Compassion-Focused-Therapy Model and Research Paul Gilbert, Kirsten McEwan, Corinne Gale & Jean Gilbert Mental Health Research Unit, Kingsway Hospital, Derby UK www: Compassionatemind.co.uk

Talk Today Outline basic philosophy and model of Compassion focused Therapy Note the powerful effects of our self- evaluation systems (self-criticism vs self compassion) Explore the main therapeutic work as overcoming the fear of compassion and self compassions 2

To understand ourselves we must understand our brains

What happens when new brain is recruited to pursue old brain passions? why we have complex brains and minds that are difficult to understand regulate 1. Old Brain Emotions: Anger, anxiety, sadness, joy, lust Behaviours: Fight, flight, withdraw, engage Relationships: Sex, status, attachment, tribalism 2. New Brain Imagination, fantasise, look back and forward, plan, ruminate Integration of mental abilities Self-awareness, self-identity, and self-feeling 3. Social Brain Need for affection and care Socially responsive, self-experience and motives What happens when new brain is recruited to pursue old brain passions? 4

Sources of behaviour Interaction of old and new psychologies New Brain: Imagination, Planning, Rumination, Integration Old Brain: Emotions, Motives, Relationship Seeking-Creating Archetypal

Understanding our Motives and Emotions Motives evolved because they help animals to survive and leave genes behind Emotions guide us to our goals and respond if we are succeeding or threatened There are three types of emotion regulation Those that focus on threat and self-protection Those that focus on doing and achieving Those that focus on contentment and feeling safe

Types of Affect Regulator Systems Content, safe, connected Drive, excite, vitality Non-wanting/ Affiliative focused Safeness-kindness Soothing Incentive/resource- focused Wanting, pursuing, achieving, consuming Activating Threat-focused Protection and Safety-seeking Activating/inhibiting Anger, anxiety, disgust

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

Dispersal and avoid others

Protect and Comfort: Less ‘instinctive brain – post birth learning

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

Affectionate Interactions Secure attachment linked to self-confidence, empathy and use of attachment strategies when stressed (Mikulincer & Shaver 2005) Maturation of the brain (e.g. frontal cortex) and affect regulation (Gerhardt, 2004; Schore, 1994) Effects of low birth weight (Tully et al, 2004. JCCP, 72, 218-226) Testosterone and aggression (Booth et al., 2003. Developmental Psychology, 39, 85 – 98) Self-to-self-relating e.g. self criticism vs self-reassurance

Internal Threat and Soothing Self-affiliation – experiences a lovable self Calms Affiliative/ Soothing Threat Neurophysiological networks Internal representations of helpful others and sources of comfort Emotional memories of soothing

Internal Threat and More threat No self-affiliation – experiences a unlovable self Calms Affiliative/ Soothing Threat Neurophysiological networks Others are threats or alarming Emotional memories of no soothing

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

Compassion Compassion can be defined in many ways: “As a sensitivity to the suffering of self and others with a deep commitment to try to relieve it” Dalai Lama Eight fold path - represents a multi-modal approach for training one’s mind

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

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

Key Targets of Therapy Thinking Reasoning Attention Imagery Fantasy Behaviour Motivation Emotions Their pattern gives rise to a certain type of mind

Compassionate Mind Compassion Thinking Reasoning Attention Imagery Fantasy Compassion Behaviour Motivation Emotions

Threatened Mind can block Compassion Thinking Reasoning Attention Imagery Fantasy Threat Behaviour Motivation Emotions

Self-Critical Mind is also Threat-focused Mind Thinking Reasoning Attention Imagery Fantasy Self- Critical Behaviour Motivation Emotions

How our own thoughts and images affect our brains Sexual Bully-threat Meal Sex Meal Bully- threat Kind, warm and caring Emotion Brain Compassion Soothed Safe Stomach acid Salvia Fearful Depressed Arousal Pink represents our inner images and thoughts

Questions How does self-criticism and self-compassion/ reassurance work in the brain? Are their individual differences linked to trait self- criticism? How might compassion training influence neurophysiology?

fMRI Study (Aston University) STUDY Olivia Longe, Gina Rippon, Paul Gilbert & Frankie Maratos 2X2 Factorial: 2 X Statement Scenarios, 2 X Imagery Perspectives Statements pre-tested (n=12), for imagability (i.e. ease of imagining self-critical or self-reassuring thoughts), 1-7 Likert Scale. Self- Criticize Self- Reassure Self- Criticize Self- Reassure “A third job rejection letter in a row arrives in the post” “The second free local newspaper in a row arrives in the post”. Emotion Scenario(-) Neutral Scenario

Self-Criticism during Emotional Scenarios vs. Neutral Axial slices displaying left lateral PFC (BA 47, 45,9) and right lateral PFC (BA 46) activation Longe, et al (2010). Having a word with yourself: NeuroImage, 49, 1849-1856 27

Self-Reassurance during Emotional Scenarios vs. Neutral Whole brain and axial slices displaying left temporal pole (BA 38) and insula activation Longe, et al (2010). Having a word with yourself: NeuroImage, 49, 1849-1856 28

Parent recall and SC and SR Irons Gilbert Baldwin et al Parent recall and SC and SR Irons Gilbert Baldwin et al., 2006 Br J Clin Psych .24 (.31) Inadequate Self Rejection .31 (.33) .26 (.60) .15 (.25) Overprotection Depression .22 (.55) Hated Self -.31 (-.56) .37 (.30) Warmth Reassure Self

Parent recall and SC and SR Irons Gilbert Baldwin et al Parent recall and SC and SR Irons Gilbert Baldwin et al., 2006 Br J Clin Psych .24 (.31) Inadequate Self Rejection .31 (.33) .26 (.60) .15 (.25) Overprotection Depression .22 (.55) Hated Self -.31 (-.56) .37 (.30) Warmth Reassure Self

Imagining a self-critical part of self 197 students from Derby and McGill Universities (with Chris Irons and Mark Baldwin) Self-criticism Power Anger 0.53 0.51 Self-reassurance - 0. 33 - 0.33

Imagining a Self-Compassionate Part of Self 197 students from Derby and McGill Universities (with Chris Irons and Mark Baldwin) Self-criticism Power Warm - 0.54 - 0.34 Self-reassurance Power warm 0. 58 0.43 Gilbert et al (2005)

Compassionate Mind Self- Compassionate Thinking Reasoning Attention Imagery Fantasy Self- Compassionate Behaviour Motivation Emotions

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

Internal Threat and Soothing Compassionate imagery Self-Criticism Compassionate Re-focusing Calms Affiliative/ Soothing Threat Worry Rumination Compassionate imagery

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

PROBLEM -Compassion is a threat Compassionate imagery Re-focusing Affiliaitve/Soothing Threat Compassionate imagery Shame-self criticism Mentalizing Fear of closeness Trauma Memory Meta- beliefs

Kindness, Attachment and Threat Kindness from therapist or imagery Activate attachment system Activate memories Fight, flight shut down Fight, flight shut down Neglect aloneness Abuse, shame vulnerable Activate learnt and current defences - cortisol Bowlby: Kindness opens the attachment system and then whatever ever fears, anger or despair is coded there will become available and can be intensely threatening

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

Parasympathetic nerves to heart Slows HR Sympathetic nerves to heart Increases HR and stroke volume

Successive Inter-beat Intervals (ms) 945 897 858 799 821 846 851 879 Standard Deviation of Inter-beat Intervals over 300 second period = SDNN

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

Correlations between change in HRV and self-report scales SDNN Inadequate Self Anxious Attachment -.54* -.48* Depend Attachment Social Safeness .52* .57** * p<.05 ** p <.01

Basic Beliefs and Meta-cognitions Fears of Compassion Basic Beliefs and Meta-cognitions

Fear of Compassion For Others Scale People will take advantage of you if you are too compassionate If I’m too compassionate, others will become too dependent on me I can’t tolerate others distress

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

Fear of Compassion Towards Self Scale I fear that if I develop compassion for myself, I will become someone I don’t want to be I fear that if I am more self-compassionate I will become a weak person I fear that if I start to feel compassion for myself, I will be overcome with loss/grief

Fear of Compassion Data Com for others Com from Others . 47** Self com . 37** . 67**

Fear of Compassion Data C for Others C from Others Self Com Anxiety . 22** . 46** . 44** Dep . 17* . 37** . 40*

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

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

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

Data From Group Study

Data From Group Study

Data From Group Study

Data From Group Study

Data From Group Study

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

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

Mayhew and Gilbert 2008 Three voices hearers with CFT Results showed decreases for all participants in depression, psychoticism, anxiety, paranoia, OCD and interpersonal sensitivity. All participants’ auditory hallucinations became less malevolent, less persecuting and more reassuring

Some other studies Laithwaite et al., (2010) (University of Glasgow) in a study of group based CFT study for 19 clients in a high security psychiatric at Carstairs found “… a large magnitude of change for levels of depression and self-esteem ….. A moderate magnitude of change was found for the social comparison scale and general psychopathology, with a small magnitude of change for shame. These changes were maintained at 6-week follow-up”.

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