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Advances in psychiatric treatment (2009), vol. 15, 199–208  doi: 10.1192/apt.bp.107.

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Introducing compassion-focused ARTICLE

therapy
Paul Gilbert

therapy adopts the philosophy that our under­ Paul Gilbert is Professor of Clinical
Summary Psychology at the University of
standing of psychological and neurophysiological
Shame and self-criticism are transdiagnostic prob­ Derby and consultant psychologist
processes is developing at such a rapid pace that we at Derbyshire Mental Health
lems. People who experience them may struggle to
are now moving beyond ‘schools of psychotherapy’ Services NHS Trust. He is a Fellow
feel relieved, reassured or safe. Research suggests of the British Psychological Society
towards a more integrated, biopsycho­social science
that a specialised affect regulation sys­tem (or sys­ and has been actively researching
tems) underpins feelings of reassurance, safeness of psycho­t herapy (Gilbert 2009).
shame-related processes in mood
and well-being. It is believed to have evolved with disorders and compassion as a focus
attachment systems and, in particular, the ability Clinical focus for therapeutic interventions. He is
to register and respond with calming and a sense currently seeking research monies
Compassion-focused therapy and compassionate for appropriate trials.
of well-being to being cared for. In compassion- mind training arose from a number of observations. Correspondence  Professor Paul
focused therapy it is hypothesised that this affect First, people with high levels of shame and self- Gilbert, Mental Health Research
regulation system is poorly accessible in people with Unit, Kingsway Hospital, Derby
criticism can have enormous difficulty in being
high shame and self-criticism, in whom the ‘threat’ DE22 3LZ, UK. E-mail: p.gilbert@
kind to themselves, feeling self-warmth or being
affect regulation system dominates orientation to derby.ac.uk
their inner and outer worlds. Compassion-focused self-compassionate.
therapy is an integrated and multimodal approach Second, it has long been known that problems
that draws from evolutionary, social, developmental of shame and self-criticism are often rooted in
and Buddhist psychology, and neuro­s cience. histories of abuse, bullying, high expressed emo­
One of its key concerns is to use compassionate tion in the family, neglect and/or lack of affection
mind training to help people develop and work (Kaufman 1989; Andrews 1998; Schore 1998).
with experiences of inner warmth, safeness and Individuals subjected to early experiences of this
soothing, via compassion and self-compassion. type can become highly sensitive to threats of
Declaration of interest rejection or criticism from the outside world and
None. can quickly become self-attacking: they experience
both their external and internal worlds as easily
turning hostile.
The healing properties of compassion have been Third, it has been recognised that working with
written about for centuries. The Dalai Lama often shame and self-criticism requires a thera­peutic
stresses that if you want others to be happy – focus focus on memories of such early experiences
on compassion; if you want to be happy yourself (Kaufman 1989; Schore 1998; Brewin 2003,
– focus on compassion (Dalai Lama 1995, 2001). 2006; Gilbert 2005b). This work can overlap
Although all clinicians agree that compassion is substantially with the therapeutic interventions
central to the doctor–patient and therapist–client developed for trauma (Lee 2005; Ogden 2006; Van
relationship, recently the components of com­ der Hart 2006; Wheatley 2007).
passion have been looked at through the lens And fourth, there are clients who engage with
of Western psychological science and research the cognitive and behavioural tasks of a therapy,
(Gilbert 2000, 2005a, 2009; Davidson 2002; Neff and become skilled at generating (say) alternatives
2003a,b). Compassion can be thought of as a skill for their negative thoughts and beliefs, but who
that one can train in, with in­c reasing evidence still do poorly in therapy (Rector 2000). They are
that focusing on and practising com­passion can likely to say, ‘I understand the logic of my alterna­
influence neurophysiological and immune systems tive thinking but it doesn’t really help me feel much
(Davidson 2003; Lutz 2008). Compassion-focused better’ or ‘I know I’m not to blame for the abuse but
therapy refers to the under­pinning theory and I still feel that I am’. A key element of compassion-
process of applying a compassion model to psy­ focused therapy is related to the observation that
chotherapy. Compassionate mind training refers to individuals prone to high levels of shame and
specific activities designed to develop compassion­ self-criticism can find it very difficult to generate
ate attributes and skills, particularly those that feelings of cosntentment, safeness or warmth in
influence affect regula­t ion. Compassion-focused their relationships with others and themselves.

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1192/apt. Its function is to notice threats other. strategies can involve combinations of styles of thinking. ‘jumping to conclusions’) protection systems. ‘better regulation system (Depue 2005): threat and safe than sorry’. fight. behaving and feeling. What are the affect • Stimuli impinging on organisms must be checked out systems that enable us to feel reassured. behaviours (e. These are not by any means the only way result of an interaction between genes and learning our emotional regulation system can be mapped • Response options within the threat protection system and conceptualised. (Linehan 1993. connect and to avoidance in the face of interpersonal conflict (Gilbert 2005a. disgust historically plot and validate the functions and ori­ gins of safety strategies (partly to de-shame them) fig 1 Affect regulation systems. creating confusion in various ways (Panksepp 1998). but they offer • Brain states choreographed from the threat protection a useful heuristic for clinical thinking. These feelings ripple and inhibiting both fight and flight. 199–208  doi: 10. being passive as anxiety. increasingly well understood (LeDoux 1998. with permission of Routledge. plays a role in the functioning of the ‘threat as conditioned and perhaps conflicting responses. 2007). 2009). submission) and cognitive biases (e. early life events may have sensitised the individual’s flight and submission (Marks 1987. 1. flight. Gilbert 2001). In compassion- through our bodies. It is difficult to engage in both fight and quickly (through attention-focusing and attention. alerting and urging us to take focused therapy. The behavioural outputs include fight.and underdevelopment of sensitivities in threat- protection underpin many psychopathologies Threat and protection All living things have evolved with basic threat- detection and protection systems (Box 1). 2007. protection system’ (Caspi 2006). vol. Such strategies can Incentive/resource increase their vulnerability to anxiety and de­ focused Affiliative focused Seeking and Soothing/safeness pression.107. These predispose them to than sorry’ (Gilbert 1998) it is easily conditioned being aware of the rank. leading to the development The genetic and synaptic regulation of serotonin of safety strategies that can operate automatically. drive.g. we can distinguish at least three types of emotion freeze. Van der Hart 2006. to engaging in appeasing behaviours. 200 Advances in psychiatric treatment (2009). excite.g. as inferior. soothing to certain kinds of threats and operate a better safe and safeness systems. and contentment. anxiety. threat protection system. Anger. Partly because For example. for example. vitality Content. The clinician will identify. some people have well-developed sub­ the system is programmed in favour of ‘better safe missive safety strategies.. status and power of others (Rosen 1998) and is the source of many aspects of in relation to them­selves. to being quick to feel socially anxious and un­certain. The The smooth operation of the threat protection neurophysiology of this system in humans is system may be difficult. to perceiving them­selves psychopathology. 2005a.005264 . resource-seeking and • Threat protection systems have evolved to be attuned excitement systems. anxiety. flight behaviour at the same time. Ogden 2006. into the neurophysiology of emotion suggests that anger.bp. Sensitised strategies and phenotypes for threat Threat-focused Safety-seeking detection and protection can become major influ­ Activating/inhibiting ences on the ways in which a person perceives and Serotonin (?) navigates their world. content for potential threat and safe. 15.g. because. Drive. A simple system can bias other processing systems depiction of their interaction is given in Fig. and submissive biasing) and then give us bursts of feeling such behaviour may involve staying put. So in the evolution­ Dopamine (?) ary model. I will explore each of these in than sorry policy turn and their relationship to compassion-focused • Sensitivity and response to specific threats are the therapy. lower their self-esteem and interfere with behaviour-activating Opiate (?) their ability to pursue life goals. The formulation explores how ourselves. From Gilbert (2005a). anger or disgust. and they can be subdivided can conflict. safe. many of its response options conflict with each Panksepp 1998). clinicians explain and ex­plore action to do something about the threat – to protect this with clients. or to register human warmth? Research • Mammalian defences include a menu of emotions (e. disgust).Gilbert Evolution and the neurosciences Box 1 Threat protection systems One way of approaching this problem is to focus on the evolved functions that underpin certain types • All living things have evolved threat-detection and of feeling and styles of social relating (Gilbert protection systems 1989. • Over..

especially when we toms are ‘not their fault’ but have often emerged are driven to avoid negative events. Introducing compassion-focused therapy Gilbert 2007).1192/apt. The function of this goal things (e. responsibility and learning to cope with them. The positive emotions of the system they are likely to stimulate. material possessions reflection on the fact that they needed to develop and achievement in order to feel safe and avoid these safety strategies. 15.107. vol. Is there disappointment or an attack on self system in humans (Box 2) is to give us positive or others? Some individuals have a self-identity feelings that energise and guide us to seek out goal to be ‘nice and liked’. In compassion-focused therapy the striving’ mind that is mindful and compassion focus is on understanding the functions of a per­ focused (Dalai Lama 2001). In compassion-focused therapy. In Buddhist contentment system (Box 3) are very different from psychology. feeling energised and even ‘hyped up’. subordination or inferiority. pass an exam or get to go out with a desired person. soothing and social safeness can have feelings of excitement and pleasure. In Buddhism • When animals are not threatened and not seeking happiness comes from cultivating a calm ‘non. The first aspects of compassion grow Interaction of the two systems out of this part of the formulation because it helps The drive system and the threat protection system the client recognise that their pathology and symp­ can be linked in complex ways. Depue & Morrone- once individuals stop criticising. • It underpins the development of desires and some goals safeness and social-connectedness. Animals need emotion and motivational systems creating feelings of loss of positive affect and moti­ that direct them towards important rewards and vation (Gilbert 2007). sexual oppor­ explores the function of the client’s goals and how tunities. resources and achievements. (Depue 2005). Some begin to develop compassionate and validating individuals pursue status.bp.g. thoughts competitiveness and working to avoid rejection or feelings. blaming them­selves for their symptoms. friendships). These include food. If we win a competition. positive affects and sense of well-being.g. to be constantly achieving. threats and dangers. ‘oughts’ and ‘musts’. condemning and Strupinsky (2005) suggest that status-seeking. In Drive and excitement depression there is a toning down of the system. of desires’ that guides us to important life goals and if this fails they can become self-critical. contentment Box 2 The drive system is not just the absence of threat • The evolution of attachment behaviour utilised the • This system motivates and directs us to important contentment system. nest sites. system may be called ‘social safeness’ seeking status or fame) • The contentment/social safeness system is internally • It is an activating system highly stimulated by certain wired to act as a regulator of the threat protection and drugs drive systems • The positive emotions flowing from this system are • Compassion-focused therapy and compassionate mind often the focus of Western psychology and materialistic training are directed at facilitating development of the cultures soothing and social safeness system Advances in psychiatric treatment (2009). territories and so the individual reacts if they stumble or fail to reach forth. they are freer to move towards taking are all linked to the drive system. resources they can become content • Contentment is associated with a positive ‘calm’. So the function of the drive and excitement them. they may enter states of content­­ people take cocaine or amphetamine this is the ment (Depue 2005). This is an approach also feelings of rejection. it is a ‘system is to win affection and avoid rejection and conflict. If sufficient resources. There is increasing concern that modern societies overstimulate the drive system (Pani 2000). 199–208  doi: 10. This aspect of the – both material and those linked to self-esteem (e. sex. From here it is possible to in thoughts of ‘shoulds’. Compassion-focused therapy resources. feelings associated with this system are linked to or deal with. and enabled signals of caring resources and kindness to have soothing qualities that activate • It is a source of anticipation and pleasure positive affects linked to feelings of well-being. food. which shows up with safety strategies. and they have arousal. son’s symptoms and difficulties in terms of safety strategies. alliances. well developed in dialectical behavioural therapy They may feel the need to prove themselves and (Linehan 1993). positive feelings linked to this type of system of achievement and satisfying desires can give us pleasures but not happiness because Box 3 The contentment system our pleasure feelings are dependent on acquiring rewards. we Contentment. The When animals are not having to be attentive to.005264 201 .

therapy. to tolerate soothed and calmed within relationships (Carter and feel safe with what is explored in the therapy.1192/apt. 1998. Caring-affiliation operates through an opiate the drive and threat protection systems. The caring behaviour of the parent. is helped to develop an internal compassionate oversimplifications of complex processes. that struggling to feel soothed. 15. 2007. acceptance and threat (dis)stress in the individual receiving and being cared for. Individuals find it difficult to feel content or safe within themselves and in inter­ Sensitivity personal relationships. self-criticism. 2007. has a soothing effect system find it hard to feel reassured or calmed/ on the infant’s physiology. For quiescence – a state of ‘not-seeking’. soothed when they generate (believable) alternative focused therapy integrates findings and concepts thoughts or engage in helpful behaviours. Depue 2005). in fear circuits of the amygdala (Kirsch 2005). a person may have received more threats is not just the absence of threat or low activity in from their parents than soothing. Contentment example. and thus soothing overarousal interpersonal cues of social safeness. It is also key to the regulation of care.bp. Rather. trust and feeling safeness in their interactions with them. Thus. 2005a. this system is particularly sensitive to safeness system. This requires harnessing the motivation to be Heightened sensitivity and overactivity of the caring for the purpose of alleviating distress and threat protection and/or drive systems is a com­ facilitating the flourishing and development of the mon problem in people with high shame and target of the caring. compassion. may develop anxious or avoidant attachment Depue & Morrone-Strupinsky (2005) point out and inter­p ersonal styles (Mikulincer 2007). 199–208  doi: 10. Thus. A common one is that it ated with a sense of peacefulness. Contentment is associ­ many reasons for this.Gilbert those of the drive system. 2009). Thus. the The neurophysiology and evolutionary concepts therapist instils them in the client. It is believed Care for well-being that these three systems can become unbalanced. they form a foundation for compassion-focused condemning and self-critical one (Box 4). It is also linked to social affiliation. and rebalancing them is one of the goals of therapy. 2009). there is increasing evidence that it reduces sensitivity. it is clear why compassion- in close interpersonal relationships and soothe each focused therapy focuses on the development of other. this can leave the individual to be a particular system. Central to compassion-focused therapy is Balancing the systems compassionate mind training: by demonstrating the skills and attributes of compassion (Fig. evolutionary and modifications in mammals to allow them to engage neurophysiology model. they mediates feelings of well-being and contentment. Wang and to replace self-criticism with self-kindness 2005). linked to the opiates. 2005a. from attachment research (Bowlby 1969.005264 . Individuals who cannot access this especially physical proximity. 2). According to the principles The individual is sensitive to distress and needs. Oxytocin is a neurohormone role of the therapist is to help the client experience linked to feelings of affiliation. In consequence. especially to socially threatening Working compassionately stimuli. the soothing system and able to recognise and distinguish the feelings is in­suf­ficiently accessible to them. in which the therapist’s formulations and thoughts are organised around three affect regulation The attributes of compassion systems (Panksepp 1998. attributes and skills (Gilbert 1989. the client outlined in the previous sections are. How­ev­ relation­­ship with themselves to replace the blaming. I have previously referred to this system Compassion and its components may be defined as a social safeness system linked to affection and in many ways. and calming. Uväns-Morberg 1998. Gilbert 2005a. 202 Advances in psychiatric treatment (2009). both of which have soothing properties com­­passion is understood in terms of specific (Gilbert 1989. and (Gilbert 2007). of course. well-being and has been under­stimulated during early life. social. vol. Depue 2005. There may be and needs of the target of their caring. As we of caring behaviour in stimulating the soothing and have seen. the and oxytocin system.107. The key point is to recognise the importance the social safeness system in the therapy. that the contentment system has been significantly Compassion-focused therapy proposes that it is the developed with the evolution of attachment soothing system that also provides a sense of relief behaviour. In compassion-focused therapy kindness. Mikulincer 2007). of compassion-focused therapy. As attachment the threat protection system. Porges (2007) has The social safeness/soothing system written extensively on the way the sympathetic and as a focus in the therapy parasympathetic nervous systems have undergone Given this developmental. er. there seems research has shown.

probed about the emotional textures of their criticising.107. Indeed. 199–208  doi: 10. shaming or rejecting. therapeutic interventions that focus on thoughts. therapist In compassion-focused therapy. Introducing compassion-focused therapy Sympathy Warmth Skills of Warmth Having sympathy involves being emotionally compassion moved by the feelings and distress of the target of Imagery their caring. shocked or (inner ring) and the skills training required to develop them (outer ring). Therapists should moment ‘as it is’. feelings and behaviours (Mace 2007. well-being compassion tolerance Non- Distress tolerance Empathy Behaviour judgement Feeling Having distress tolerance means being able to contain. the associated with warmth. fearfully Sensation Warmth Warmth divert from. kindness to others or previous coping. (2009) with permission of Constable and Robinson. Compassionate attention Compassionate attention is the focusing of our attention in a way that helps and supports us. Williams Non-judgement 2007).005264 203 . Clients are Advances in psychiatric treatment (2009). If we attributes of compassion are in conflict with someone. rather than avoid. this does not mean we explore whether clients are trying to force or do not have preferences. and safe. we often overlook • The client experiences their interaction with the the things that we like about them: by refocusing therapist as one that is de-shaming. the therapist • The therapist helps the client to develop compassionate focuses on identify­i ng the client’s strengths.bp. stay with and tolerate complex and high levels of emotion. It is particularly important to teach the client to use these skills on themselves. clients with high shame judgement does not mean non-preference. From Gilbert frightened by the client’s emotions or. • The therapist uses the skills and expresses the or it might involve compassionate imagery. Empathy The skills of compassion Feeling empathy involves working to understand The skills of compassion involve creating feelings the meanings. In the therapeutic relationship this Reasoning means that the client is able to experience the Sensitivity Sympathy therapist as being emotionally engaged with their Attention story as opposed to being emotionally passive or Care for Attributes of Distress distant. compassionate our attention we can regain a more balanced view. People can be ability to stand back from and understand our own taught to engage mindfully with a whole range of thoughts and feelings. in contrast to being very much prefer the world to be less cruel and supportive and encouraging of their own efforts more compassionate. and from. support and kindness. The client experiences the therapist as able to contain their own emotions and the client’s fig 2 Multimodal compassionate mind training: the key aspects and attributes of compassion emotions. The therapist is not alarmed. ideally. For Box 4 The three aspects of compassionate therapeutic engagement example. For and self-criticism often reveal that they use a cold. example. functions and origins of another of warmth. vol.1192/apt. contradict. it may involve remembering times when we were kind to others or others were kind to us. they contain it and act in an appropriate way. Self-empathy is the to many other psychotherapies. When Being non-judgemental means not condemning. The Dalai Lama would bully themselves to change. However. close down. non- efforts to help themselves. these can be highly to do so. invalidate or deny them. such as their courage. pursued life goals. attributes and skills directed at the self positive attributes or skills. kindness and support in a range person’s inner world so that one can see it from of activities which are (like the attributes of their point of view. Empathy takes effort in a compassion) essentially multimodal and common way that sympathy does not. if they are. 15. However. non-judgement is important in Buddhist bullying or aggressive inner tone to try to change psychology where we learn to experience the their thoughts and behaviours. the client will experience each of the The experience of refocusing attention needs to be attributes and skills of compassion in.

assertive rather than submissive: it also seeks to stimulate positive affect processing. warm tone positive qualities. All the time the client is taught to use Therapists can also teach attention-directing warmth. and development. system will be focused on problems and potential Compassion-focused therapy is not just about difficulties. Lee 2005). exploring feelings as a compassionate intervention. dialectical behavioural they are unfamiliar and the individual feels ‘off therapy (Linehan 1993) and mentalising (Fonagy guard’. focused therapy the therapist encourages the client In many psychopathologies. The client may. thoughts. This is a repetition of what would normally happen For example. compassion-focused therapy. Behavioural tasks encouraging exposure 2006) we have a range of interventions to help people to positive emotions can help the client to learn develop more balanced reasoning. their facial expressions. for courage is important in compassion-focused example. Compassion. Shame rewarding effort and in which many believe that and self-critical thinking are clearly targets in ‘second is not good enough. compassion and gentleness as a reference exercises linked to the savouring of experiences. explore what their ideal compassionate therapy – indeed. The therapist guides the client requires clear collaboration on ‘the new behaviour’ through such imagery exercises. where the parent spend time appreciating the taste of their food. clients learn to itself. and acknowledges and validates clients’ emotions and to appreciate that rather than focusing on how far personal meanings.1192/apt. supportive and helpful.bp. So. The Compassionate imagery therapist teaches the problems of certain types of The technique of using compassionate imagery rumination and how to substitute compassionate involves a series of exercises that help the client refocusing in one’s thinking. Logic is not enough: Following behavioural traditions. In cognitive emotions can feel threatening because (in part) therapy (Beck 1979). In distress and facilitating develop­ment and growth. the threat protection to take this orientation to themselves. There have been many approaches to developing Compassionate behaviour compassionate feelings by using imager y Compassionate behaviour is focused on alleviating (Frederick 1999. their future and their sense of self. 199–208  doi: 10. vol. rather than task-focused is also important. to enjoy experiencing them (fear of compassion is focused therapists build on these interventions discussed in a separate section below). giving courage. whereby the therapist listens warmly. we are living in ruminate and reflect on their current mood a society that has become more contemptuous of states. Helping the client to have courage their voice tones. 15. but it is important to came second?’ understand the functions of self-critical thinking and the fears people may have of giving it up. no matter how small. These images are is undertaken in the spirit of compassionate usually fleeting and never clear in the mind. the word encouraging means other might look like. The process of the therapy rather than their results. Some clients Compassionate reasoning have developed a fear of enjoying themselves or Compassionate thinking involves how we reason doing nice things for themselves and positive about the world.107. Exposure work associated with various images. is important for this (Linehan short they fall from their goal. Unfortunately. or is encouraging and supportive. point to move into the more frightening activities. Leighton 2003.005264 . the therapist works This does not mean avoiding engaging with to help the client create and explore their image difficult or painful realities or behavioural tasks: of their ‘ideal’ of compassion. when the individual the therapist advises the client of this. In compassion- the colours of the sky or a certain style of music. generate compassionate feelings for themselves. who remembers who compassion-focused therapy. Thus. effort appreciation. compassion- ‘evidence’ is secondary to the experience of being focused therapy helps people focus on their efforts helped and supported.Gilbert taught to pay attention and bring to mind their they will try to create an encouraging. and self-critical clients have never learnt this Particularly important is how people reason. Many high-shame 1993). an individual may be encouraged to within a parent–child relationship. ourselves and others. and working on those aspects of self. but also devote a lot of time to ensuring that Helping people become more process-focused clients experience alternative thoughts as kind. and individuals can therefore benefit counter­acting threat-based processing or devel­ from practising the refocusing of their attention oping different defences such as learning to be and liberating it from this dominance. for example. to develop the client’s appreciation and gratitude. attend to their effort. Sometimes has to engage in difficult or frightening behaviour clients prefer non-human images such as an 204 Advances in psychiatric treatment (2009). perhaps by revisiting positive in their minds associated with the supportive memories.

just imagining a lovely meal & Fanning (1992) view self-compassion as under­ (internal signal) can have the same physiological standing. focusing for ourselves we may be able to stimulate and develop the contentment. those signals stimulate particular systems in experiencing compassion from others and being self. Indeed. Definitions of self-compassion. These too must be physiological power of our thoughts. vol. if we did not have those systems we compassionate. voice tones protection system and stress reactions. psychological disorders has gained recent research if we are hungry and we see a lovely meal (external interest. as angry with them when things did not go well.1192/apt. The therapist asks the client to consider wisdom. memories and imagined as sentient. for others and for the self. acceptance and forgiveness. opposed to being some ‘higher being’ outside of Usually. and styles of thinking. But equally we constructs related to kindness. soothing The importance of self-compassion and safeness system. behaviour and imagery. The self-esteem cognitive therapists McKay flowing. compassion from others. Common humanity Advances in psychiatric treatment (2009). From there the therapist can person. common humanity can just fantasise.107. focusing/ruminating on self-criticism role. 199–208  doi: 10. facial expressions. Neff (2003a. strength. attention. leads straight to the re-focus on compassion. Introducing compassion-focused therapy animal. undermining their confidence. The clear examples that the tones and ways of thinking. safe and relieved. examples. This is like method acting.bp. voice and anxious states. By working with and developing would not experience those feelings.b) this can stimulate release of hormones from the sees compassion as consisting of three bipolar pituitary to give sexual arousal. Clients can be encouraged to self-criticism can be so constant in a person’s practise each day at becoming ‘the compassionate mind that it literally harasses them into depressed self’. kindness and support. with the appropriate facial expressions. Compassionate sensation kindness and gentleness from others (in contrast Compassionate sensation refers to the way the to bullying. a tree or a mountain. If we see something sexual on the television psychology and Buddhist tradition. The client imagines themselves as a highly or bringing to mind times when they have been compassionate person and explores their sense of criticised or put down will stimulate the threat age. different parts of the brain. however. the idea of training Compassion-focused therapy follows a behavioural the brain to think and feel certain things as a way approach in suggesting that internal thoughts and of stimulating physiological systems is now well images can act just as external stimuli do. Kindness involves understanding stimulate the pituitary to the same effect. It also thinking. This is because bodies when they focus on being compassionate. Time spent clarifying the way our internal As noted throughout. one’s difficulties and being kind and warm in the The therapist shares such facts with the client face of failure or set-backs rather than harshly because they provide strong insight into the judgemental and self-critical. To demonstrate and explore this with clients the therapist might draw Definitions and the evidence base a simple outline of the brain and discuss the effects Self-focused compassion as a way of alleviating of both external and internal signals. using very concrete the therapeutic relationship and focused attention. 15. clients are able to identify feelings of human experience. For example. criticism and put-down) we feel much therapist helps the client to explore feelings in their more soothed. for example via different physiological systems. body postures. Indeed. It follows these skills. using our own imagination to and mindfulness. images and warmth. compassion-focused therapy tries to therefore that if we can practise generating these help the client create within themselves feelings of (compassionate) types of thoughts. images and memories can stimulate generated in a number of ways. anxiety and depression and can recognise that this There are also exercises related to body postures is because critical signals stimulate their threat and imagining oneself as a deeply compassionate protection system. the brain. when one help the client understand how switching to self- practises adopting and getting into a particular criticism. signal) this can start our saliva and stomach acids vary.005264 205 . with specific qualities of images. From a social effect. The therapist points out that if we receive understanding. Equally. compassionate feelings are thoughts. becoming been through similar situations to themselves. how they would feel if someone kept putting them Clients often like to imagine that their image has down. therapist has already given of how thoughts and images can stimulate physiological systems enable Compassionate feeling the client to appreciate the potential power of their Compassionate feeling relates to experiencing own self-criticism. warmth and non-judgement. activating established (Begley 2007). can pay off in the long term.

1192/apt. and connectedness that have a direct soothing effect In fact. 15. feelings rather than trying to force them away or As mentioned above. It also (especially a therapist) will reactivate the attach­ draws on many other therapeutic models that have ment system (Mikulincer 2007). In Shame: Interpersonal associated with closeness or shame of closeness. Compassion-focused therapy focuses on beliefs about compassion. 199–208  doi: 10. may all be easier to engage in if some compassion work is undertaken before or at the same time as the Fear of compassion exposures and reworking. self-esteem tends to increase when we become lazy. rather than being focused on backgrounds. self-esteem can give us a sense of favourable therapist is constantly exploring the interactions comparison with others. As for all developments a caring other.g. particularly those from harsh how our minds work. including the activation of powerful References sadness and grief. our similarities and common humanity with others. and pointed out that particular type of emotion towards the self that compassion may also require courage and direct can loosely be called self-warmth or self-kindness. isolating and resistances are worked through. Mayhew 2008). they may also and shaming. are key to the future of compassion-focused therapy. some clients have negative deny them. The compassion-focused therapist will help to Although there are limited data on the value of the normalise. 2007). Various therapies the value of training people in self-compassion in address this in different ways (Brewin 2003. Moreover. 2007. much of the work in compassion-focused on the threat protection system (e.005264 . There may be many reasons for this. self-compassion focuses on generating a of compassion in therapy. conditioned emotions of abuse Andrews B (1998) Shame and childhood abuse. feelings or memories. Ogden both student (Leary 2007) and clinical populations 2006. of warmth and kindness in therapy can ignite There is a long tradition of compassion- considerable sadness and grief. Kirsch. evolutionary kindness and compassion from another person and Buddhist psychology. whereas that they will be punished for self-compassion by self-compassion is important when we are doing ‘paying for it later’ or having it taken away. 2005). model or process. B Andrews): 176– These individuals can be among the most difficult 90.Gilbert involves seeing one’s experiences as part of the to help develop self-compassion. unpleasant or unlovable. and neuro­science. This usually indicates a fear of A number of researchers have focused on the dif­ developing or experiencing self-compassion. 2006.107. or not deserved. Gilbert 2005b. Self-kindness too can be the skills and attributes of compassion as depicted viewed with suspicion. therapy addresses people’s fears and resist­a nces to becoming self-compassionate and some­t imes to Conclusions becoming forgiving and compassionate to others. outcome and process research even disassociate from the pain of their grief. compassion is Many clients cannot easily access the soothing and designed to stimulate feelings of safeness. contain and work with those approach (Gilbert 2006. Oxford University Press.b. Some think are doing well. In a recent study we found that some people still much to do to attract funding to research its find compassion-focused imagery physiologically efficacy. Compassion-focused therapy is an integrated therapy Attachment theorists suggest that signals of that draws from social. for high-shame and psychotherapy based on research and understanding self-critical people. This is ‘distress focused interventions in Buddhist psychology and calling’ and despair as the social safeness system compassion-focused therapy has been profoundly recognises that there may (now) be a response from influenced by that tradition. engagement in exposure to threatening and feared There is limited but increasing research showing situations. there is feelings. validate. Mayhew 2008). stressful (Rockliff 2008). yet once their fears human condition rather than as personal. Compassion-focused therapy and feelings within the attachment system may is in the traditions that seek to build a science of come to the fore. developmental. where we think in terms between the functions of self-criticism and the fear of social rank. 206 Advances in psychiatric treatment (2009).bp. but they (Gilbert 2006. the beginning of the experience a particular school. Psychopathology and Culture (eds P Gilbert. Behavior. In this article I have underlined the importance Crucially. afraid that if they give up self-criticism they will For example. whereas self-compassion focuses on and avoidance of self-compassion. The badly. Wheatley. When that developed interventions for specific types of mental happens the (complex and unresolved) memories health problems. Leary 2007). 2. as being soft. Some clients are overwhelmed or in psychotherapy. vol. self-indulgent in Fig. Commonly. Van der Hart. succeeding or achieving. mindful acceptance involves mindful gain greatly from compassionate mind training – awareness and acceptance of painful thoughts and although we await research evidence for this. warmth social safeness system that under­pins compassion. ferences between self-compassion and self-esteem Exploration might reveal that the individual is (Neff 2003a.

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005264 . 15.1192/apt. vol.bp. 4 Compassion-focused therapy teaches 2 Compassion-focused therapy is derived people to: from: a avoid things they find difficult a Freud’s theory of the Oedipal complex b practise generating feelings of warmth for b evolutionary theory themselves c forensic psychology c find ways to threaten their internal self-critic d anxiety management d rely on logic to regulate emotion e studies of anger management.107.Gilbert MCQs 3 Formulation in compassion-focused 5 Compassion-focused therapy uses 1 Compassion-focused therapy was therapy is focused on: analogies of: developed for: a identifying maladaptive schema a every cloud has a silver lining a obsessive–compulsive disorder b revealing unconscious conflicts b physiotherapy for the mind b shame and self-criticism c linking background fears to safety strategies c disassociating oneself from difficulties c fear of flying d only current problems d the ends justifying the means d depersonalisation e identifying behavioural deficits. 208 Advances in psychiatric treatment (2009). e always express their feelings. e hypomania. 199–208  doi: 10. e all’s well that ends well.