Working group for scientific psychotherapy

Compassion Focused Therapy

Compassion Focused Therapy (CFT) was developed by Prof. Paul Gilbert and is of great interest worldwide. Compassion, according to Gilbert, is defined as “sensitivity to one’s own suffering and the suffering of other people, combined with the striving to alleviate this suffering and prevent suffering.” So it’s always about benevolence and empathy as well as strong commitment and competence. This approach can therefore be seamlessly integrated into the concept of balance between acceptance and change developed by M. Linehan.

CFT’s approach is aimed at people who have chronic and complex psychological problems related to low self-esteem and self-criticism and shame. In well-structured exercise units, CFT teaches the skills to acquire the skills to experience inner peace, benevolence and joy in social cooperation – to develop compassion towards yourself and others. CFT represents an independent treatment program, but the interventions can easily be integrated modularly into any individual or group therapy. We have had excellent experiences by enriching the DBT with CFT components.

What is compassion-focused therapy?

Compassion Focused Therapy (CFT) according to Gilbert (2014) is based on the Dalai Lama’s definition, according to which compassion includes “sensitivity to one’s own suffering and the suffering of others, combined with a deep desire to alleviate it or prevent suffering.” In German, the term “compassion” comes closest to this definition. CFT aims to develop compassion for yourself and others and at the same time to be able to better accept the compassion shown to you by other people. In contrast to Mindful Self-Compassion according to Neff and Germer (MSC; Neff & Germer, 2013), which primarily has self-compassion as the target construct of treatment, CFT includes feeling and accepting compassion in exchange with the social environment. Specifically, this means developing a compassionate mind, a repertoire of compassionate skills: the motivation to treat oneself and others with kindness, the sensitivity to one’s own thoughts and feelings and those of others, to be able to accept and tolerate feelings of oneself or others, openness towards to show one’s own suffering and that of others, and to be able to deal with suffering with courage and commitment. It involves a shift from a judgmental, self-critical view to a curiosity about how our brains work, to showing responsibility and commitment to making the best of ourselves or others.

CFT was originally developed on the basis of clinical observations of patients with severe mental disorders who showed little improvement in standard therapeutic procedures and in whom self-criticism and shame were particularly pronounced. Scientific studies have shown that some groups of people have great difficulty in their ability and motivation to develop compassion (Ebert, Edel, Gilbert, & Brüne, 2018; Gilbert et al., 2012; Gilbert, McEwan, Matos, & Rivis, 2011 ; Kelly, Carter, Zuroff, & Borairi, 2013; MacBeth & Gumley, 2012; Xavier, Gouveia, & Cunha, 2016). These groups include individuals who exhibit a variety of characteristics, including: self-harm, self-criticism and shame, insecure attachment, alexithymia, low levels of empathy and mindfulness, increased symptoms of depression and anxiety, rumination tendencies, and eating disorders. Early insecure attachment experiences, neglect, abuse, traumatization, and excessive feelings of shame have been identified as particularly relevant predictors of the development of fear of compassion (e.g., Matos et al., 2017). Against this background, a recent study found that patients with borderline personality disorder in particular have significantly higher levels of self-reported self-criticism and shame as well as fear of self-compassion, compassion for others and from others, both in comparison to healthy comparison persons and to other patient samples (Biermann et al., 2020) Against this background, the implementation of elements from CFT into psychotherapy is of particular importance for this patient group.

Conceptual background:

CFT integrates techniques and concepts from cognitive behavioral therapy, evolutionary and social psychology, developmental psychology as well as Buddhism and neuroscience. The theoretical basis is the assumption of three evolutionary emotion regulation systems: threat/protection, drive and calming. Compassion as an innate safety and coping strategy plays a central role in connection with the calming system. Furthermore, it is assumed that the autonomous nervous system of mammals is hierarchically adapted to the respective security situation, so that a distinction is made between bond building, compassion and care in a safe state, mobilization to fight or flee in a dangerous state, and immobilization, i.e. playing dead when life is in danger. Furthermore, it is assumed that the human brain, due to its different ages of brain structures and their functions, functions according to a “right-of-way principle”, which does not always fit optimally with today’s situations (“tricky brain”), so that it is necessary to develop and train additional calming and Coping strategies are required, such as those developed within the framework of CFT. Given people’s difficulties in developing and cultivating compassion, it is believed that primary attachment experiences create conditioned emotional memories in which the need for reassurance, security, and care is associated with fear, guilt, shame, loneliness, and sadness (Gilbert, 2010; Liotti, 2004). Furthermore, the CFT assumes that a lack of experience with safety, security and care in childhood is associated with an underdeveloped system of security and reassurance, which in turn affects the development of one’s own abilities to feel warmth and security and to feel safe in social relationships as well as effectively regulating one’s own emotions (Gilbert, 2009, 2010; Matos & Pinto-Gouveia, 2014; Porter et al., 2020). For example, research supporting these assumptions suggests that fear of compassion is predictive of lower oxytocin levels in patients with borderline personality disorder (Ebert et al., 2018). Consequently, in CFT, engaging in compassionate experiences or behaviors is thought to be associated with fears of being viewed as weak or complacent, of being judged or rejected for compassionate efforts, of becoming overly excited or overwhelmed by the needs of others, or being exploited or manipulated by others (Gilbert & Mascaro,2017; Vitaliano, Zhang, & Scanlan, 2003).

Contents of the CFT:

In CFT, participants develop an understanding of the complex nature of the human brain and their own “emotional right-of-way rules”. Furthermore, your own “inner critic” and its function are explored and observed. The image of an inner “benevolent companion” is created, which makes compassionate, supportive, inner processes tangible. Self-critical assumptions are observed and compassionate self-encouragement is developed in their place. Strategies for dealing with intense shame are developed, compassion for others and by others, and connection with others are developed. The aim is to learn and cultivate a so-called “compassionate mind”, a compassionate attitude towards yourself and others. The content is addressed in a psychoeducational manner, using mindfulness and imagination exercises, exercises on your own or in role plays with others.

State of research:

Compassion as a psychological concept has gained increasing scientific interest in the last 20 years. A variety of studies have shown that compassion influences emotional processing, that is, attention, processing, memory, and response to emotional stimuli (Kirby, Doty, Petrocchi, & Gilbert, 2017; Seppälä et al., 2017). On a physiological level, these key processes are directly related to the activity of the autonomic sympathetic nervous system, which enables emotion-related action tendencies such as maintaining relationships with other people. The activity of the parasympathetic nervous system is accompanied by appropriate calming and coping strategies. Scientific studies have shown that giving and receiving compassion is physiologically related to heart rate variability (e.g. Cosley, McCoy, Saslow, & Epel, 2010; Kim et al., 2020; Kim et al., 2017; Kirby et al., 2017 ; Matos et al., 2017; Petrocchi et al., 2017; Rockliff, Gilbert, McEwan, Lightman, & Glover 2008), which is linked to blood pressure and cortisol reactivity (Cosley et al., 2010). Compassion training has been found to influence the activation of the amygdala and other brain areas involved in emotional processing and empathy (Derntl et al., 2010; Desbordes et al., 2012; Klimecki, Leiberg, Lamm, & Singer, 2013). On a psychological level, several studies have found significant reductions in anxiety, depression, feelings of inferiority and shame, self-criticism, and fear of compassion as a result of compassion training. These studies also showed significant increases in well-being, positive affect and belonging, feelings of relaxation and security, self-compassion, compassion for and of others (e.g., Gilbert & Procter, 2006; Klimecki, Leiberg, Lamm, & Singer , 2013; Leaviss & Uttley, 2015; Matos et al, 2017; Petrocchi, Ottaviani, & Couyoumdjian, 2017), life satisfaction and well-being (e.g. Barnard & Curry, 2011; Neff & Germer, 2013; Neff, Kirkpatrick, & Rude , 2007; Zessin et al, 2015), an increase in close social relationships (e.g., Yarnell & Neff, 2013), and feelings of social connectedness (e.g., Cozolino, 2006; Crocker & Canevello, 2012; Petrocchi et al. , 2017). Compassion has also recently become the focus of interventions for a range of mental illnesses.A first systematic review of the effectiveness of CFT interventions in clinical samples showed an improvement in psychopathological symptoms, self-compassion, interpersonal and social functioning levels, and quality of life (Leaviss & Uttley, 2015). Against the background of pronounced shame and self-criticism as well as fear of compassion for oneself and others in patients with borderline personality disorder, the feasibility, acceptability and effectiveness of a 12-week group-based CFT intervention with adolescent borderline patients was examined. The results show a high level of acceptance of the intervention among patients, as well as a significant reduction in shame, self-criticism, fear of compassion and the severity of psychopathological symptoms. Due to the large number of group interventions carried out in this context to date, CFT is now part of DBT and DBT-PTSD and its content also fits into the core concepts of acceptance and change.

Bibliography:

Barnard, L.K., & Curry, J.F. (2011). Self-compassion: Conceptualizations, correlates, & interventions. Review of general psychology, 15(4), 289-303.
Biermann, M., Bohus, M., Gilbert, P., Vonderlin, R., Cornelisse, S., Osen, B., … & Kleindienst, N. Psychometric properties of the German version of the fears of compassion scales . Clinical Psychology & Psychotherapy.
Biermann, M., Bohus, M., Gilbert, P., Vonderlin, R., Heser, M., & Lis, S. Shame and self-criticism in BPD. in prep.
Cosley, BJ, McCoy, SK, Saslow, LR, & Epel, ES (2010). Is compassion for others stress buffering? Consequences of compassion and social support for physiological reactivity to stress. Journal of Experimental Social Psychology, 46(5), 816-823.
Cozolino, L. (2006). The social brain. Psychotherapy in Australia, 12(2), 12.
Crocker, J., & Canevello, A. (2012). Consequences of self-image and compassionate goals Advances in experimental social psychology (Vol. 45, pp. 229-277): Elsevier.
Cunha, M., & Paiva, M.J. (2012). Text anxiety in adolescents: The role of self-criticism and acceptance and mindfulness skills. The Spanish Journal of Psychology, 15(2), 533-543.
Derntl, B., Finkelmeyer, A., Eickhoff, S., Kellermann, T., Falkenberg, DI, Schneider, F., & Habel, U. (2010). Multidimensional assessment of empathic abilities: neural correlates and gender differences. Psychoneuroendocrinology, 35(1), 67-82.
Desbordes, G., Negi, LT, Pace, TW, Wallace, BA, Raison, CL, & Schwartz, EL (2012). Effects of mindful-attention and compassion meditation training on amygdala response to emotional stimuli in an ordinary, non-meditative state. Frontiers in human neuroscience, 6, 292.
Ebert, A., Edel, MA, Gilbert, P., & Brüne, M. (2018). Endogenous oxytocin is associated with the experience of compassion and recalled upbringing in Borderline Personality Disorder. Depression and anxiety, 35(1), 50-57.
Gilbert, P. (2010). An introduction to compassion focused therapy in cognitive behavior therapy. International Journal of Cognitive Therapy, 3(2), 97-112.
Gilbert, P. (2014). The origins and nature of compassion focused therapy. British Journal of Clinical Psychology, 53(1), 6-41.
Gilbert, P., Clarke, M., Hempel, S., Miles, J.N., & Irons, C. (2004). Criticizing and reassuring oneself: An exploration of forms, styles and reasons in female students. British Journal of Clinical Psychology, 43(1), 31-50.
Gilbert, P., & Mascaro, J. (2017). Compassion: Fears, blocks, and resistances: An evolutionary investigation. The Oxford handbook of compassion science, 399-420.
Gilbert, P., McEwan, K., Gibbons, L., Chotai, S., Duarte, J., & Matos, M. (2012). Fears of compassion and happiness in relation to alexithymia, mindfulness, and self-criticism. Psychology and Psychotherapy: Theory, Research and Practice, 85(4), 374-390.
Gilbert, P., McEwan, K., Matos, M., & Rivis, A. (2011). Fears of compassion: Development of three self-report measures. Psychology and Psychotherapy: Theory, Research and Practice, 84(3), 239-255.
Gilbert, P., & Procter, S. (2006). Compassionate mind training for people with high shame and self-criticism: Overview and pilot study of a group therapy approach. Clinical Psychology & Psychotherapy: An International Journal of Theory & Practice, 13(6), 353-379.
Kelly, AC, Carter, JC, Zuroff, DC, & Borairi, S. (2013). Self-compassion and fear of self-compassion interact to predict response to eating disorders treatment: A preliminary investigation. Psychotherapy Research, 23(3), 252-264.
Kim, JJ, Parker, SL, Doty, JR, Cunnington, R, Gilbert, P, & Kirby, JN (2020). Neurophysiological and behavioral markers of compassion. Scientific Reports, 10(1), 1-9.
Kirby, J. N., Doty, J. R., Petrocchi, N., & Gilbert, P. (2017). The current and future role of heart rate variability for assessing and training compassion. Frontiers in public health, 5, 40.
Klimecki, OM, Leiberg, S., Lamm, C., & Singer, T. (2013). Functional neural plasticity and associated changes in positive affect after compassion training. Cerebral cortex, 23(7), 1552-1561.
Leaviss, J., & Uttley, L. (2015). Psychotherapeutic benefits of compassion-focused therapy: An early systematic review. Psychological medicine, 45(5), 927-945.
Liotti, G. (2004). Trauma, dissociation, and disorganized attachment: three strands of a single braid. Psychotherapy: Theory, research, practice, training, 41(4), 472.
MacBeth, A., & Gumley, A. (2012). Exploring compassion: A meta-analysis of the association between self-compassion and psychopathology. Clinical psychology review, 32(6), 545-552.
Matos, M., Duarte, C., & Pinto-Gouveia, J. (2015). Constructing a self protected against shame: The importance of warmth and safety memories and feelings on the association between shame memories and depression. International Journal of Psychology and Psychological Therapy, 15, 317-335.
Matos, M., Duarte, C., Duarte, J., Pinto-Gouveia, J., Petrocchi, N., Basran, J., & Gilbert, P. (2017). Psychological and physiological effects of compassionate mind training: A pilot randomized controlled study. Mindfulness, 8(6), 1699-1712.
Matos, M., & Pinto-Gouveia, J. (2014). Shamed by a parent or by others: The role of attachment in shame memories relation to depression. International Journal of Psychology and Psychological Therapy,, 14, 217-244.
Matos, M., Pinto‐Gouveia, J., & Gilbert, P. (2013). The effect of shame and shame memories on paranoid ideation and social anxiety. Clinical psychology & psychotherapy, 20(4), 334-349.
Neff, KD, & Germer, CK (2013). A pilot study and randomized controlled trial of the mindful self-compassion program. Journal of clinical psychology, 69(1), 28-44.
Neff, KD, Kirkpatrick, KL, & Rude, SS (2007). Self-compassion and adaptive psychological functioning. Journal of research in personality, 41(1), 139-154.
Petrocchi, N., Ottaviani, C., & Couyoumdjian, A. (2017). Compassion at the mirror: Exposure to a mirror increases the efficacy of a self-compassion manipulation in enhancing soothing positive affect and heart rate variability. The Journal of Positive Psychology, 12(6), 525-536.
Pinto‐Gouveia, J., Castilho, P., Matos, M., & Xavier, A. (2013). Centrality of shame memories and psychopathology: The mediator effect of self-criticism. Clinical Psychology: Science and Practice, 20(3), 323-334.
Porter, C., Palmier‐Claus, J., Branitsky, A., Mansell, W., Warwick, H., & Varese, F. (2020). Childhood adversity and borderline personality disorder: a meta‐analysis. Acta Psychiatrica Scandinavica, 141(1), 6-20.
Rockliff, H., Gilbert, P., McEwan, K., Lightman, S., & Glover, D. (2008). A pilot exploration of heart rate variability and salivary cortisol responses to compassion-focused imagery.
Seppälä, EM, Simon-Thomas, E., Brown, SL, Worline, MC, Cameron, CD, & Doty, JR (2017). The Oxford handbook of compassion science: Oxford University Press.
Vitaliano, P. P., Zhang, J., & Scanlan, J. M. (2003). Is caregiving hazardous to one’s physical health? A meta-analysis. Psychological bulletin, 129(6), 946.
Xavier, A., Gouveia, JP, & Cunha, M. (2016). Non-suicidal self-injury in adolescence: The role of shame, self-criticism and fear of self-compassion. Paper presented at the Child & Youth Care Forum.
Yarnell, L.M., & Neff, K.D. (2013). Self-compassion, interpersonal conflict resolutions, and well-being. Self and Identity, 12(2), 146-159.
Zessin, U., Dickhäuser, O., & Garbade, S. (2015). The relationship between self-compassion and well-being: A meta-analysis. Applied Psychology: Health and Well‐Being, 7(3), 340–364.