1. Compassion Focused Therapy for Psychosis

2. What is Compassion? Gilbert defines the essence of compassion as “a basic kindness, with deep awareness of the suffering of oneself and of other living things, coupled with the wish and effort to relieve it” (2009, p. xiii). Compassion also includes the idea of balance, which can be tricky: Compassion for those who need care, and for the caretaker Compassion for the parts of the self that feel attacked, and for the attacker Slide by Paul Gilbert

3. Contrast self-compassion to self-esteem Self-Esteem Access when things going well Individuality/differenceAchievement/doing/drive Competitive mentality Self-Compassion Access when not going well Common humanity Acceptance/being/content Caring mentality Slide by Paul Gilbert

4. 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. Slide by Paul Gilbert

5. 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 thoughtsWe 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.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) Slide by Paul Gilbert

6. Slide by Christine Braehler

8. Threat Relations Conflicts of Strategies Dominant Submissive Care- Seeking blocks blocks blocks Each strategy can have a variety of forms, functions, behaviours and memories Slide by Paul Gilbert

9. 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. Slide by Paul Gilbert

10. Background Others as Critical, absent, frightening, blaming Key fears/Memories Hurt, rejection, ‘being to blame’ aloneness Safety Strategies Threat focused Inhibit, submit avoid anger Be as others want Unintended Cs Feel worthless Controlled by others Loose sense of self -alone Ruminate on emptiness Ruminate on emptiness Self-attack, access shame memories Concealing Confused, depressed angry, dissociate fragment Develop feeling compassion for background and safety strategies Understanding our minds, not our fault Compassionate acceptance and integration of multi-self Compassion imagery, focus (e.g. attention, behaviour) and reframe Slide by Paul Gilbert

11. The Core of Recovery from Psychosis “ “unbearable affect is at the core of psychosis and …. recovery involves the processes of acknowledging, bearing, and putting in perspective the intolerable emotions which often have their origins in early development.” From Gumley, A., Braehler, C., Laithwaite, H., MacBeth, A., & Gilbert, P. A Compassion Focused Model of Recovery after Psychosis. International Journal of Cognitive Therapy, 3(2), 186-201. doi: 10.1521/ijct.2010.3.2.186 Slide by Paul Gilbert

12. Slide by Christine Braehler

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

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

18. Slide by Christine Braehler

20. 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 Slide by Paul Gilbert

21. Turning It Around When we suffer, we often feel more separate from others –But if we turn it around, we can see the suffering itself as evidence of our common humanity –People have learned to see their suffering as evidence of shameful differences, for example of having a “mental illness” that separates them from others Normalizing helps reconnect with common humanity, reduce shame

22. So, Basic Philosophy is That: We all just find ourselves here with a brain, emotions and sense of (socially made) self we did not choose but have to figure out Life involves dealing with tragedies (threats, losses, diseases, decay, death) and people do the best they can Much of what goes on in our minds is not of ‘our design’ and not our fault We are all in the same boat De-pathologising and de-labelling – understanding unique coping processes Slide by Paul Gilbert

23. A Few Questions When can compassion and soothing be a threat, rather than helpful? Who are those most likely to see compassion and soothing as a threat? Does compassion always feel good, or can it lead to feeling increased pain and distress? What can be done when compassion itself is experienced as a threat?

24. Kindness, Attachment and Threat Kindness from therapist or imagery Activate attachment system Activate memories Neglectaloneness Abuse, shame vulnerable Activate learnt and current defences - cortisol Fight, flight shut down Fight, flight shut down Slide by Paul Gilbert

25. Integrating Compassion with Wisdom Wisdom involves developing discretion around when to let the threat system do its job, and when to invoke soothing Compassion supports wise choices about when to invoke which system Appreciate limits to knowledge, uncertainty –Frame attempts to create more compassion as experiments Because people are unique, can’t be sure what will be helpful

26. “Experience the Practice for Yourself First!”

27. Long history to use of compassionate imagery Buddhist loving kindness imagery Sequences: Bodhisavattas having developed the ideal qualities of compassion – to identify with and copy – non judgement just observation (see Vessantara (1993) Meeting the Buddha's Sequences: Bodhisavattas having developed the ideal qualities of compassion – to identify with and copy – non judgement just observation (see Vessantara (1993) Meeting the Buddha's) Compassion Mediation cycle Imaging the Compassion Buddha; harnessing the compassionate energies of the universe; directing the compassion to you; the Buddha merging with you – becoming the Compassion Buddha - directing compassion back into the universe for all living things – To explore each position and what ‘comes up’ in one’s mind, reflect and develop one’s mind (See chapter in by Rimpoche and Mullen in Gilbert 2005; ) Slide by Paul Gilbert

28. Developing Compassion Images Ideal caring and compassionate self and/or image --- define ideal as everything you would want, need Wisdom a sentient mind who understands the struggles of humanity and self. Empathic stance, self-transcendentWisdom a sentient mind who understands the struggles of humanity and self. Empathic stance, self-transcendent Strength as ‘calm authority’ fortitude, endurance, complete benevolenceStrength as ‘calm authority’ fortitude, endurance, complete benevolence Caring as a genuine desire for one’s well- being –Commitment and motivationCaring as a genuine desire for one’s well- being –Commitment and motivation Slide by Paul Gilbert

29. Other-Focused Compassion Sit comfortably in chair with soothing rhythm breathing. Work on getting into the compassion role. Now imagine focusing on ‘desire for others to be happy and free from suffering’. (This can start off with people one knows and then extend outwards to eventually all sentient beings). Imagine facial expressions and voice tones. Explore people’s experience - reflection/meditation. Explore the value of compassionate self or compassionate imagery in generating and feeling the desire within oneself for others ‘to be happy and free from suffering’. Explore blocks, fears and facilitators. Slide by Paul Gilbert

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

31. Extending Compassion to “Enemies” Enemies can be internal, like voices, critical parts Distinguish compassion from submission, or “losing” One way of framing this: –Desiring the other to be happy and free from suffering “in a good way” This carries with it the idea of balance, –aiming for the other to be well but not at the expense of oneself

32. Compassionate Writing Exercises Pick a difficult event or issue –Write about it from a compassionate frame Focus on your breathingFocus on your breathing Now bring compassionate image to mindNow bring compassionate image to mind Focus on sensory qualities (trying to access care-focused mentality)Focus on sensory qualities (trying to access care-focused mentality) What would your compassion part/image say?What would your compassion part/image say? How do they see this situation?How do they see this situation? What opportunities for growth and change might be here?What opportunities for growth and change might be here? What is a compassionate thing to do now?What is a compassionate thing to do now?

33. 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? Slide by Paul Gilbert

34. Slide by Christine Braehler