Compassion Focused Therapy Derby December 2008

1. Compassion Focused TherapyDerby December 2008 Paul Gilbert PhD FBPsS Mental Health Research Unit, Kingsway Hospital Derby p.gilbert@derby.ac.uk Mary Welford Greater Manchester West Mental Health NHS Foundation Trust mary.welford@gmw.nhs.uk Ken Goss, Ian Lowens, Chris Gillespie & Chris Irons www. compassionatemind.co.uk If you wish to use this material please respect sources

2. 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

3. 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

4. Key Targets of Therapy

5. 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

6. Innate and Acquired (v) Genotype ? (v) Environment = (v) Phenotype � Genotypes are 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

7. 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

8. 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

9. 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

10. 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?

11. Sources of behaviour

12. Humans are an Evolved Species Human Symbolic thought and self, theory of mind, metacognition Mammalian Caring, group, alliance- building, play, status Reptilian Territory, aggression, sex, hunting

13. 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

14. The Challenges 5 Interconnectedness and interdependency Co-operation, sharing, training Tribalism, group loyalties, Submissive following 6. Individual differences Personality Gender Talents Ethnicities 7 Self-to-self-relating Imagination Thinking Self-reflections

16. The Challenges 8 The 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

17. 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

18. Compassion Solutions

19. Key Targets of Therapy

20. Types of Affect Regulator Systems

21. Key Idea Various therapies have developed exposure and other techniques for toning down negative emotions but not for toning up certain 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.

22. 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.

23. 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

24. 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.

25. 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.�

26. 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

27. 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)

28. 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

29. 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

30. 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

31. Two Types of Processing System

32. 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

33. Self-Protection: A Design for Life All organisms are structured for self-protection: Safe --- Not safe

34. Better safe than sorry: Our Minds are designed to easily assume the worst -safer Threat No Yes Run Don�t Run

35. Self-Protection In species without attachment only 1-2% make it 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 fast detection 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

36. Menu of Defensive / Protective Strategies linked to Coordinated set of: Motives Emotions Behaviours Cognitive Processes

37. Self-Protective Motivations/Drives Get or stay safe Damage limitation vs enhancement Hold on to what one has Act to reduce future threat

38. 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

39. 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

40. Menu of Defensive / Protective Cognitive 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

41. Neural Bases of Threat Processing (LeDoux, 1994) Animal studies have shown that the amygdala receives sensory information via two routes: a rapid but crude input from the sensory thalamus (via the amydala) and a a slower but more detailed representation from the sensory cortex. �Snake example & stick analogy� Animal studies have shown that the amygdala receives sensory information via two routes: a rapid but crude input from the sensory thalamus (via the amydala) and a a slower but more detailed representation from the sensory cortex. �Snake example & stick analogy�

43. 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

44. 2) Threat Emotions can set up Conflicts

45. 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.

46. 4) One Protection Strategy Creates Another Express feelings Don�t express feelings Others angry Others ignore Reject my wishes Feel bad Feel bad

47. 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

48. 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

49. Conditioning Care seeking No response shut down

50. 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?

51. 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

52. 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.

53. 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

55. Problems of balance Examples of Threat-protection focused difficulties Triggers, intensity, duration, frequency, coping Emotion containment Impulsiveness Emotional, cognitive and behavioral avoidance Prediction Rumination

56. 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

57. 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

58. 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

59. Overview of an EvolutionaryJourney Attachment Threat Safeness Compassion Mutual support Self -Regulation

60. Qualities of Care

61. 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

62. 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 Safeness creates an inner state that organizes multiple processes Free(dom): To move, to grow, explore, integrate, slow reflective Open attention

63. 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 systems to detect presence and absence Soothing, calming or alerting of affiliative emotion

64. 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�

65. Types of Affect Regulator Systems

66. 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

67. 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

68. 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

69. 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

70. 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

71. 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

72. Key Shame Concepts Exercise 1

73. 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.

74. Strategies for Gaining and Maintaining Rank and Status

75. 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

77. 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

78. 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 (1995 p. 277 ) It is therefore not so much failing to meet standards but the meaning and experience of self from seeking and falling short

79. Types of Affect Regulator Systems

80. 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

81. Threat Responses in Social-Contexts Embarrassment External shame Internal shame Humiliation

82. Types of Negative Self-Conscious Experience: 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.

83. Embarrassment

84. 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.

85. 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

86. Types of Negative Self-Conscious Experience: 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.

87. Types of Negative Self-Conscious Experience: 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

88. Types of Negative Self-Conscious Experience: 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. .

90. 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

91. 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

92. 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

93. 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

94. 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

95. 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.

96. Types of Negative Self-Conscious Experience: 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

97. 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)

98. 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?

99. Shame And Trauma The Co-construction of Self and Other

100. Shame Memories Fuse Multiple Systems: .

101. Associations of threat �meanings� in shame-traumas .

102. Shame experiences - memories can be work like �Trauma�

103. 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. Shame and Therapy

104. 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)

105. 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

106. 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)

107. Self-Attacking in Psychosis 70% of voices are malevolent Commands � sometimes with threats Insults (direct and indirect)

108. 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

109. 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

110. Internalised Self-Attacking and Shame: Self as an object for evaluation Pre-modern Inner demons; possession Freudian Superego � related to internalised parental prohibitions Gestalt Top-dog versus under dog Behavioural Self-punishment Cognitive Self-attacking, self-critic Evolutionary Internalised hostile dominate signal Ideal mismatch Frustrated generated attacks � the unattractive or undesirable self

112. 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.

113. 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)

114. Affects and self-attacking Ideal self Actual 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)

115. 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

116. A Submissive Strategy Powerful Other(s) (Gods) (harmful and/or protective) Appease, submit, comply (sacrifice) Harmful things (still) happen Sense of aloneness Self-monitor Self-Blame May also blame others for non-compliance for upsetting the dominant (Persecute)

117. Submissive functions of SA Live in close proximity to powerful other or powerful other controls threats/access to resources (Gods) Must maintain awareness of where Powerful Other is to in relation to you Self-monitor to work out how to avoid provoking powerful other or losing their support/protection Regulate anger and aggressive behaviour Self-blame and try hard if you fail

119. Imagining the self critical part of self

120. 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

121. 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

122. 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?)

123. 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)

124. 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

125. 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.

126. 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)

127. 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?

128. 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)

129. Types of Affect Systems .

130. 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

131. 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

132. 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

135. 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)

136. 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)

137. 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)

138. 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

139. 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?

140. Compassion Focused TherapyDerby December 2008 Paul Gilbert PhD FBPsS Mental Health Research Unit, Kingsway Hospital Derby p.gilbert@derby.ac.uk Mary Welford Greater Manchester West Mental Health NHS Foundation Trust mary.welford@gmw.nhs.uk Ken Goss, Ian Lowens, Chris Gillespie & Chris Irons www. compassionatemind.co.uk If you wish to use this material please respect sources

141. 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

142. 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

143. 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.

144. Contrast self-compassion to self-esteem

145. 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 soothing system as a key affect regulator. It involves mindful practice of compassion focusing via attention, thinking, behaviour and feeling that involves: Process Imagery Goals

146. 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

147. Types of Affect Systems .

148. Types of Affect Systems .

149. 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�

150. 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

151. 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

152. Compassion as Flow Different practices for each Other Self Self Other Self Self Non linear empathy for other begins early in life

153. 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

154. Components of compassionfrom the care giving mentality

155. 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

156. 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

157. 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

158. Multi-Modal Compassionate Mind Training

159. Types of Affect Regulator Systems

160. 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

161. 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

162. Starting Basic Skills Clarify direction of travel Doing what for why Compassionate motivations, compassionate attention, compassionate thinking, compassionate behaviour, and compassionate feeling

165. 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

166. Compassionate Focus

167. 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?

168. 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

175. 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

176. Workshop Outline Stage 2 Considering the Nature of Self Compassion Compassionate Mind Training Deepening Self-Compassion Fear of Compassion

177. Compassion Imagery Using imagery to access and work with soothing systems and the interactions between threat and soothing systems

178. Why Develop Compassionate Imagery

179. Preparing for Imagery

180. Safe Place Imagery

181. Long history to use of compassionate imagery

182. 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

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

184. Imagery: Self-Compassionate Part of Self Can have properties of: Friendliness Soft - light Acceptance, warmth, support Focus on what is helpful

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

186. Other-Focused Compassion

187. Self-focused Compassion

188. Imagining the Compassionate Other

189. Relational Process .

190. Other-Focused Compassion

191. Developing image �with half smile �soothing breathing Ideal caring 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-Judgement as no criticism , curiosity

192. 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

193. Imagining Connetedness

194. Point of Imagery

195. Use of compassionate imagery

196. 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?

197. 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

198. 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

199. Re-Evaluating Third chair practising Compassionate thinking Compassionate attention Compassionate behaviour Compassionate letter writing

200. Compassionate Letter Writing

201. 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.

202. 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

203. 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.

204. 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.

205. 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

206. 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

207. 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.

208. Fear of Compassionvery common Operates at implicit and explicit levels

209. 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

210. 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

211. Threatening Compassion Focus Kindness

212. Kindness, Attachment and Threat Kindness from therapist or imagery

213. 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

214. 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 actually quite fierce! (Vessantara (1993) Meeting the Buddha's. See also Leighton, 2003

215. 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�

216. 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

217. 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