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 empathyâwhich can be seen as âcompassionateâ. 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 âcompassionâ comes from the Latin word compati, which means âto suffer withâ. Probably the best-known definition is that of the Dalai Lama who defined compassion as âa sensitivity to the suffering of self and others, with a deep commitment to try to relieve itâ, i.e., sensitive attention-awareness plus motivation. In the Buddhist model true compassion arises for insight into the illusory nature of a separate self and the grasping to maintain its boundariesâfrom what is called an enlightened or awake mind. Kristin Neff (2003a, 2003b; see 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 oneâs 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 aloneâan 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 caringâboth 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 emotionsâand there are different brain systems underpinning these positive emotionsâthen 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 âsoothe it awayâ, but rather is a way of engaging with the painful. In Point 29 weâll 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 sameâthere arenât 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).
Interventions
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 âbodyâ 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 practiceâto 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, âI understand the logic of [say] CBT, but I canât feel any differentâ. 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 âalternative thoughtsâ were not âexperiencedâ as helpful. This revealed that the emotional tone, and the way that such clients âheardâ alternative thoughts in their head, was often analytical, cold, detached or even aggressive. Alternative thoughts to feeling a failure, like: âCome on, the evidence does not support this negative view; remember how much you achieved last week!â 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-worksâ 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 contentâ 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 âdeveloping inner warmthâ (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 âtarget settingâ. We teach how to use oneâs 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 âsafenessâ to explore, discover, experiment and develop. Key is to provide emotional contexts where the client can experience (and internalize) therapists as âcompassionately alongside themââno 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 âtogethernessâ. CF therapists are sensitive to how clients can actually find it hard to experience âtogethernessâ or âbeing cared aboutâ, and wrap themselves in safety strategies of sealing the self off from âthe feelings of togetherness and connectednessâ (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 togetherâas a team. CFT also focuses on (mind) âsharingâ. The evolution of sharing (and motives to share), e.g., not only objects but also our thoughts, ideas and feelings, is one of humansâ most important adaptations and we excel at wanting to share. As an especially social species, humans have an innate desire to shareânot only material things but also their knowledge, values and the content of their mindsâto 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 âflow of mindsâ that can be problematic for some people and the way that the therapist âunblocksâ 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 âemotional bulliesâ, 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 relationshipâfor example, autocratic therapists with dependent patients, or dependent therapists with autocratic patients. So, compassion is not about submissive ânicenessââit can be tough, setting boundaries, being honest and not giving clients what they want but what they need. An alcoholic wants another drinkâthat is not what they need; many people want to avoid ...