Compassion-Focused CompassionFocused-Therapy Model and Research

Paul Gilbert, Kirsten McEwan, Corinne Gale & Jean Gilbert Mental Health Research Unit, Unit, Kingsway Hospital, Derby UK

www: Compassionatemind.co.uk

Talk Today
Outline basic philosophy and model of Compassion focused Therapy Note the powerful effects of our self selfevaluation systems (self (self-criticism vs self compassion) Explore the main therapeutic work as overcoming the fear of compassion and self compassions

To understand ourselves we must understand our brains

why we have complex brains and minds that are difficult to understand regulate
1. Old Brain Emotions: Behaviours: Relationships: Anger, anxiety, sadness, joy, lust Fight, flight, withdraw, engage Sex, status, attachment, tribalism

2. New Brain Imagination, fantasise, look back and forward, plan, ruminate Integration of mental abilities SelfSelf -awareness, selfself-identity, and self self-feeling 3. Social Brain Need for affection and care Socially responsive, selfself-experience and motives

What happens when new brain is recruited to pursue old brain passions?

Interaction of old of and new psychologies Sources behaviour

New Brain: Imagination, Planning, Rumination, Integration

Old Brain: Emotions, Motives, Relationship SeekingSeeking -Creating Archetypal

Understanding our Motives and Emotions

Motives evolved because they help animals to survive and leave genes behind Emotions guide us to our goals and respond if we are succeeding or threatened

There are three types of emotion regulation

1. Those that focus on threat and self self-protection 2. Those that focus on doing and achieving 3. Those that focus on contentment and feeling safe

Types of Affect Regulator Systems

Drive, excite, vitality
Incentive/resourceIncentive/resourcefocused Wanting, pursuing, achieving, consuming Activating ThreatThreat -focused Protection and SafetySafety -seeking Activating/inhibiting

Content, safe, connected

Non-wanting/ NonAffiliative focused Safeness-kindness Soothing

Anger, anxiety, disgust

SelfSelf -Protection
In species without attachment only 1-2% make it to adulthood to reproduce. reproduce . Threats come from ecologies, food shortage, predation, injury, disease. disease. At birth individuals must be able to go it alone be mobile and disperse

Dispersal and avoid others

Protect and Comfort: Less instinctive brain post birth learning

The Mammalian Importance of Caring Minds

Caring as looking after. after. Seeking closeness rather than dispersion dispersion. . Individuals obtain protection, food, and care when ill ill. . Key also is soothingsoothing -calming and physiological regulation. regulation. Few offspring but high survival rate in comparison to species without attachment attachment. . Affection and kindness CoCo-operative and mutual support can develop as we see that our prosperity impacts on that of others, sharing and not not-exploiting

Affectionate Interactions
Secure attachment linked to selfself-confidence, empathy and use of attachment strategies when stressed (Mikulincer & Shaver 2005) Maturation of the brain (e.g. frontal cortex) and affect regulation (Gerhardt, 2004; Schore, 1994) Effects of low birth weight (Tully et al, 2004. JCCP, 72, 218218226) Testosterone and aggression (Booth et al., 2003. Developmental Psychology, 39, 85 98) SelfSelf -toto-selfself-relating e.g. self criticism vs self self-reassurance

Internal Threat and Soothing

Self-affiliation experiences a lovable self

Calms Threat Affiliative/ Soothing

Internal representations of helpful others and sources of comfort Emotional memories of soothing

Neurophysiological networks

Internal Threat and More threat

No self-affiliation experiences a un unlovable self

Calms Threat Affiliative/ Soothing

Others are threats or alarming Emotional memories of no soothing

Neurophysiological networks

Compassion Solutions
Ancient wisdom Compassion is the road to happiness (Buddhism) Evolution Evolution has made our brains highly sensitive to internal and external kindness Neuroscience Specific brain areas are focused on detecting and responding to kindness and compassion

Compassion
Compassion can be defined in many ways ways: : As a sensitivity to the suffering of self and others with a deep commitment to try to relieve it Dalai Lama

Eight fold path - represents a multimulti-modal approach for training ones mind

Compassion as Flow
Different practices for each Other Self Self Self Other Self

Non linear empathy for other begins early in life

Data
Practice of imagining compassion for others produces changes in frontal cortex and immune system (Lutz et al, 2009) 2009) Loving kindness meditation (compassion directed to self, then others, then strangers) increases positive emotions, mindfulness, feelings of purpose in life and social support and decreases illness symptoms (Frederickson et al, 2008, 2008, JPSP) Compassion meditation (6 weeks) improves immune function, and neuroendocrine and behavioural responses to stress (Pace, 2008, 2008, PNE) Viewing sad faces, neutrally or with a compassionate attitude influences neurophysiological responses to faces (Ji (Ji-Woong Kim, 2009, 2009 , NP) Compassion training reduces shame and self self-criticism in chronic depressed patients (Gilbert & Proctor, 2006, 2006, CPP)

Key Targets of Therapy

Attention Thinking Reasoning

Imagery Fantasy

Behaviour

Motivation

Emotions

Their pattern gives rise to a certain type of mind

Compassionate Mind
Attention Thinking Reasoning

Imagery Fantasy

Compassion

Behaviour

Motivation

Emotions

Threatened Mind can block Compassion

Attention Thinking Reasoning

Imagery Fantasy

Threat

Behaviour

Motivation

Emotions

SelfSelf -Critical Mind is also ThreatThreat-focused Mind

Attention Thinking Reasoning

Imagery Fantasy

SelfSelfCritical

Behaviour

Motivation

Emotions

How our own thoughts and images affect our brains

Sexual Meal Meal Sex Bullythreat Kind, warm and caring Bully-threat

Emotion Brain

Compassion Soothed Safe

Stomach acid Salvia Arousal

Fearful Depressed

Pink represents our inner images and thoughts

Questions
How does self self-criticism and self self-compassion/ reassurance work in the brain?

Are their individual differences linked to trait selfself - criticism?

How might compassion training influence neurophysiology?

fMRI Study (Aston University)

STUDY Olivia Longe, Gina Rippon, Paul Gilbert & Frankie Maratos
SelfCriticize SelfReassure SelfCriticize SelfReassure

A third job rejection letter in a row arrives in the post

Emotion Scenario(-) Neutral Scenario

The second free local newspaper in a row arrives in the post.

2X2 Factorial: 2 X Statement Scenarios, 2 X Imagery Perspectives

Statements pre-tested (n=12), for imagability (i.e. ease of imagining self-critical or selfreassuring thoughts), 1-7 Likert Scale.

Self-Criticism during Emotional Scenarios vs. Neutral

Axial slices displaying left lateral PFC (BA 47, 45,9) and right lateral PFC (BA 46) activation
Longe, et al (2010). Having a word with yourself: NeuroImage, 49, 1849-1856

Self-Reassurance during Emotional Scenarios vs. Neutral

Whole brain and axial slices displaying left temporal pole (BA 38) and insula activation
Longe, et al (2010). Having a word with yourself: NeuroImage, 49, 1849-1856

Parent recall and SC and SR

Irons Gilbert Baldwin et al., 2006 Br J Clin Psych
.24

Rejection
.31 (.33)

(.31)

Inadequate Self
.26 (.60)

.15 (.25)

Overprotection
.22

Depression Hated Self

(.55)

-.31 (-.56)

.37

Warmth

(.30)

Reassure Self

Parent recall and SC and SR

Irons Gilbert Baldwin et al., 2006 Br J Clin Psych
.24

Rejection
.31 (.33)

(.31)

Inadequate Self
.26 (.60)

.15 (.25)

Overprotection
.22

Depression Hated Self

(.55)

-.31 (-.56)

.37

Warmth

(.30)

Reassure Self

Imagining a selfself-critical part of self

197 students from Derby and McGill Universities (with Chris Irons and Mark Baldwin) SelfSelf -criticism Power Anger

0.53
SelfSelf -reassurance Power

0.51

Anger

- 0. 33

- 0.33

Imagining a SelfSelf-Compassionate Part of Self

197 students from Derby and McGill Universities (with Chris Irons and Mark Baldwin) SelfSelf -criticism Power Warm

- 0.54
SelfSelf -reassurance Power 0. 58
Gilbert et al (2005)

- 0.34
warm 0.43

Compassionate Mind
Attention Thinking Reasoning

Imagery Fantasy

SelfSelfCompassionate

Behaviour

Motivation

Emotions

Why a Compassion Focus?

People with chronic problems often come from neglectful or abusive backgrounds, have high levels of shame, and are often self self-critical, selfselfdisliking, or selfself-hating Live in a world of constant internal and external threat Have few experiences of feeling safe or soothed and are not able to do this for themselves. themselves. Often do poorly in trials

Internal Threat and Soothing

Self-Criticism Compassionate Re-focusing

Calms
Worry

Threat

Affiliative/ Soothing

Rumination

Compassionate imagery

Fear of Compassion
Certain types of positive feelings are threatening It is dangerous to feel safe Compassion feeling are linked to beliefs such that its an indulgence and weakness Activated grief and or abuse memories

PROBLEM -Compassion is a threat

Compassionate Re-focusing

Threat

Affiliaitve/ Soothing

Shame-self criticism Fear of closeness Trauma Memory Meta- beliefs

Compassionate imagery

Mentalizing

Kindness, Attachment and Threat

Kindness from therapist or imagery

Fight, flight shut down

Activate attachment system Activate memories

Fight, flight shut down

Neglect aloneness

Abuse, shame vulnerable

Activate learnt and current defences - cortisol

Bowlby: Kindness opens the attachment system and then whatever ever fears, anger or despair is coded there will become available and can be intensely threatening

Study of reactions to compassionate imagery

Control of the mechanisms for balance between sympathetic and parasympathetic nervous system have been modified and are linked to evolution of mammalian, attachment and social engagement systems This relative balance can be measured in heart rate variability Heart rate variability linked to adaptive balance and flexibility, soothing and safeness - low variability to relative control/dominance of one over the other - threat

Parasympathetic nerves to heart

Slows HR

Sympathetic nerves to heart

Increases HR and stroke volume

Successive InterInterbeat Intervals (ms) 945 897 858 799 821 846 851 858 879 879

Standard Deviation of InterInter -beat Intervals over 300 second period = SDNN

Tasks of study
Relaxation condition was focusing on relaxing calming images/thoughts Control condition was to imagine making your favourite sandwich and the pleasure you will get from eating it (control for type of positive affect and also the effects of mental imagery) Compassion imagery was to imagine their ideal compassionate person and how kind, warm and caring they were for the self

Diagram showing mean SDNN for each group at baseline & during imagery conditions
65.00

SDNN change grouping variable Grp 1downs Grp 2 ups

60.00

Mean SDNN

55.00

50.00

45.00

40.00 Baseline Control Imagery Compassionate Imagery

Condition

Diagram showing mean cortisol for each group at baseline & after Imagery
Grouping variabile for SDNN change Grp 1downs Grp 2ups

5.800

5.600

Mean cortisol (ng/ml)

5.400

5.200

5.000

4.800 CortA CortB

Sample

Correlations between change in HRV and selfself-report scales

SDNN
Inadequate Self -.54* Anxious Attachment -.48*

Depend Attachment .52*

Social Safeness .57**

* p<.05

** p <.01

Fears of Compassion
Basic Beliefs and MetaMeta-cognitions

Fear of Compassion For Others Scale

People will take advantage of you if you are too compassionate If Im too compassionate, others will become too dependent on me I cant tolerate others distress

Fear of Compassion From Others Scale

I fear that if I need other people to be kind, they wont be I worry that people are only kind and compassionate if they want something from me If I think someone is being kind & caring towards me, I put up a barrier

Fear of Compassion Towards Self Scale

I fear that if I develop compassion for myself, I will become someone I dont want to be I fear that if I am more selfself-compassionate I will become a weak person
I fear that if I start to feel compassion for myself, I will be overcome with loss/grief

Fear of Compassion Data

Com for others Com for others Com from Others Self com Com from Others

. 47** . 37** . 67**

Fear of Compassion Data

C for Others C from Others Self Com

Anxiety

. 22**

. 46**

. 44**

Dep

. 17*

. 37**

. 40*

Tentative ideas
To emotional (shame type) events - being selfselfreassuring vs self self-critical activates different brain systems People high in self self-criticism seem to struggle to activate soothing system and may find efforts to be self -compassionate a threat (sadness?) Question: can we teach selfQuestion: self-critics to be self soothing and would this training affect change physiological responses to threatening threatening-self linked events?

Therapy
Life history and contextual rather than symptom focused Background, key threats, safety strategies undesired/unintended consequence High focus on validation, on not your fault, courage and doing your best. Clarify three circle model and why we will explore helpful behaviour for each circles Desensitisation to affiliative positive affect to be able to feel safe and self compassionate

Treatment
Attendance one of two programmes Patients invited to take part in a research trial of CMT at community meetings Criteria for inclusion were mid treatment (six months to one year), well engaged with the service and to have selfself -attacking, negative thoughts Nine patients agreed to take part in the study (five men and four women) Three did not complete the study: hence six completed Twelve two hour sessions Gradual process of developing compassionate imagery and soothing exercises and then engaging with self critical thinking

Data From Group Study

Pre and Post Compassionate M ind Training
60 50 40 Scale 30 20 10 0 Self criticism Self compassion 18.8 10.2
Bef ore After

54.2

56.4

Data From Group Study

Functions of Se lf-to-Se lf Re lating
30 25 20 S core 15 10 5 0 Self Correction Self Persecution 28 (15.79) 21.67 (11.74) 17.5 (8.62) Bef ore 9.6 (8.45) Af ter

Data From Group Study

HADS
16 14 12 10 S c ore 8 6 4 2 0 Anxiety Depression Subs cale 6.83 (2.93) 4.3 (2.73) 10.33 (2.67) Bef ore Af ter 14.67 (3.78)

Data From Group Study

Forms of Se lf-to-Se lf Re lating
35 30 25 20 15 10 5 0
In ad eq ua te
31.33 (5.16) 19.83 (8.21)

14.5 15.17 (7.01) (3.76) 5.67 6.17 (5.40) (6.40)

Score

Before After

S el f

H at ed

R ea ss ur e

S el f

se lf

Data From Group Study

Others as Shamer
60 48.5 50 ( 17 . 2 7 ) 36.33 40 ( 12 . 13 )

Social Com parison 70 60 50 Score

Before

58 . 6 7 ( 2 6 .0 0 )

40 30 20 10

3 4 .8 3 ( 2 1. 50 )

Before After

30

After

20

10

0
Ot hers as Shamers

Social comparison

Reflections
I would just like to tell you all here today what (CMT) means to me me. . It seemed to awaken a part of my brain that I was not aware existed. existed. The feeling of only ever having compassion for other people and never ever contemplating having any for myself. myself . Suddenly realising that its always been there, just that I have never knew how to use it towards myself myself. . It was such a beautiful, calming feeling to know it was Ok to feel like this towards myself without feeling guilty or bad about it it. . Being able to draw on this when I was frightened and confused, to calm myself down and to put things in prospective and say to myself ITS OK TO FEEL LIKE THIS. THIS .

Reflections
Having compassion for myself means I feel so much more at peace with myself myself. . Knowing that it is a normal way of life to have compassion for myself and its not an abnormal way of thinking, but a very healthy way of thinking thinking. . It felt like I was training my mind to switch to this mode when I start to feel bad about myself or life situations were starting to get on top of me me. . What is striking about this, and what other participants thought, was how much they had (previously) felt that being selfself -compassionate and empathic to ones distress was a self selfindulgence or weakness and definitely not something to cultivate. cultivate .

Mayhew and Gilbert 2008

Three voices hearers with CFT Results showed decreases for all participants in depression, psychoticism, anxiety, paranoia, OCD and interpersonal sensitivity. sensitivity. All participants auditory hallucinations became less malevolent, less persecuting and more reassuring

Some other studies

Laithwaite et al., (2010) (University of Glasgow) in a study of group based CFT study for 19 clients in a high security psychiatric at Carstairs found a large magnitude of change for levels of depression and selfself-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 66-week follow follow-up.

Conclusions
CFT linked to evolved and neurophysiological systems : Must distinguish different types of positive emotion systems Self-toSelfto-self relationships are important mediators between early rearing styles and distressed states CFT focuses on this inner relationship shifting it to a self compassionate one First movements to compassion in selfself-critics are often aversive so this system needs to be detoxified Takes time and should focus on practice rather than focusing on feelings first up Clients like the neurophysiological and Mind Training aspects -like going to the gym analogies