding of the emotional regulation system (with a ‘not your fault’ approach), coping strategies and also to develop self-compassion for difficulties they have faced in the past and for the challenges of recovery. Goss explains, ‘Although we share aspects of a CBT approach, we have far more focus on building emotional capacity to behave compassionately, along with practising distress tolerance skills. We also use the group to facilitate building a safe attachment. Patients have fed back to us that they have found CFT elements more effective than standard CBT. They couldn’t make changes without something in place. It’s also, perhaps, more gutsy – it can be a therapy that’s difficult to tolerate: needing to change the way you eat and relate to yourself.’
Although CFT is fairly new as a treatment approach, it seems to understand much wisdom of both ancient and contemporary thinking. A formalised university-accredited course has yet to be developed, although introductory and more advanced workshops are available. If they are delivered with the energy and compassion colleagues embody, I’ll be attending one soon.
For further information, please visit www.compassionatemind.co.uk
1. Gilbert P. Introducing compassion-focused therapy. Advances in Psychiatric Treatment. 2009; 15:199-208.
2. Gilbert P. Compassion focused therapy. London: Routledge; 2010.
3. Goss K, Allan S. Compassion focused therapy for eating disorders. International Journal of Cognitive Therapy. 2010; 3(2):141-158.