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Compassion Focused Therapy Derby December 2008. Paul Gilbert PhD FBPsS Mental Health Research Unit , Kingsway Hospital Derby [email protected] Mary Welford Greater Manchester West Mental Health NHS Foundation Trust [email protected]

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Compassion focused therapy derby december 2008

Compassion Focused TherapyDerby December 2008

Paul Gilbert PhD FBPsS

Mental Health Research Unit, Kingsway Hospital Derby

[email protected]

Mary Welford

Greater Manchester West Mental Health NHS Foundation Trust

[email protected]

Ken Goss, Ian Lowens, Chris Gillespie & Chris Irons

www. compassionatemind.co.uk

If you wish to use this material please respect sources


Warm up exercise

Warm-up Exercise

  • In threes or small groups introduce yourself and then consider clients whose shame and self-criticism have been hard to work with

  • What was the nature of the ‘stuckness’ how did you formulate this, and how did you try to resolve it?

  • What might have helped you


Workshop outline

Workshop Outline

First leg

  • Introduction to the model

  • Our Basic Threat-Defence Systems

  • Safeness: A Missing Component

  • Key Shame Concepts

  • Identifying Critical Dialogues & Associated Affects

  • The Diagrammatic Model / Formulation


Key targets of therapy

Key Targets of Therapy

Attention

Imagery

Thinking

Reasoning

Behaviour

Motivation

Emotions

Evolved Dispositions and Designs


Basic philosophy and model

Basic Philosophy and Model

To derive models of psychopathology based on the science of mind

To derive models of psychotherapy based on the science of mind

To derive models of both that integrate all the relevant sciences e.g., genetic neuroscience, development, cognitive psychology through to social and political psychology and beyond

Contextualise mind in it’s environment


Innate and acquired

Innate and Acquired

(v) Genotype  (v) Environment = (v) Phenotype

Genotypesare potential competencies for -

Examples: Language, symbolic thought, attachment, defensive behaviours

Phenotypes are the expressed or manifest traits/outputs that are observable or measurable

Examples: Styles of language, attachment


Basic evolutionary orientation

Basic Evolutionary Orientation

Phenotypic vulnerabilities

Normal reactions to abnormal/hostile’ environments e.g.,:

abusive environments develop threat focused phenotypes

Safe environment develop trust, openness phenotypes

Multiple systems specialised ‘trying to do their best’ thus protective but can conflict

Population variation

Co-constructions


The challenges

The Challenges

Old brain

Motives: Safeness, food, shelter, social

Emotions: Anger, anxiety, sadness, joy, lust

Behaviours: Fight, flight, withdraw, engage

Relationships: Sex, power, status, attachment, tribalism


The challenges1

The Challenges

Archetypes and Social Mentalities

Innate tendencies for organising basic psychological processes (motives, emotions, attention, thinking and behaving) for the creation of social roles and relationships

Consider their organisation for

Care-seeking

Care providing

Cooperation

Competition

Sexual

KEY POINT: Different social mentalities organise our minds in different ways


The challenges2

The Challenges

Old brain

Motives:Safeness, food, shelter, social

Emotions: Anger, anxiety, sadness, joy, lust

Behaviours: Fight, flight, withdraw, engage

Relationships: Sex, power, status, attachment, tribalism

2. New Brain

Imagination

Planning

Ruminations

Integration of mental abilities

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


Sources of behaviour

The Evolved Brain

Sources of behaviour

New Brain:Imagination,

Planning, Rumination, Integration

Old Brain: emotions, behaviours, relationship seeking


Humans are an evolved species

Humans are an Evolved Species

HumanSymbolic thought and self,

theory of mind,

metacognition

MammalianCaring, group, alliance-

building, play, status

ReptilianTerritory, aggression, sex, hunting


The challenges3

The Challenges

Curse of the self

Aware and seeking to create a self-identity

Self As: wants to be, does not want to be

Shame, sense of personal failure, alienation

What you think about me

Mammal brain requires nurturing, caring and kindness

Affects brain a maturation

Experience of safeness and pro-social behaviour

Physiological regulating

Health and well-being


The challenges4

The Challenges

5Interconnectedness and interdependency

Co-operation, sharing, training

Tribalism, group loyalties,

Submissive following

6.Individual differences

Personality

Gender

Talents

Ethnicities

7Self-to-self-relating

Imagination

Thinking

Self-reflections


Compassion focused therapy derby december 2008

Stimulus-Response

Sexual

Bully-threat

Meal

Sex

Meal

Bully- threat

Kind, warm and caring

Limbic system

Compassion

Soothed

Safe

Stomach acid

Salvia

Fearful

Depressed

Arousal


The challenges5

The Challenges

8The Tragedies of Life

Death, decay and an awareness of this

Diseases, famines, droughts and wars

Moralities

Justice vs compassion

Morality as feeling (and genes)

Social conditioning

Developmental stage

Fear of compassion

Weakness

Indulgence

Vulnerable


The challenges6

The Challenges

So basic philosophy is that

We all just find ourselves here with a brain, emotions and sense of self we did not choose but have to figure out

‘Not our fault’ – all in the same boat –clearly convey – de-pathologising


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 Solutions


Key targets of therapy1

Key Targets of Therapy

Attention

Imagery

Thinking

Reasoning

Behaviour

Motivation

Emotions

Evolved Dispositions and Designs


Types of affect regulator systems

Types of Affect Regulator Systems

Content, safe, connect

Drive, excite, vitality

Affiliative focused

Soothing/safeness

Opiates (?)

Incentive/resource focused

Seeking and behaviour activating

Dopamine (?)

Threat-focused

safety seeking

Activating/inhibiting

Serotonin (?)

Anger, anxiety, disgust


Key idea

Key Idea

Various therapies have developed exposure and other techniques for toning down negative emotions but not fortoning upcertain types of positive ones. Can’t assume that by reducing negative emotion the positives will ‘come on line.’

Two types of positive affect related to

achievements/doing/excitements

affectionate, soothing

Some clients have major difficulties in being able to access the soothing system - implications - so CMT/D targets this system.


Therapeutic philosophy

Therapeutic Philosophy

We use a variety of safety strategies, both innate and learnt

(e.g. avoidance, excessive submissiveness, striving to prove oneself) to try to help ourselves get though life’s challenges

We can get trapped and stuck in self-protective systems and strategies

Compassion Focused Therapy

To understand shame and self-attacking as threat and safety focused

Compassion training/therapy is an opportunity to discover and develop our minds to be self soothing – as a way to tone down and alleviate the impact of shame and self-criticism.


What is compassion focused therapy

What is Compassion Focused Therapy?

1. CFT draws on many branches of psychology (e.g., developmental social and evolutionary) and neuroscience science

2. It utilizes interventions derived from many western and eastern therapies.

3. The therapy is not technique driven but process driven.

4. The focus is on developing capacities for compassion and balancing the affect regulation systems


Cft can involve

CFT Can Involve

The therapeutic relationship,collaboration, guided discovery, personal meaning, Socratic dialogues, inference chains – (bottom line/catastrophe/major fear/threat), functional analysis, chaining analysis, maturation awareness, shared formulation, change through practice, behavioral experiments, exposure, developing emotional tolerance, mindfulness, guided imagery, expressive writing, reframing, generating alternative thoughts and independent out-of –session practice -- to name a few!

There should be increasing overlaps in our therapies if we are being science based.


What is helpful

What is helpful

Cognitive-Behavioural focused therapies help people distinguish unhelpful thoughts and behaviours - that increase or accentuate negative feelings - and alternative helpful thoughts and behaviours that do the opposite. This approach works well when people experience these alternatives as helpful. However, suppose they say “I can see the logic and it should feel helpful but I cannot feel reassured by them” or “I know that I am not to blame but still feel to blame.”


What is helpful1

What is helpful

This is called the cognition-emotion mismatch. In these cases, the problem may be that their soothing systems simply do not register the alternative thoughts as helpful i.e. the opiate / oxytocin system is insufficiently stimulated and thus they do not feel reassured. The emotional systems that give rise to feelings of reassurance are not active enough -- or the threats are so great that the threat system overrides them. Safeness can feel unfamiliar or dangerous


Key message

Key Message

  • We need to feel congruent affect in order for our thoughts to be meaningful to us. Thus emotions ‘tag’ meaning onto experiences. In order for us to be reassured by a thought (say) ‘I am lovable’ this thought needs to link with the emotional experience of ‘being lovable’. If the positive affect system for such linkage is not activated there is little feeling to the thought. People who have few memories/experiences of being lovable or soothed may thus struggle to feel reassured and safe by alternative thoughts

  • Compassion focused therapy therefore targets the activation of the soothing system so that it can be more readily accessed and used to help regulate threat based emotions of anger, fear, and disgust and shame.(page 12)


What is the point of change

What is the Point of Change?

Clarify the ‘direction of travel’ and the destination: Symptom reduction, achieve a goal, transformation of one’s being - the re-organisation of one’s mind.

Making a decision that suffering is not desirable – one’s own mind contributes to it (luxury flat)

If we loose the sense of direction then change process can seem overwhelming and lost

The importance of cultivation (wild vs cultivated garden)

Knowing one’s mind – different levels and types of subject and objective knowing

Change requires courage - purposeful vs purposeless suffering


Buddhist

Buddhist

To investigate the nature of consciousness and reside there

The light is not what it illuminates: Water is water whether it carries a poison or medicine

Mindfulness helps us reside in consciousness and not content

Making a decision to reflect on the nature of suffering, it’s nature and consequences


Compassionate knowledge some basic themes

Compassionate KnowledgeSome Basic Themes

Understand how our minds were designed

If therapy involves psycho-education then what do we teach clients about how our minds work?

Evolution-informed and functional and focus


Two types of processing system

Two Types of Processing System

These systems interact but can conflict. Therapy should work with both systems and may require different interventions


Workshop outline1

Workshop Outline

First leg

  • Introduction to the model

  • Our Basic Threat-Defence Systems

  • Safeness: A Missing Component

  • Key Shame Concepts

  • Identifying Critical Dialogues & Associated Affects

  • The Diagrammatic Model / Formulation


Self protection a design for life

Self-Protection: A Design for Life

All organisms are structured for self-protection:

Safe --- Not safe


Compassion focused therapy derby december 2008

Better safe than sorry: Our Minds are

designed to easily assume the worst -safer

Threat

NoYes

Run

Don’t Run

Action


Self protection

Self-Protection

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

Over millions of years a variety of fastdetection and response systems have been built into animal and human minds to cope with a variety of threats and are the basis for UCSs and UCRs

Threat responses need to match the stimuli and context


Menu of defensive protective strategies linked to coordinated set of

Menu of Defensive / Protective Strategies linked to Coordinated set of:

Motives

Emotions

Behaviours

Cognitive Processes


Self protective motivations drives

Self-Protective Motivations/Drives

Get or stay safe

Damage limitation vs enhancement

Hold on to what one has

Act to reduce future threat


Menu of implicit threat protective emotions

Menu of Implicit Threat - Protective Emotions

Anger –increase effort and signal threat

Anxiety –alert to danger and select defensive behaviour

Disgust –expel / keep away from noxious or undesirable

Sadness –acknowledge loss, signal distress

Jealousy –threaten and defend

Envy –undermine / spoil benefits of the

other


Menu of defensive protective behaviours

Menu of Defensive / Protective Behaviours

Stop - Hyper-alert/ hyper vigilance – predict threat early

Flight - Escape, prevent exposure (Cannon 1929)

Fight - Protection or deterrent – subdue others / exert control

Hiding and camouflage

Tonic immobility – ‘play dead’ (Bracha 2004)

Cut off - turning away from

Demobilisation -- short-term and long-term

Clinging ‘on to’

Help seeking - hyper activation of proximity seeking

Submission - appease, comply


Menu of defensive protective cognitive processes

Menu of Defensive / ProtectiveCognitive Processes

Better Safe than Sorry requires rapid decisions

Selective attention - scan for threat

Crude analysis

Dichotomous thinking

Over-generalisation

Disqualify positive – can’t risk false hope

Sensitive to nonverbal signals

Helps select automatic appropriate defence (e.g., flight, submit or attack)

May be into process before conscious awareness e.g., we find ourselves submitting and then make self-referent explanation


Neural bases of threat processing ledoux 1994

Neural Bases of Threat Processing (LeDoux, 1994)


Compassion focused therapy derby december 2008

Cerebral

cortex

Amygdala

Hippocampus


The complexity of the threat system

The Complexity of the Threat System

1) Different processing systems active

2) Threat emotions can set up conflicts

- The power of approach-avoidance conflicts

3) One protection strategy creates another

4) Emotional Conditioning


2 threat emotions can set up conflicts

Threat – boss criticises your work

2) Threat Emotions can set up Conflicts

Rapid access of safety strategies

Angry-attack revenge

Anxious - flee submit

Cry want to seek reassurance

Threat to self-identity and self as social agent in social role

Fragmented and fragmenting, confused and secondary safety strategies at management of inner conflicts


Conflicts e g approach avoidance

Conflicts (e.g. Approach-Avoidance)

Experimental neurosis – trigger two different behaviours at same time e.g., seek reward and avoid threat – Pavlov, Liddell & Cooke etc

Incompatible decisions – choosing one violates another: Disorganisation of systems (also classic Sci-fi; Hale in 2001 a Space Odyssey and 2010 the Return)

Dilemmas (e.g., risk change or trust vs stay safe); head heart

Increase in stress arousal and inhibits abilities to think – dissociation. Confusing to client and therapist (Liotti..)

Therapeutic task is to clearly articulate the conflict, explain how conflict affects the brain, and then brain storm – May take time to work through – resolution may not be easy – hard life decisions.


4 one protection strategy creates another

4) One Protection Strategy Creates Another

Express feelings Don’t express feelings

Others angry Others ignore

Reject my wishes

Feel bad Feel bad


5 emotional conditioning

5) Emotional Conditioning

How emotions and desires can become non-conscious (Ferster 1973)

Anger Punishment

Anxiety

Any emotion or motivation (urge) can become a CS of any other


Conditioning

Conditioning

Care seeking Punishment

Anxiety

Care seeking systems can become conditioned to threat rather than safeness. If happens early, people may not recall specific memories but experience confusing feelings in close relationships


Conditioning1

Conditioning

Care seeking No response

shut down


Own behaviours as threats

Own Behaviours as Threats

Anxiety can be an alerting signal for not to do something –a ‘don’t’ signal.

Brain can also automatically change the balance of emotional regulation as in Protest-Despair.

Infants separated from caregiver first shows protest (pining and anxiety) but then becomes quite and withdrawn – this stops movement, getting lost, and attracting attention of predators

Toning down of positive emotions most likely in poorly supportive, low pay off and/or risky environments –

So what is the protective strategy underpinning low mood?


Source of threat

Source of threat

External

Shared with other animals focus on the outside and how to behave in the outside world to minimise threat and harm

Internal

Can be threatened by the emergence of internal emotions, desires fantasies and memories

Both can be very clear or very subtle threats


Emotions as internal threat stimuli

Emotions as Internal Threat Stimuli

Emotions are evolved, specialised processing systems that provide internal knowledge about our relationship to the outside world and guide actions (Greenberg)

Without emotions nothing matters, with them anything can (Tomkins). Motives and emotions guide us to goals and are non-logical (e.g., falling in love, wanting children, grief).

Human evolution has resulted in the fact that we cannot learn about our emotions or develop integrated systems for emotional processing without the minds of others interacting with us

Parent is the only regulator in first months and then becomes a coach, source for social referencing and validator.


Emotional schemas leahy

Emotional schemas (Leahy)

Can develop threat based beliefs and coping strategies for emotions and desires that emerge from how we experience our own emotions and others responses to them

Emotions can become threats themselves related to beliefs that one’s desires, fantasies and emotions are incomprehensible, unique to the self, shameful, can never be validated or expressed and /or that one’s emotions will go out of control if experienced. Beliefs that one should be rational and logical all the time, never have conflicting feelings, and should ruminate in order to figure things out. Ruminations can be a way to try to work things out without needing help (soothing) from others


Compassion focused therapy derby december 2008

Emotions:

anger

anxiety

sexual

sadness

Attention to emotion

Cognitive avoidance

Negative Interpretations:

guilt

lack of consensus with others

simplistic view

incomprehensible

cannot accept emotion

overly rational

Emotion is normal

dissociation

bingeing

drinking

drugs

numbness

Emotion is problematic

accept,

express,

experience validation

learn

lose control

long duration

rumination

worry

avoid situations that elicit emotions blame others

From Leahy 2001


Problems of balance

Problems of balance

Examples of Threat-protection focused difficulties

Triggers, intensity, duration, frequency, coping

Emotion containment

Impulsiveness

Emotional, cognitive and behavioral avoidance

Prediction

Rumination


Self protection1

Self-Protection

All organisms are structured for self-protection: Safe --- Not safe. Thus high priority and urgency are given to this decision in all biological systems

Symptoms often arise from perceived threats and efforts to cope defend and protect

Some phenotypes have undesirable effects and are linked to suffering

Resistance is related to threat of change – fears of ‘new’ self

These are shared views of many therapies

Language of self-protection and better safe than sorry and validation rather than pathologising


Workshop outline2

Workshop Outline

  • Introduction to the model

  • Our Basic Threat-Defence Systems

  • Safeness: A Missing Component

  • Key Shame Concepts

  • Identifying Critical Dialogues & Associated Affects

  • The Diagrammatic Model / Formulation


Safeness a missing component

Safeness: A missing Component?

Feeling safe from physical, psychological and self- attack is essential for well-being

Consider process and mechanisms that create states of safeness


Overview of an evolutionary journey

Overview of an EvolutionaryJourney

Attachment

ThreatSafenessCompassion

Mutual support

Self -Regulation


Qualities of care

Qualities of Care

Accessibility of the otherAvailability of the other

Disposition of the other Competencies of the other

Interpersonal style of otherHow one exists in the

mind of the other


Self vs others protection

Self-vs-others protection

Attachment as “looking after.” Individuals obtain protection, food and care when ill. Seeking closeness rather than dispersion. Key also is soothing-calming and physiological regulation.Few offspring but high survival rate in comparison to species without attachment

Co-operative and mutual support when ‘your’ prosperity impacts on mine


Safeness vs safety

Safeness vs Safety

Safety Seeking is often about escaping, avoiding, hiding, preventing - when threat is the focus of attention (better thought of as defensive behaviour). Highly conditionable

Safenesscreates an inner state that organizes multiple processes

Free(dom):

To move, to grow, explore, integrate, slow reflective

Open attention


Evolution of safeness

Evolution of Safeness

Mastery, De-sensitisation, Familiarization - mindfulness

Social Safeness

Can be passive or active –freedom of movement, explorative

Attachments

Group living --- Belonging

Connectedness

Signal-sensitive systemsto detect presence and absence

Soothing, calming or alerting of affiliative emotion


Emotion system for care

Emotion System for Care

Evolved motivations to care, and competencies to care, by attuning to needs of the other and engaging behaviour that impacts on the object of care

Being Cared For

Innate, signal sensitive systems that seek out and are responsive to certain stimuli and cues

These specialised physiological systems detect (evolved form contentment) code for “safeness”


Types of affect regulator systems1

Types of Affect Regulator Systems

Content, safe, connect

Drive, excite, vitality

Affiliative focused

Soothing/safeness

Opiates (?)

Incentive/resource focused

Seeking and behaviour activating

Dopamine (?)

Threat-focused

safety seeking

Activating/inhibiting

Serotonin (?)

Anger, anxiety disgust


Functions of caring attachments needs sensitivity

Functions of Caring-Attachments - Needs Sensitivity

The Carer-Provider offers……

Protection: anticipating/preventing; build nest out of harms way, defending/standing up for – advocate

Distress call responsive:listening out for;rescuing; coming to the aid of – responding to distress

Provision: physical care, hygiene, food,

Affection: warmth positive affects that acts as key inputs for brain maturation

Education and Validation: teach/learn life skills in family context: understanding one’s own mind

Interaction: being present, stimulating and regulating various affect systems: curiosity, play, soothing – socialising agent –shaping phenotypes


Key sources of safeness

Key Sources of Safeness

Safeness is not just the absence of threat but there are specialised systems in the brain linked to social cues. Thus soothing systems are regulated via differ pathways.

First are cues of physical affection (facial, holding, touch comforting) – highly sensory based

Second needs can be meet, soothed and contented

Third, learning how we live in the minds of others – and learn about our own mind -- ‘your reactions to my mind’

Fourth social referencing for what is safe – the self to become

Fifth create internal memories of others as soothing supportive, kind and forgiving and self as lovable

All these play different roles in threat regulation and feeling safe/content


Safeness

Safeness

Carer creates a safe base – and provides inputs for working models of relationships (Bowlby)

Parent and peers regulate exposure to external threats - and loss of access is itself a threat

Parent and peers regulate internal threat states – soothing - and facilitate internal self-regulation

Key to CFT however are the data on the neurophysiological systems responsive to care-focused and safeness signals from others


Workshop outline3

Workshop Outline

  • Introduction to the model

  • Our Basic Threat-Defence Systems

  • Safeness: A Missing Component

  • Key Shame Concepts

  • Identifying Critical Dialogues & Associated Affects

  • The Diagrammatic Model / Formulation


Living in the minds of others

Living in the Minds of Others

Major evolved specialised processing systems and abilities (linked to inter-subjectivity and theory of mind)

Long history of recognizing the importance of how (we think) we exist in the minds of other

Clear in play writers and novelists (e.g., Shakespeare) – and key for:

Cooley, Rogers, Bowlby, Kohut


Living in the mind of others

Living in the Mind of Others

Colley 1902 Looking Glass Self:

Many people of balanced mind and congenial activity scarcely know that they care about what others think of them, and will deny, perhaps with indignation, that such care is an important factor in what they are and do. But this is illusion. If failure or disgrace arrives, if one suddenly finds that the faces of men show coldness and contempt instead of the kindness and deference that he is used to, he will perceive from shock, the fear, the sense of being outcast and helpless, that he was living in the minds of others without knowing it, just as we daily walk the solid ground without thinking of how it bears us up


Key shame concepts

Key Shame Concepts

Exercise 1


Insight exercise

Insight Exercise

  • To help you recognise the complexities of shame and also see that you already have intuitive knowledge of shame, we would like to you to engage in a short imagery exercise.

  • Let’s take a hypothetical situation: Imagine that as part of this workshop you will be asked to describe something you feel ashamed about, and would rather keep hidden, to the person sitting next to you. We would like you to explore this is a series of steps. Rest assured this is hypothetical, but try to imagine it as if it were to be the case.


Strategies for gaining and maintaining rank and status

Strategies for Gaining and Maintaining Rank and Status

StrategyAggressionAttractiveness

Tactics usedCoerciveShow Talent

ThreateningShow competence

AuthoritarianAffiliative

Outcome desiredTo be obeyedTo be valued

To be reckoned withTo be chosen

To be submitted toTo be freely given to

Purpose of strategyTo inhibit othersTo inspire, attract others

To stimulate fearTo stimulate positive affect

From Gilbert & McGuire 1998


Safeness and the minds of others

Safeness and the minds of others

Creating positive feelings and thoughts in the minds of others, about oneself, makes the world safe

safe and will not rejected or attacked

likely to be available in time of need

co-create advantageous relationships (e.g., sexual, co-operative)

physiologically regulating (e.g. oxytocin, cortisol)

stimulates positive feelings for self and other

lay down emotional memories of warmth

External shame is experiencing negative feelings (contempt, anger, ridicule) in the minds of others lead to attack, rejection or ‘un-included’

major threat --- generating defensive behaviours such as,

fight/flight/submit


Compassion focused therapy derby december 2008

Self-Conscious Emotions

Pride

Shame Guilt

Embarrassment

Humiliation

From 2 yrs old - Self conscious competencies

recognise self as an object for others, theory of mind,

awareness of the contingencies for approval and disapproval,

role taking and understanding social rules, metacognition

Rage/anger

Fear/anxiety

Disgust sadness

Happiness

Joy Fun

Primary Emotions


Attracting competition and social rank

Attracting, Competition and Social Rank

Competing for resources and social place and thus be able to engage others as helpful partners in roles

Helpful partners (expressing liking) also help make the world safe and stimulates soothing system

Competing to stimulate positive affect (desires) in the mind of others about the self is competitive because an audience will choose in their best interests too


The undesired unattractive self

The Undesired/Unattractive Self

….. when ashamed, participants talked about being who they did not want to be. That is, they experienced themselves as embodying an anti-ideal, rather than simply not being who they wanted to be. The participants said things like. "I am fat and ugly," not "I failed to be pretty;" or "I am bad and evil," not "I am not as good as I want to be." This difference in emphasis is not simply semantic. Participants insisted that the distinction was important......

(Lindsay-Hartz, de Rivera and Mascolo (1995p. 277 )

It is therefore not so much failing to meet standards but the meaning and experience of self from seeking and falling short


Types of affect regulator systems2

Types of Affect Regulator Systems

Content, safe, connect

Drive, excite, vitality

Affiliative focused

Soothing/safeness

Opiates (?)

Incentive/resource focused

Seeking and behaviour activating

Dopamine (?)

Threat-focused

safety seeking

Activating/inhibiting

Serotonin (?)

Anger, anxiety disgust


A cost of evolving self awareness

A Cost of Evolving Self-Awareness

The evolution of self-conscious and self-awareness is linked to humans becoming more flexible, sharing, mutually influenced beings with ‘de-modularised, systems intelligence's’.

But it also means we live in a private world (alone). We can ‘only exist/be’ in our own minds - others can never actually know us – and only relate to them as ‘other’ and outside.

So we must relay on signals, inference and trust. Thus the importance of

secure attachment

insecure attachment


Threat responses in social contexts

Threat Responses in Social-Contexts

Embarrassment

External shame

Internal shame

Humiliation

Guilt


Types of negative self conscious experience embarrassment

Types of Negative Self-ConsciousExperience: Embarrassment

  • In embarrassment we focus on behavioural faux pas not major flaws in the self.

  • The experience is often transitory, and can ignite a humorous response in observers – and even ourselves after the event.

  • We cover embarrassment with smiles and displays of modesty and embarrassment.

  • We ‘hang our head’ in shame.


Embarrassment

Embarrassment


Shame is a self conscious emotion

Shame is a self-conscious emotion

It is an emotion about the self. It depends of certain types of mental abilities that include a form of self-awareness and theory of mind of ‘how we exist in the minds of others’ – and our ability to imagine a self and a self as thought about by others

Shame recruits various negative and threat based emotions into the experience of self (e.g., anger, anxiety, and disgust). It is not a separate emotion but a cognitive-emotion blend.


Components of shame

Components of ‘Shame’

  • Social and eternally focused – on self in the mind of the other.

  • Internally focused – oneself as felt and judged by self

  • Emotions – anger, anxiety and disgust We ‘hang our head’ in shame.

  • Behaviours –avoid, hide. shut-down, attack

  • Physiological profiles – forms of arousal and activation – high cortisol response


Types of negative self conscious experience external shame

Types of Negative Self-ConsciousExperience: External Shame

What one thinks others think/feel about oneself

Believes the self is looked down on by others, seen as inferior,

inadequate or bad – as a socially unattractive/undesirable

agent/person.

Believes others may feel anger, anxiety, contempt, disgust or

ridiculing humour for the self.

Shame feelings may blend with feeling socially anxious, depressed

or angry – but possible to have relative indifference.


Types of negative self conscious experience internal shame

Types of Negative Self-ConsciousExperience: Internal Shame

What one thinks/feels about oneself

Believes the self is personally inferior, inadequate or bad. Negative social comparison. Internal attributions

A socially unattractive agent – an undesirable self.

Internal shame blends with feeling angry, anxious, contempt or disgust with the self. Internal shaming


Types of negative self conscious experience humiliation

Types of Negative Self-ConsciousExperience: Humiliation

Feels attacked, devalued, put-down by others

However, may not focus on self as personally inferior, nor as undesirable self. See the other as bad or unjustified for attacks, put-down. External attributions

May feel anger, anxiety, contempt, and disgust to the other – often strong sense of injustice with desire for revenge.

.


Compassion focused therapy derby december 2008

Innate motives for attachment and group belonging;

needs to stimulate positive affect in the minds of others;

Unfolding cognitive competencies for self-evaluations

Social-cultural contexts, cultural rules for honour/pride/shame

PERSONAL EXPERIENCES OF SHAMING - STIGMA

Family: Criticism, high expressed emotion, negative labelling, abuse

Social group: Bullying, discrimination, prejudice, stigma

External Shame

devalued by other

Excluded, avoided criticised, NAMOs

Humiliation

other-devaluation

external attribution

unjust - revenge/anger

Internalised Shame

self-devaluation

internal attribution

depressed/anxious

reflected stigma (to family or others)

rejection by the community


Comparing shame and guilt often fused to varying degrees

Comparing Shame and Guilt(often fused to varying degrees)

Shame is linked to the competitive mentality thus to social comparison, sensitivity to put down and rank linked defences of attack or submission avoidance (high association to psychopathology)

Guilt is linked to the care-giving, cooperative mentalities and focused on specific behaviours and is thus linked to harm avoidance, taking responsibility, reparations (often negative relationship to psychopathology)

Repairing shame opens possibilities for guilt


The foci of shame

THE FOCI OF SHAME

SHAME CAN HAVE A SPECIFIC OR GENERALISED FOCUS

The body The body in action and functions

Failures Relationships/roles

Feelings/fantasises Coping/needing

Past events Group based (stigma Cons)

Self as

lacking, as different, bad, powerless , defined by other


Examples of coping with shame inferiority

Examples of Coping with Shame/Inferiority

Compensation:Making up for deficits

Concealment:Hiding things ‘from view’

Aggression:Threaten others to ‘never notice’

Externalise - ‘not on me’

Avoidance:Avoid situation/encounters where shame affects may arise

Projection:Others see me as I see myself:Shame others

Dissociation:Acting without feeling, separating

Numbing Substance misuse


Shame as a distance regulator

Shame as a Distance Regulator

Need to hide or be alone when I feel bad

Don’t want others to see me this way

Don’t want others to be the worst for seeing me

Bad to cry, lose control or be aggressive

But when he left the ward (safety behaviour)

I’m isolated, feel alone misunderstood, no-one to help. It is pointless. Angry with self and everyone. I hate feeling like this


What makes shame so aversive

What makes shame so aversive?

*Shame is a normal emotion and some degree of it is helpful for everyday functioning (imagine a ‘shameless’ person)

*Archetypal and innate threat of rejection and social exclusion – major survival risk -- so our brains are highly sensitive to it

* Early experiences of being shamed often linked with powerful, hostile, rejecting others. The context of being shamed was one of threat –thus trauma memories.

* Damage may be long-term (e.g., to a reputation). Social contexts

* Different safety strategies for coping with shame (e.g., concealment, compensation, avoidance). Safety strategies can inhibit learning helpful coping and acceptance


The dance of shame

The Dance of Shame

When activated in interactions people shift to automatic threat-focused processing – little reflective thought

Easily spiral out of control and then defences become more extreme (dominate-subordinate). An interaction-amplifying spiral

Feel damaged or have damaged relationship and now not know how to repair and/or back to shame - so stay dissociated, avoid, minimise, externalise, ruminate

Therapy: normalise then careful micro-analysis of behaviour - noting threat-self protection as focus. Role switching – compassion focusing, forgiveness CH.


Types of negative self conscious experience guilt

Types of Negative Self-ConsciousExperience: Guilt

Harm done by specific behaviours

Focus on effects of our behaviour on welfare of self, others or objects. Internal attributions

Must have empathic connection to harm

Behaviours aimed to try to repair harm. Common affect is sadness/ remorse. Easily ‘fused’ with shame


Summary soothing and shame

Summary Soothing and Shame

Soothing system evolved with attachment system and is a threat-affect regulator (parent is protector/soother)

Become safe by eliciting positive affect in the mind of others – ‘care’ cues are soothing ( from parent to peers)

Access to soothing system enables reflective thinking

Shame is the experience of becoming the undesired and undesirable self vulnerable to rejection, marginalistion and involuntary subordination

A range of defensive strategies (links affect cognition and behaviour) - internalising (low rank, submissive) and externalising (dominant, aggressive)


Therapist feelings scenario

Therapist Feelings Scenario

Client came for few weeks then said what we were doing was not helpful - actually she was feeing worse and seemed angry

What cognitions and behaviours would go with

External Shame, Internal shame, Humiliation Guilt, Indifference, Empathic-sympathy.

How might you respond for each?


Shame

Shame

And Trauma

The Co-construction of Self and Other


Shame memories fuse multiple systems

Shame Memories Fuse Multiple Systems:

Experienced arousal of own emotions (e.g., fear, paralysis) and defensive behaviours (e.g., blocked flight)

Experienced emotions (e.g., rage disgust) and intentions in the mind of the other directed at the self

.

Verbal labels and personal self referent meaning (e.g., stupid, bad, disgusting)

Draw out with Client


Associations of threat meanings in shame traumas

Associations of threat ‘meanings’ in shame-traumas

FROM OTHER

ARISING IN SELF

.

Emotion and intent flowing from the other e.g. Aggression/contempt

Alone – no help/rescue

Others are frightened or joiningin (bullying)

Intense sense of fear-rage-contempt

Entrapment

Verbal labels defining the self stupid/bad

THREAT

Sense of having done something wrong/terrible

Acute sense of self as ‘under attack’ and defined


Shame experiences memories can be work like trauma

Shame experiences - memories can be work like ‘Trauma’

* Sensory stimulus triggers emotional response (fear, anger, disgust, sadness) via the amygdala

* Intrusive and prominent

* Reoccurring Flashback-like

De-shaming is linked to working through

1. Fear and anger

2. Acceptacne in the eyes of self and others


Shame and therapy

Shame and Therapy

Therapy relationship – safe or shaming?

(non-verbal, pacing, empathic + therapist's shame area)

Shame during therapy (e.g., revealing, crying, losing control)

Shame and safety behaviour/styles (related to past events)

Shame and internal self-attacking (safety behaviours?)

Compassion as a shame antidote.


Therapy

Therapy

Discuss multiple systems in our minds and it is normal to feel conflicts

Socratic explorations of what else might you have been feeling, thinking? What is dangerous to acknowledge –threatened self-identity?

Mindfulness watching observing

Mindfulness involves learning to direct one’s attention in a nonjudgmental fashion in order to become aware of one’s thoughts, feelings, and actions as they emerge in a present moment. It involves cultivating an attitude of intense curiosity about one’s inner experience as it unfolds (Kabit Zinn, 2005; Katzow & Safran in press)


Workshop outline4

Workshop Outline

  • Introduction to the model

  • Our Basic Threat-Defence Systems

  • Safeness: A Missing Component

  • Key Shame Concepts

  • Identifying Critical Dialogues & Associated Affects

  • The Diagrammatic Model / Formulation


Why focus on self attacking

Why Focus on Self-Attacking

Self-critics have poor social relationships (Zuroff et al., 1999)

Depressed people become more self-critical as mood lowers (Teasdale & Cox, 2001)

Self-critics may do less well with standard CBT (Rector et al., 2002)


Self attacking in psychosis

Self-Attacking in Psychosis

70% of voices are malevolent

Commands – sometimes with threats

Insults (direct and indirect)


Self attackers

Self-Attackers

Early abusive histories, inappropriate parenting,high EE, criticism. Low or inconsistent affection

Internal Shame with highly critical internal dialogues

Developed from early experience

Trauma, culture, abuse, deprivation

Often unaware of extent or power of SC

Generate different intra personal and inter personal styles of interaction

Chronic long term difficulties

Concurrent cognitive/affective themes

Ongoing sense of external (the world) and internal (inside self) threat (amygdala and threat system sensitisations)

Lack of safeness –poor abilities to self-soothe

Easily accessibly sensory based shame-trauma memories and scenes


Internal roles

Internal Roles

Two key types of internal self self relationship

Hostile dominant self fearful, subordinated self

Caring emphatic self cared for, soothed self

Mediated through and reflected in affect, behaviour and self-talk


Internalised self attacking and shame self as an object for evaluation

Internalised Self-Attacking and Shame: Self as an object for evaluation

Pre-modernInner demons; possession

FreudianSuperego – related to internalised parental prohibitions

GestaltTop-dog versus under dog

BehaviouralSelf-punishment

CognitiveSelf-attacking, self-critic

EvolutionaryInternalised hostile dominate signal

Ideal mismatchFrustrated generated attacks – the unattractive or undesirable self


Compassion focused therapy derby december 2008

Stimulus-Response

Sexual

Bully-threat

Meal

Sex

Meal

Bully- threat

Kind, warm and caring

Limbic system

Compassion

Soothed

Safe

Stomach acid

Salvia

Fearful

Depressed

Arousal


Key questions

Key Questions

Need to ask:

1. Is it possible that some recent adaptations in the brain make us more vulnerable to mental health difficulties – e.g., self-awareness, anticipation and rumination self criticism?

2. Is it possible that some recent adaptations in the our social-cultural life styles make us more vulnerable to mental health difficulties e. g., entrapments, domestic violence, mass media, social comparison.


Self critical thinking styles

Self-Critical Thinking Styles

Social Comparison

Personalisation and Self-blaming

Self-labelling/condemning

FORMS

Self-attacking (frustration)

Self-criticism (to improve/correct)

Self-hatred/disgust (to hurt or destroy)


Affects and self attacking

Affects and self-attacking

Ideal selfActual self

Disappointment Gap

Self-attacking

* Separate feeling of frustration from self-attacking

* What are the key fears of failure

* What is the emotional focus (e.g., anger, sadness

hatred, contempt)

* Ability to experience and tolerate frustration

without self-attack (conditioning)


What are your fears or change

What are your fears or change?

External

Others will not like or accept me –rejection or harm

Lack of help or if they get close they will see bad tings, turn harmful or demanding

Internal

Related to who I am… what I can do…. and who I want to be

Must not have certain feelings/fantasies (metacognitive fears of) “they will overwhelm me, not be validated by others, too painful, out of control, mean I am bad etc.” Avoid certain memories

Unable to accept my limitations; unable to recognise my potential

Unrealistic goals

Feedback onto external fears is often key ..“if then” Anger at others can be poorly processed


Imagining the self critical part of self

Imagining the self critical part of self

Now for a moment let’s imagine that this self-critical part of you could be thought about as a person. If those self-critical thoughts took on the appearance of an actual person what might they be like? Maybe you could think about their facial expressions, if they are big or small, the tone of their voice, the emotion. Just spend 30 seconds imagining this.


Imagery self critical part of self

Imagery: Self-critical part of self

Can have properties of:

Big rather than small

Powerful-dominate rather than subordinate-weak

Hostile, angry or contemptuous rather than friendly

Issues threats


Functional analysis

Functional Analysis

Safety (defensive) behaviours

as a warning of threat

cuing from memory (eg. voice of parent)

habit

avoid aggression (who are you protecting?)

identity linked (what kind of person would I be if I didn’t self-attack)

affect regulation


Experience of self criticism

Experience of Self-Criticism

Emotional system sensitive to nonverbal communications

Visualisation of NSC. The look, voice tone and affect

Does it attend to the evidence against?

Emotional awareness of the power and damage

(automatic and ruminative)

Discuss rehearsal and harassment

Name as part of self (e.g, inner bully –but good at what it does?)


Functional analysis nscs

Functional Analysis NSCs

Explore the relational and dialogic nature of self- cognitions (e.g., two chairs) bully-bullied

Origins of bullying voice – their credentials

Why submissive acceptance response to self-attack?

(linked to history of submission to authority)

Submission as safety behaviour; self blame as safety cognition –acknowledge desire for safeness

Functional analysis of critic (improve, ridicule, destroy)


Working with s c

Working with S.C

Examples of self-blaming and self-condemning as safety-defensive behaviours

What is hidden?

What is your worse fear in ‘giving up’ self-attacking

So not (just) evidence based but:

safeness

identity

habit

loyalty


Working with scs

Working with SCs

What evidence would be a reasonable alternative

Flash cards

Playing dominant role - to internal S.C image, two chairs or in memory (fear/guilt/shame of assertiveness)

Mindfulness – just observing self-critical thoughts images.


Special problem of self contempt

Special problem of self-contempt

Linked to affect of disgust – Core sense of badness – being contaminated by ……..

Defensive (disgust) emotions and action tendencies are getting rid of, expelling, cutting out ‘destroying the bad,’ cleansing

Trying to ‘purify’ leads to splitting – common even in religions and social groups

Transformation new meaning rather than purification (nature of the universe)


Special problem of hatred rage

Special problem of hatred rage

Rage and hatred are dangerous because (External threat – destroy other or end up alone Internal threat out of control)

Not that kind of person – unreasonable (meta-cognition)

Feel alone and unlovable when expressed

How to handle it if felt in the therapeutic relationships?

How might it be involved in self-harm – what fear or hurt does it cover?


Therapist positions

Therapist Positions

Understand the evolved forms and automatic nature of basic threat systems processing

Normalising contempt and rage as understandable though not desirable - empathises with how unpleasant they are

Therapist contains it by open discussion of these as basic to our nature and possibilities – notes points of hidden anger – curiosity not interpretation

Think through together how to discuss and deal with these feelings – how would patient like therapist to handle them (advantages and disadvantages)


Types of affect systems

Types of Affect Systems

Affiliative focused

Soothing/safeness

Opiates (?)

Incentive/resource focused

Seeking and behaviour activating

Dopamine (?)

Threat-focused

safety seeking

Activating/inhibiting

Serotonin (?)

.


Summary of self criticism

Summary of Self-Criticism

Social threat THE major threat to humans – shame is becoming the undesired and undesirable self

Self-criticism has multiple origins – abuse, neglect bullying, competitive relationships, trying to win approval - is usually linked to feeling ‘socially unsafe’ – thus with external threat

Velco-like trauma like memories – ‘threat first’ processing

Different functions of self-criticism: Self correcting and self-persecuting can be linked to complex networks of meaning, self-identity and social relationships


Workshop outline5

Workshop Outline

  • Introduction to the model

  • Our Basic Threat-Defence Systems

  • Safeness: A Missing Component

  • Key Shame Concepts

  • Identifying Critical Dialogues & Associated Affects

  • The Diagrammatic Model / Formulation


The model

The Model

Our experiences together with our evolved brains results in key fears around harms, injuries and loses

These can be external and internal

It is understandable that the individual engages in a range of safety strategies aimed at protection

These safety strategies give rise in unintended consequences

The individual engages in (further) self attacking, experiences a range of emotions, ruminates and feel;s trapped in the


Compassion focused therapy derby december 2008

Unintended Cs

Feel worthless

Controlled by others

Loose sense of self -alone

Ruminate on emptiness

Background

Others as Critical, absent, frightening, blaming

Key fears/Memories

Hurt, rejection, ‘being to blame’ aloneness

Safety Strategies

Threat focused

Inhibit, submit avoid anger

Be as others want

Develop feeling compassion for background and safety strategies

Self-attack, access shame memories

Concealing

Understanding our minds, not our fault

Confused, depressed angry, dissociate fragment

Compassionate acceptance and integration of multi-self

Compassion imagery, focus (e.g. attention, behaviour) and reframe


Compassion focused therapy derby december 2008

Unintended Cs

Others don’t see me as a person

Feel worthless

Controlled by others

No sense of self

Safety Strategies

Threat focused

Withdraw

Be as others want

Background

Others as critical, overprotective, being treated as a victim

Key fears

Rejection, powerless, being alone

Develop feeling compassion for background and safety strategies via experience, explanation of the science & formulation

Self-attack

Shame

Understanding our minds, not our fault

Depressed, angry, anxious

Compassionate acceptance and integration of multi-self

Compassion imagery, focus (e.g. attention, behaviour) and reframe

Well-being


Therapy1

Therapy

Discuss multiple systems in our minds and it is normal to feel conflicts

Socratic explorations of what else might you have been feeling, thinking? What is dangerous to acknowledge –threatened self-identity?

Mindfulness watching observing

Mindfulness involves learning to direct one’s attention in a nonjudgmental fashion in order to become aware of one’s thoughts, feelings, and actions as they emerge in a present moment. It involves cultivating an attitude of intense curiosity about one’s inner experience as it unfolds (Kabit Zinn, 2005; Katzow & Safran in press)


Rebellion model to change

Rebellion model to change

* Listening and considering possibilities that dominant (e.g. critical parent/teacher/bully) was/is wrong (still high fear)

* Externalising and voicing new ideas, beliefs of rebellion (‘you’ (e., parent) are wrong about me)

* Behaving against values and dictates of dominant (e.g. acts of defiance) (Milgram 1974)

* Distinguish helpful from destructive rebellions

(Gilbert & Irons, 2005)


Rebellion model to change1

Rebellion Model to change

Don’t Rush Rather be aware of rebellion as fear of: disloyalty and loss or connection

coping with ambivalence, guilt

retaliation,

aloneness,

protect ‘them’ from my anger.

Blaocks can also arise from desire to hold onto pain for secondary gains (show them what they have made me do, induce guilt – wait for recognition of rescue) – the trophies of suffering.

(Gilbert & Irons, 2005)


Therapy2

Therapy

Explain how our brains are set up to try to protect us

Explain how our threat-defense systems work -

that they are designed to be rapid and can emerge in us before we are aware of it (NOT OUR FAULT) –common to us all and even animals; ask patients to generate examples

Explain sensitization as relevant to that person –over and over again come back to protection strategies –that can be involuntary ‘the better safe than sorry’ rule of the mind

Avoid terms such as distorted thoughts or maladaptive schema as these can be shaming and we are wanting to develop compassionate understanding for how our ‘mind works’ rather than pathologise it


Therapist feelings scenario1

Therapist Feelings Scenario

Client came for few weeks then said what we were doing was not helpful - actually she was feeing worse and seemed angry

What cognitions and behaviours would go with

External Shame, Internal shame, Humiliation Guilt, Indifference, Empathic-sympathy.

How might you respond for each?


Compassion focused therapy derby december 20081

Compassion Focused TherapyDerby December 2008

Paul Gilbert PhD FBPsS

Mental Health Research Unit, Kingsway Hospital Derby

[email protected]

Mary Welford

Greater Manchester West Mental Health NHS Foundation Trust

[email protected]

Ken Goss, Ian Lowens, Chris Gillespie & Chris Irons

www. compassionatemind.co.uk

If you wish to use this material please respect sources


Workshop outline6

Workshop Outline

Stage 1

  • Introduction to the model

  • Our Basic Threat-Defence Systems

  • Safeness: A Missing Component

  • Key Shame Concepts

  • Identifying Critical Dialogues & Associated Affects

  • Formulation

  • Stage 2

  • Considering the Nature of Self Compassion

  • Compassionate Mind Training

  • Deepening Self Compassion

  • Fear of Compassion


Stages of cmt

Stages of CMT

Explanation of model

Shared formulation

Validation of fears

Makes sense of protection strategies

Identify critic or inner bully as safety strategy

Its not your fault

Promotion of grief reaction to suffering

Development of compassion for self

Through relationship (NV communication)

Imagery

Attention, behaviour, thought, mindfulness

Visualise, practice, rehearse compassionate focus on self, goals and future


Buddhist concepts

Buddhist Concepts

Metta: is loving kindness or friendly care, which is an orientation to self and others.

Mudita: appreciating and taking joy from being alive ‘in this moment’ (e.g. the colours of the clouds, a rainbow or a sunset, the taste of food). Sympathetic joy in the flourishing of others. It is a wellspring of feelings of peaceful well-being.

Karuna: compassion that involves ethical behavior, patience and generosity with action.

Upekkha: equanimity and a sense of connectedness -similarity to other humans and all living things – that all are seek happiness and none seek suffering, that we are all the same in our struggles in life.


Contrast self compassion to self esteem

Contrast self-compassion to self-esteem


Compassion practice

Compassion Practice

Mindful compassion involves learning to direct one’s attention in a nonjudgmental fashion in order train one’s mind to organize itself via compassion and activate soothingsystem as a key affect regulator.

It involves mindful practice of compassion focusing via attention, thinking, behaviour and feeling that involves:

Process

Imagery

Goals


Compassion work

Compassion Work

Uses many CBT, MI and other therapy ‘change agents’ including: Socratic approach, guided discovery, collaboration, psycho-education, looking a things from different points of view, behavioral experiments, exposure, reflections ‘homeworks’ but with a focus on development and becoming – compassion (mentality) focused

Much ‘in vivo’ work and experiencing via exercises


Types of affect systems1

Types of Affect Systems

Affiliative focused

Soothing/safeness

Opiates (?)

Incentive/resource focused

Seeking and behaviour activating

Dopamine (?)

.

Threat-focused

safety seeking

Activating/inhibiting

Serotonin (?)


Types of affect systems2

Types of Affect Systems

Affiliative focused

Soothing/safeness

Opiates (?)

Incentive/resource focused

Seeking and behaviour activating

Dopamine (?)

Threat-focused

safety seeking

Activating/inhibiting

Serotonin (?)

.


Definitions of compassion

Definitions of Compassion

Ethical Behaviour

Patience

Concentration

Compassion

Generosity

Buddhist As loving kindness; open heartedness

‘deep feeling and understanding of the suffering of others associated with a deep commitment and responsibility to try to alleviate it’

Effort

Wisdom

Develop the Perfections (Paramitas - to carry across –oceans of suffering to enlightenment)


Definitions of compassion1

Definitions of Compassion

Buddhist As loving kindness; open heartedness

‘deep feeling and understanding of the suffering of others associated with a deep commitment and responsibility to try to alleviate it’

Aristotle’s view suggested three key cognitive elements to summarised as:

The first cognitive element of compassion is a belief or appraisal that the suffering is serious rather than trivial. The second is the belief that the person does not deserve the suffering. The third is the belief that the possibilities of the person who experiences the emotions are similar to the sufferer (Nassbaum 2003 p. 36)

Page33


Other views of compassion

Other Views of Compassion

Definitions stretch back to Buddhism and Aristotle: suffering as non- trivial; non-deserved. and one can have empathy

McKay & Fanning (1992)

understanding, acceptance and forgiveness

Neff (2003)

Kindness-warmth

Common humanity

Mindfulness-Non-judgemental

Gilbert (1989, 2000, 2005)

A mental orientation that combines various, care focused

qualities of mind and is dependent on those qualities


Compassion as flow

Compassion as Flow

Different practices for each

Other Self

SelfOther

Self Self

Non linear empathy for other begins early in life


Compassion and the promotion of well being and growth

Compassion and the promotion of well-being and growth

Caring focused on well being

The provision of guidance, protection and care for the purpose of fostering developmental change congruent with the expected potential of the object of nurturance (Fogel et al., 1986)

Awareness of need to nurture

Motivation to nurture

Expression of nurturance

Choice of object

Fluid alteration of nurturance to fit object of nurturance


Components of compassion from the care giving mentality

Components of compassionfrom the care giving mentality

Sympathy

Distress sensitive

Compassion

Care for well being

Distress tolerant

Non-judgement

Empathy

Create opportunities for growth and change With Warmth


Opening to compassion

Opening to Compassion

Care for well-being Desire to heal, commitment and responsibility. Consider benefits of “if I could.” Kind of self one would like to be (self-identity). Focus on feelings of kindness and warmth as emotions to develop and practice

Distress sensitivity: Often blocked by fear of distress or hostile emotions, and depth of distress and negative beliefs about emotions (see Leahy paper)

Explore and educate on the power of rumination


Opening to compassion1

Opening to Compassion

Sympathy explain sympathy, explore fear of being emotionally moved by (one’s) distress and fear of grieving, or acknowledging hostile emotions. Explore negative beliefs about sympathy

Distress tolerance de-shame distress, not one’s fault, common humanity. Address fear of emotions, Practice mindfulness and acceptance. Forgiveness

Empathy Deepening one’s understanding of our minds. Common humanity. Problems as unintended efforts at self-protection - automatic nature. Linking to personal history and making sense of feelings and self-attacking


Opening to compassion2

Opening to Compassion

Non judgement:to give up self-condemning, shift from shame and submissiveness to acceptance and responsibility. Articulate preferences

What are the Greatest fears in making the shift in each component


Multi modal compassionate mind training

Multi-Modal Compassionate Mind Training

SKILLS -TRAINING

Warmth

Warmth

Imagery

ATTRIBUTES

Attention

Reasoning

Sympathy

Sensitivity

Distress tolerance

Compassion

Care for well-being

Feeling

Behaviour

Empathy

Non-Judgement

Sensory

Warmth

Warmth


Types of affect regulator systems3

Types of Affect Regulator Systems

Content, safe, connect

Drive, excite, vitality

Affiliative focused

Soothing/safeness

Opiates (?)

Incentive/resource focused

Seeking and behaviour activating

Dopamine (?)

Threat-focused

safety seeking

Activating/inhibiting

Serotonin (?)

Anger, anxiety, disgust


Compassion and the three circles

Compassion and The Three Circles

Balancing the mind – insight – kindness and courage

Understanding sources of suffering and the path to the alleviation of suffering (broken leg)

Understand the sources of flourishing and the path to contentment - joyful giving, facilitating, charity

Father Christmas and boundary setting


Understanding soothing what we can do for each other and ourselves

Understanding soothing – what we can do for each other and ourselves

Social referencing - able to trust others

Existing positively in the minds of others

Being heard and understood

Validation

Reasoning

Desensitisation to the feared – enhancing courage


Starting basic skills

Starting Basic Skills

Clarify direction of travel

Doing what for why

Compassionate motivations, compassionate attention, compassionate thinking, compassionate behaviour, and compassionate feeling


Compassion

Compassion

Discuss the components of compassion and that each one might take practice ( maybe in stages)

Emphasise the importance of empathy for distress including self-attacking. Acceptance and compassion grow from genuine understanding - especially of safety behaviours –Recognise when patient tries to minimise distress with rationalisation

Empathy for distress often grows naturally from the work you have done on safety behaviours


Compassionate focus

When generating alternatives one is trying to work with different processing systems –stimulating a care-focused mentality

Empathy for distress – standing back

* What would compassionate motives look like?

* What would compassionate ‘attention’ attend to or

focus on?

* What would compassionate ‘thinking’ ‘think/reflect?

* How could you take compassion into behaviour?

* Reflecting on these ideas and actions; how could you

bring warmth into the experience of them?

Compassionate Focus


Compassion focus

Compassion Focus

Looking at a person’s alternative thoughts or behaviours or choice of homework

Ask

* How might this be an example of compassionate motivation, attention, thinking, behaviour and give it feeling

* Stay with alternative(s) until a new feeling emerges

* What might be (was) difficult to do

* How might the self critic respond?


Compassionate focus1

Compassionate Focus

Designed to stimulate different (care-based) affects, thoughts and role relationships with self

What would help you feel supported

What would you say/do to someone you care for

What would like some who cared for you to say/do

Use examples and education to build insight and desire to use rational compassionate approach –can see the point


Thought feeling focusing

Thought-feeling focusing

When you have generated some alternatives - focus on staying with them until affect changes –

DO NOT rely on logic/evidence alone to produce change

Give plenty of time for feeling the difference

You can stay with visualising each alternative and imagine how that feels

Dissolving - fading via practice rather than challenging-convincing


Workshop outline7

Workshop Outline

Stage 2

  • Considering the Nature of Self Compassion

  • Compassionate Mind Training

  • Deepening Self-Compassion

  • Fear of Compassion


Compassion imagery

Compassion Imagery

Using imagery to access and work with soothing systems and the interactions between threat and soothing systems


Why develop compassionate imagery

Powerful way to access affect systems

Quickly reveals affect blocks and fears (but should be helpful not overwhelming)

Provides new sensory based experiences to work with other, threat-based ones

Uses a form of theory of mind – another mind ‘with you’

Re-focuses attention

A different way of ‘thinking’ of alternatives as co-constructed, and affect/compassion focused

Why Develop Compassionate Imagery


Preparing for imagery

Preparing for Imagery

Preparing the body – breathing – find the rhythm of one’s own soothing - not that long – minute or so – then longer if possible.

Body posture

Fear of engaging may need to switch to sensory focus (e.g., tennis ball)

Intrusions of thoughts and feelings – normalise and teach ‘with kindness to just return the attention’


Safe place imagery

Safe Place Imagery

Explain that imagery is fleeting - offering glimpses and fragments - it is the feelings that are important

The focus on feeling safe and soothed in a place (also to feel ‘joyful’ if the person finds that helpful)

Focus on all the senses

Imagine the place is pleased/happy to see you and you have sense of welcome and belonging


Long history to use of compassionate imagery

Long history to use of compassionate imagery

Buddhist loving kindness imagery

Sequences: Bodhisavattas having developed the ideal qualities of compassion – to identify with and copy – non judgement just observation (see Vessantara (1993) Meeting the Buddha's)

Compassion Mediation cycle

Imaging the Compassion Buddha; harnessing the compassionate energies of the universe; directing the compassion to you; the Buddha merging with you – becoming the Compassion Buddha - directing compassion back into the universe for all living things – To explore each position and what ‘comes up’ in one’s mind, reflect and develop one’s mind

(See chapter in by Rimpoche and Mullen in Gilbert 2005; )


Types of compassionate imagery

Types of Compassionate Imagery

Guided Memory

Recall feelings when someone was kind to you

Recall feelings of you being kind to others

Guided Fantasy

The ideal compassionate self

The ideal compassionate other (unique vs given)

human verse non-human

Keep in mind all the time: Fear of feeling compassion for self


Imagining the self compassionate part of self assuming a role

Imagining the self-compassionate part of self - Assuming a role

Now for a moment, imagine that a self-supporting, or compassionate part of yourself could be thought about as a person. Imagine becoming that person. Think of the ideal qualities you would like to have as a compassionate person. It does not matter if you are actually like this. Think about your age and appearance, your facial expressions and postures, you inner emotions of say gentleness – create a half or slight smile that conveys this. Now like an actor about to take on a part feel yourself into these. For this moment you are a compassionate person


Imagery self compassionate part of self

Imagery: Self-Compassionate Part of Self

Can have properties of:

Friendliness

Soft - light

Acceptance, warmth, support

Focus on what is helpful


Imagining the self compassionate part of self assuming a role1

Imagining the self-compassionate part of self - Assuming a role

Learn to practice each day

Remind oneself of the self one would like to be or become today.

Compassionate walking, breathing voice tones, facial expression, thoughts

Smile and forgiveness when one’s anger, in-patience and anxiety gets the upper hand – back to principle propose is ‘to be happy and free from suffering and help others be happy and free from suffering’


Other focused compassion

Other-Focused Compassion

Sit comfortably in chair with soothing rhythm breathing. Work on getting into the compassion role. Now imagine focusing on ‘desire for others to be happy and free from suffering’. (This can start off with people one knows and then extend outwards to eventually all sentient beings). Imagine facial expressions and voice tones.

Explore people’s experience - reflection/meditation.

Explore the value of compassionate self or compassionate imagery in generating and feeling the desire within oneself for others ‘to be happy and free from suffering’.

Explore blocks, fears and facilitators.


Self focused compassion

Self-focused Compassion

Sit comfortably in a chair with soothing rhythm breathing and imagine focusing on ‘desire to be happy and free from suffering’.

Explore people’s experience of that reflection/meditation.

Explore the value of compassionate self or compassionate imagery in experiencing the desire within oneself ‘to be happy and free from suffering’.

Explore blocks, fears and facilitators.


Imagining the compassionate other

Explain point of Compassionate-other imagery work

Inner helper, perfect nurturer (D.Lee), inner guide, access to self-soothing system through relating (no different in principle to activating any other system e.g., sexual – these systems were designed for social interactions – social mentality theory)

“Now for a moment, focus on your breathing and try to feel body rhythm. Can you look down or close your eyes and imagine your ideal caring other for you.”

Or build for someone else - a child:

Useful specific questions: would they be old or young, male or female colour of their eyes, tall or short – more than one

Imagining the Compassionate Other


Relational process

Relational Process

Self

Qualities of Source

Kindness

Wisdom

Strength

Warmth

Non-judgement

(Common-humanity)

Understanding

Distress

Growth

.

Warmth

Acceptance


Other focused compassion1

Other-Focused Compassion

Act of creating one (what one would like for one) is a step on compassion focusing

Find the type of image and form of relationship that fits for the person – images usually change

This can be an Inner: Nurturer, Guide, Friend, Mentor, Fellow Traveller; Bodhisattva, Ideal Compassionate Other

Exercise: to focus on, write about, paint - create image or ‘sense of’ ideal compassionate other’ Notice feelings and thoughts arising during the exercise. Mindful approach


Developing image with half smile soothing breathing

Developing image –with half smile –soothing breathing

Idealcaring and compassionate image --- define ideal as everything you would want, need

Caring as a genuine desire for one’s well-being

Wisdom a sentient mind who understands the struggles of humanity and self. Empathic stance, self-transcendent

Strength as fortitude, endurance but can be power too

Warmth affiliation, genuine care, gentle smile

Non-Judgementas no criticism , curiosity


Hand on heart and soothing

Hand on Heart and Soothing

When distressed or at other times - sitting or standing

take a few breaths to notice soothing rhythm

Place hand over centre of the chest

Imagine caring compassionate energy for one’s hand going through one’s chest fill that area and soothing the heart are

As the person focuses on this they may find their hand feels hot

The is an attention reallocation and affect switching technique


Imagining connetedness

Some people have problems with imaging other people in a compassionate role –can’t trust them – so you can use a non-personal image. For example

imagine a sea in front of you that is a beautiful blue, is warm and calm, lapping on a sandy shore. Imagine that you are standing just in the water with the water lapping gently at your feet. Now as you look out over the sea to the horizon imagine that this sea has been here for millions of years, was a source of life. It has seen many things in the history of life and knows many things. Now imagine the sea has complete acceptance for you, that is knows of your struggles and pain. Allow yourself to feel connected to the sea, its power and wisdom in complete acceptance of you

Imagining Connetedness


Point of imagery

Powerful way to access affect systems

Quickly reveals affect blocks and fears

Provides new sensory based experiences to work with other, threat-based, ones

Uses a form of theory of mind – another mind ‘with you’

Re-focuses attention (work on sensory qualities)

A different way of ‘thinking’ of alternatives as co-constructed and affect/compassion focused

Point of Imagery


Use of compassionate imagery

Able to teach basic relaxation as a preparation for imagery

As it can involve working of inner ‘productions’ of the mind need to be away of:

Passive/overwhelmed

Engaging with but used for controlling and regulating

Engaging with accepting and exploring

Engaging in order to develop new insights and practice for activating different parts of the self

Taylor it for individual patient –

especially in regard to self practice

Use of compassionate imagery


Compassionate reframe

Compassionate Reframe

Focus on your breathing

Now bring compassionate image to mind

Focus on sensory qualities (trying to access care-focused mentality)

What would your compassion part/image say?

How do they see this situation?

What opportunities for growth and change might be here?

What is a compassionate thing to do now?


Imagery practice experience

Imagery Practice Experience

Focusing on your image

can you feel warmth for you – what does that feel like?

can you feel empathic understanding for you – what does that feel like?

can you feel acceptance for you – what does that feel like?

can you feel strength for you – what does that feel like?

Really focus on image generating and staying with affect


Imagery experience

Imagery Experience

Images are created within one’s own mind. They are therefore part of us and by practicing them we may practice developing part of us

Note the arising and the fading of the image as products of our minds. Letting go the image.

But like a muscle, because we are unaware of it or are not using it does not mean it is not there.

Can build mindfulness around compassionate focusing – noticing, observing, not trying


Re evaluating

Re-Evaluating

Third chair practising

Compassionate thinking

Compassionate attention

Compassionate behaviour

Compassionate letter writing


Compassionate letter writing

Compassionate Letter Writing

Ideal caring self (even if one does not have those qualities) – or compassionate ideal image

Clarify point of the exercise and why its worth a go – as a behavioural experiment,

Focus on caring part of self – to put in that mode or frame of mind for ‘thinking/feeling’

Work through guided letter outline

Note: many letters will not be very compassionate an first so discuss and explore how they are felt


Compassion focused therapy derby december 2008

  • Expresses concern and genuine caring,

  • Sensitive to the person’s distress and needs

  • Sympathetic and is emotionally moved by, in tune with their distress

  • Helps them to become more mindful and tolerant of their feelings

  • Helps them become more understanding and reflective of their feelings, behaviours, difficulties and dilemmas

  • It is non-judgment/condemning

  • A genuine sense of warmth understanding and caring permeate the whole letter

  • Generates genuinely compassionate helpful encouraging attention memories thinking and feelings – what do they feel like? Are the “experienced as helpful”

  • Helps them think about the behaviour they may need to attempt in order to move forward

    The point of these letters is not just to focus on difficult feelings but to help people stand back and reflect empathically on, be open with feelings and thoughts, and develop a compassionate and balanced ways of working with them. They will not offer advice or should etc.


Example 1 compassionate letter

Example 1: Compassionate Letter

It is understandable that you been having a difficult time and continue to do so, things have been tough. You have had more of your share of negative things happen to you but it is time to change things for the better. You can’t suffer like this forever. You have a nice flat, a loving family and a couple of good friends. You have support from people , more than other people. Remember there are so many people worse off than you. Some people in Africa have nothing. They don’t expect to have anything they just accept things. Learn from them. Remember you have a lot to be grateful for. You are a kind person and that will never change. You need to look after yourself


Example 2a compassionate letter

Example 2A: Compassionate Letter

I am so sad you have had a difficult time and continue to struggle. Your sadness is understandable. You have had many negative experiences. This has resulted in anxieties and thoughts about being different. You then became depressed.

When you have a difficult time I understand why you want to hide away, but although this helps it also makes you feel more isolated. It is going to be really difficult but it may be a help to talk to other people and connect with them. This may help your mood.


Example 2b compassionate letter

Example 2B: Compassionate Letter

Other people get like this, you are not alone and shouldn’t feel as though you need to hide away. You have an inner strength and should remember that. You are kind and caring and maybe it would help to practice to turn that kindness on yourself so you can feel the warmth.

NOTE: Sometimes people will write as if from someone else using ‘you’. Sometimes they will write as ‘I’. Clarify that with people and what they would find helpful and why.


Compassion for self attacking 1

Compassion for self-attacking 1

Sit quietly for a few moments with soothing breathing and focus on becoming your compassionate self (e.g, with the facial expressions and sense self expanding)

Now with that sense of you, your wisdom, strength and warmth, imagine your self-critical part in front of you.

See its facial expression and note the feeling arising in it -now just feel compassion for that self-critical part of your _hold you own self compassionate facial expression

Watch what happens

If you feel you (or client) are being pulled into the thinking an feeling of the critic just pull back an refocus on the feelings of the compassionate self


Compassion for self attacking 2

Compassion for self-attacking 2

Sit quietly for a few moments and allow your compassionate image and sense of self to come to mind

Now with that image with you, with its wisdom, strength and warmth, imagine yourself as linked - as if on the same team with the same desires and qualities –linking to self-identity –hold the compassionate expression

Now imagine you both seek to heal your threatened or self-attacking part of you. Be mindful of your self attacking thoughts, just allowing them, and try as best you can to stay in your compassionate position


Cautions of attacking critic

Cautions of Attacking Critic

Standing up to inner-critic and working with memories of ‘critical other’ can be very helpful (especially if linked to memories of critical others Hackmann, 2005)

However if just internal

* Can model a ‘power solution’ –amygdala focused

* Often less need to directly ‘take on’ critic – but build new focus of self

* People can keep (SC) safety behaviours for as long as they think they need them – no pressure to change

* Compassion for fear behind, and function of, critic will often help to change/soften it.


Fear of compassion very common

Fear of Compassionvery common

Operates at implicit and explicit levels


Conditioning2

Conditioning

Care seeking systems can become conditioned to threat rather than safeness. If it happens early people may not recall specific memories but experience confusing feelings in close relationships

Care seeking Punishment

Anxiety

Implications for sensory memories and co-ordination of soothing systems


Conditioning3

Conditioning

Care seeking systems can become conditioned to threat rather than safeness. If happens early, people may not recall specific memories but experience confusing feelings in close relationships

Care seeking No response

shut down

Implications for sensory memories and co-ordination of soothing systems


Threatening compassion focus

Threatening CompassionFocus

Attachment system

Emotion-memory

Self –other roles/scenes

Kindness

Anger

Anxiety

Shut down


Kindness attachment and threat

Kindness, Attachment and Threat

Kindness from therapist or imagery

Activate attachment system

Activate memories

Fight, flight

shut down

Fight, flight

shut down

Neglect

aloneness

Abuse, shame vulnerable

Activatelearnt and current defences - cortisol


Blocks to compassion focus occur at both the automatic and metacognitive level

Blocks to Compassion Focus occur at both the automatic and metacognitive level

Overwhelming sadness or panic-- so may need to spend a long time developing capacity to tolerate grief and feelings of warmth

Can’t create or hold image – mindful/allowing

Meta-cognitive blocks

Compassion is weak, easily beaten down, or dangerous

Forgiveness is weak, wont achieve anything

Bullies are resistant – address their safety agendas

Responsibility for practice, practice practice


Empowerment and courage

Empowerment and Courage

Common blocks when client struggles or does not really want to be compassionate May want to fight or gain revenge but is fearful

Can use rescripting with assertive enactments

(See Hackmann 2005, in Gilbert 2005 )

Compassion my get stuck if the anger and needs for working through all the issues with anger are not addressed – so we back to compassion as courage and not submissive – Some compassion Buddha’s

and images are actuallyquite fierce!

(Vessantara (1993) Meeting the Buddha's. See also Leighton, 2003


Courage and trauma

Courage and trauma

When shame and self-criticism are linked to trauma memory then there are a variety of interventions for rescripting (see Lee 2005 in Gilbert 2005)

You can adapt these with using the compassionate self and compassionate images – but do not under-estimate the need for courageous and assertive response-development

Discuss with client - be open about courage and how to develop it – the advantages of ‘direction of travel and goal – the ‘point of the work’


What have we learnt

What have we learnt?

How might this workshop affect your practice?

What are your take home key points?

What would you like to develop?

Affect self-identity as a person and therapist

Beyond techniques – way of being with self and others


Conclusion and key points

Conclusion and Key points

CFT is an integrated biopsychosocial model – not a specific process model

Basic structure is around the three affect regulation systems

Without the ability to access the sense of soothing -safeness (calm mind) various interventions might lack emotional impact in the long term

Each system is complex and can be a target for a range interventions

Understand the power of shame to disrupt the balance of the three affect regulation system -and focus sense of ‘self as a social agent’ on threat

CFT uses stress the role of compassion in the multiple interventions (motivational emotional attention cognitive and behavioural) derived from Western and Easter approaches to change and development

Neuro physiotherapy for the mind – key is top practice the exercises – therapists would ideally have their own practice

CMT can be more than symptom reduction but can also become a focus for long term development and sense of self


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