An Introduction to Compassion Focused Therapy and Compassionate Mind Training

1. An Introduction to Compassion Focused Therapy and Compassionate Mind Training Dr Brett Grellier – Psychology Services Counselling Psychologist Westminster Rough Sleeping Services March 2016

2. Overview of the day • 9.30 – 11am: Background and Theory Applications Interventions • 11 – 11.20am: Coffee Break • 11.20am – 1pm: Therapy Stages 3 circles model • 1 – 2pm: Lunch • 2 – 3.30pm: Development of Compassion Threat & Safety Strategy Formulation Case Studies • 3.30 – 3.50pm: Tea Break • 3.50 – 4.30pm: Compassionate behaviour change Compassionate thought record

3. Compassion pioneers • Paul Gilbert: The Compassionate Mind Approach. • Chris Germer: The Mindful Path to Self-Compassion • Kristen Neff: Guided Self-Compassion. Research professor • Charles Raison: Cognitively-Based Compassion Training. Science of Compassion • Daniel Siegel: Interpersonal Neurobiology • Compassion Focused approaches come under the umbrella of third wave CBT approaches that also includes Acceptance and Commitment Therapy (ACT; Hayes, Strosahl & Wilson, 1999), Mindfulness-Based Cognitive Therapy (MBCT; Segal, Williams and Teasdale, 2002) and Dialectical Behaviour Therapy (DBT; Linehan, 1993)

4. Evidence base • In small scale studies CFT demonstrated to be effective in treatment of depression (shame and self-criticism), emotional regulation problems, eating disorders, anxiety disorders. Emerging evidence that it can be effective in reducing distress for people experiencing psychosis. • Paul Gilbert is currently working towards carrying out RCTs looking at the effectiveness of CFT. • Kristen Neff and Chris Germer (2012). 8 week Mindful Self-Compassion Programme. Increased self-compassion, compassion for others, mindfulness, happiness and life satisfaction and reduced stress, anxiety and depression. All skills maintained at 1 year follow up, with further gains in life satisfaction. • Charles Raison (2011). Compassion practice leads to reduction in IL-6 (cytokine) production and faster cortisol recovery following stressful event – reduces inflammatory responses to psychosocial stressors reducing risk of depression and physical illness such as heart disease and arthritis.

5. Compassion: Definitions • As loving kindness: open-heartedness “deep feeling and understanding of the suffering of self and others with a deep commitment to try to relieve it and prevent it” Dalai Lama • “The ability to experience affiliative emotions” Paul Gilbert • “A feeling of open-heartedness to all senses and sense of intra-dependence” Kristen Neff • “Experience of suffering with a wish to relieve it” Chris Germer

6. Empathy & Compassion Empathy – a competency that links emotional understanding and perspective taking. Compassion – a motivational system that links to sensitivity to suffering with a desire to do something about it.

7. Compassion Focused Therapy (CFT) and Compassionate Mind Training (CMT) • CFT is a CBT approach with particular focus on evolutionary factors (tricky and hard to regulate brain) and classical conditioning. • CFT was developed to target shame and self-criticism • CFT offers a way of focusing therapy, guiding therapeutic interventions especially for the development of self-soothing and self-compassion • Compassionate Mind Training (CMT) refers to the specific training and use of guided exercises to develop compassionate attributes of compassionate motivation, sensitivity, sympathy, distress tolerance, empathy, non-judging and non-condemning.

8. Why CFT? • Often clients understand on rational basis but negative affect remains - CFT works with specific affect regulation systems (“I know it but I don’t feel it”) • Clients with shame and self-criticism often come from harsh backgrounds and find it difficult to feel reassured or safe • CFT focuses on developing people’s abilities to feel inner safeness and self-reassurance as antidote to self-criticalness • Tones up and fosters certain types of positive emotions and well as reducing negative ones

9. Group ExerciseIntuitive wisdom of shame • Think about a shame related event, feeling or fantasy and imagine it? • Now think about speaking about this • My first automatic feelings would be? • Complete the exercise • Key fears • Coping behaviours • What have we learnt from this exercise?

10. Main influences • Interpersonal neurophysiology • Evolutionary theory • Buddhist Psychology • Attachment theory • CBT interventions

11. Evolutionary Theory • Threat-focused system has evolved from older evolutionary structures in the brain, such as the amygdala and the limbic system – Fight/Flight/Freeze • Affiliative-focused behaviours involve an evolved capacity for human beings to feel “safeness” and to feel soothed in the presence of stable, warm , empathic interactions with others. (Gilbert, 2009) • Wang (2005) hypothesises that compassion emerges from an evolutionary determined “species preservative” neurophysiological system, resulting from the need for defenceless young to be cared for in order to survive • Anxiety: Fight/flight/freeze responses to perceived threat • Depression: Loss of social status

12. The Flow of Life We just find ourselves here. • We didn’t choose to be born, nor choose the genes that made us • We didn’t choose our emotions • We didn’t choose our basic temperaments • We didn’t choose our body and how it works • We didn’t choose our basic human desires and needs • We didn’t choose the time in history that we were born

13. Our biological selves • Our minds brains and bodies have evolved over millions of years. • Much of goes on in our mind is not ‘of our design’ and not our fault. • We were designed to feel, want and need certain things. • We are designed for survival not happiness • Both pain and emotion have evolved to protect us, but the can be both difficult to manage.

14. Reptilian Brain • For the reptile, conscious choice is not an option – sensation is the language of the reptilian brain. All behaviours and every movement is instinctual. • It is encoded with the instinctual plans for the behaviours that ensure the survival of the species (self-preservation and reproduction). • All defensive strategies (Fight, Flight, Freeze) are genetically programmed into this primitive and highly effective brain. • Biologically and physiologically, the reptilian brain is essential to all animals, including humans.

15. Mammalian Brain • Mammals have brains that include both a reptilian core and a more elaborate structure known as the limbic brain. • The limbic brain is the primary site of complex emotional and social behaviours lacking in the reptile. • These behaviours do not take the place of instinctual impulses from the reptilian brain, they complement and enhance them – this gives the mammal more choices than the reptile. • Mammals have developed an understanding of their increased survivability as a group. • Emotions give mammals a more highly developed way to store and communicate information.

16. Human Brain • The human brain, known as the neo-cortex, allows us to form thoughts and to develop language. • This allows rational thinking, planning, worrying, ruminating, imagination, self-awareness and self-identity. • Our human (or ‘new brain’) is built by our early relationships and our early environment. We are literally shaped and moulded by our family and what we experience. • In the healthy human instinct, emotion, and intellect work together to create the widest range of choices possible in any given situation. • The interaction between the reptilian, mammalian and human brains can, however, create conflicts within us. They can get stuck in unhelpful loops.

17. Old Brain vs. New brain • Our brains are ‘tricky’ and hard to manage. • Animals don’t worry about the past or the future. • Animals don’t worry about their self-image or getting older. • Animals don’t judge or criticise their own natural responses and experiences as we do.

18. OUR TRICKY BRAINS: ‘OLD’ and ‘NEW’ NEW BRAIN: Imagine, plan, ruminate, self-monitor OLD BRAIN: Motives (harm-avoidance, food, sex, caring, status) Emotions (anger, anxiety, sadness, joy) Behaviours (fight, flight, shut down, caring) The interaction between old and new ‘minds’ can create conflicts within us. It can get us stuck into unhelpful loops

19. Buddhist conceptualisations of Compassion • Karuna – A Pali term that translates as “compassion” that involves a desire to prevent harm from occurring to others and the self. • Metta – “loving kindness” that involves a desire to bring happiness and positive emotional experience to others and the self from the Theravada tradition • Bodhicitta – not easily translated but suggests that all phenomena are inextricably woven and contemplative experience of this sense of connection will eventually result in an altruistic aspiration to work towards the alleviation of suffering for all beings

20. Conceptualisations of Mindfulness • Sati is the original Pail term that has been translated into English as “mindfulness”. Sati is a state of mind that can be said to involve a blend of attention, awareness and memory (Kabat-Zinn, 2009) • “The awareness that arises through paying attention, on purpose in the present moment, and non-judgementally” Kabat-Zinn (1994) • Many Buddhist practices are designed to foster the cultivation of compassion but the majority of these practices emerge from a foundation in the development of sati. (Tirch, 2010)

21. Mindfulness demonstration: Raisin exercise

22. Mindfulness training and structural brain changes • Scientific examination of mindfulness may be the beginning of a clinical neuro-phenomenology of a new model of mental health (Tirch, 2010) • Awareness of internal mental processes promotes neural integration (Siegel, 2007) • Neuroimaging research revealed increased thickness in middle prefrontal area and the right insula (Lazar, 2005) • Middle prefrontal areas associated with caregiver behaviour and compassion (Wang, 2005) • Insula serves as a communication channel between the limbic system and the middle prefrontal areas and also links and synthesises information about bodily sensations, emotions and the representation of others

23. Anterior Cingulate Cortex • EEG and fMRI imaging studies of meditation suggest that it is involved in changes in the ACC Cahn and Pollich (2006) • ACC involved attentional focus, decision making processes, experience of “love”, attachment and caregiving, resolution of conflict, emotional regulation and adaptive responses to changing conditions. • ACC may be involved in a neural homeostatic mechanism that regulates an individual’s response to distress (Corrigan , 2004)

24. Medial Prefrontal cortex • fMRI technology has contrasted the neural correlates involved in a “narrative” and “experiential” modes of self-reference • The mPFC is involved in maintaining a sense of self across time, comparing one’s traits to those of others and the maintenance of self-knowledge (Farb et al, 2007) • Experienced meditators – decreased mPFC activity and increased processing of emotional memories • Novice meditators had stronger coupling between narrative self-reference and areas involved in the translation of visceral emotional states into conscious feelings

25. Process and Stages of CFT & CMT • Validation of fears, painful experiences, threat sensitivities • Make sense of safety behaviours/strategies and core beliefs • Identify critic or inner bully as safety strategy • Explain 3-circles model and how thoughts, memories and images affect the brain https://www.youtube.com/watch?v=VRqI4lxuXAw

26. Process and Stages of CFT & CMTIt’s not your fault focus • We are evolved beings with built in self-protection and resource systems • Distinguish taking responsibility from condemning and blaming • Recognise that safety behaviours may not be dismantled until alternatives are in place • Move from shame and self-criticism to sadness and grief and then process the grief

27. Process and Stages of CFT & CMTDevelopment of compassion for self • Discuss compassion as a focus and ‘direction of travel’ • Note the foci of compassion: compassion for others to self; from self to others and from self-to-self • Through the therapeutic relationship • Mindfulness with re-focusing of attention, behaviour, thoughts and feelings • Use letter writing and imagery • Orientating to compassionate self-identity • Practice daily – brief and frequent

28. Psycho-education: our brain structure 1. Old Brain (Reptilian) • Emotions: Anger, anxiety, sadness, joy, lust • Behaviours: Fight, flight, withdrawal, engagement • Relationships: Sex, power, status, attachment, tribalism 2. Social Brain Mammalian) • Need for affection and care • Socially responsive, self-experience and motives 3. New Brain (Human) • We can imagine, fantasise, look back and forward, plan, ruminate • We can integrate mental abilities • We can create a sense of self-awareness, self-identity, and self-feeling

29. Link between 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: 1. Those that focus on threat and self-protection 2. Those that focus on doing and achieving 3. Those that focus on contentment and feeling safe

30. Brain Diagram (psycho-education)

31. Psycho-education: What is Compassion? “Sensitivity to the suffering of the self and others with a commitment to relieve it” Dalai Lama • Learning to become sensitive to things causing difficulty or pain • Understanding the nature and causes of our suffering in a non-judgemental way • Understanding kindness and care as courage (not weakness) • Develop a motivation to be helpful to ourselves and others

32. Three Systems model Each of the three systems orientate the mind and body in particular ways to prepare us for different forms of action. The systems are interrelated, interact with and regulate each other.

33. Threat System How it evolved: For survival and self protection. • What it does: Alerts us to potential danger and triggers our fight/flight response. • How it helps: It keeps us safe and away from danger.

34. Three types of threat • External Threat (the leopard) • Social Threat (the need to be part of the group). • Internal Threat (the negative things we tell ourselves). What an idiot I am. It’s all my fault.

35. How threat system can create problems for us • Operates on a ‘better safe than sorry’ principle and so often prepares us for danger when there is none present. • Activated in the primitive reptilian part of the brain that can be confused by signals from the modern world and from the newer frontal part of our brain • e.g. advertising interpreted as a social threat • If we are criticising ourselves this is reacted to in the same way as a ‘real’ external threat

36. Drive System • How it evolved: For motivation towards needed goals • What it does: Motivates us to get the stuff we need. • Non-social: Resources, shelter, acquisition. • Social: Achievements, relationships

37. Drive System • How it helps: It activates our reward system to make us feel good when we achieve goals that help us to flourish in our environment and to build positive relationships. • How it can be a problem: It can drive unhelpful behaviours like substance use or over-eating. We can also focus on drive/achievement to the detriment of other aspects of our lives.

38. Soothing system • How it evolved: To allow us to rest and digest after activity. In mammals it also linked to the attachment system (ensuring mothers/caregivers provide nurturance and care for helpless young) • What it does: It gives us a warm connected sense and a motivation towards nurturing. It allows us to feel soothed in the presence of a caring person.

39. Soothing System • How it helps: It allows us to recuperate and disengage and to feel connected to the people around us. Social connections and the ability to feel soothed buffer against both physical and mental health problems. • How it can be a problem: When it becomes closely tied with the threat system, e.g. when those who are supposed to care for us are also frightening or abusive.

40. Interaction of 3 systems • Threat-based Drive – great to win but what happens when we come second? • Contingent self-worth – striving to achieve to avoid feeling inferior • Affiliative & Threat link – if something bad happens most helpful to be in presence of caring other

41. Psycho-education: summary • We have brains designed for survival. • The survival instinct means our brains look out for threat all of the time. • The human brain is tricky because we can reflect back on the past and worry about the future. • The old part of our brain can’t distinguish between a real external threat (the leopard) and internal threat (negative things we think or say about ourselves). • Being kind and encouraging of ourselves is very important. • We can develop self-compassion through soothing exercises and being kind to ourselves.

42. Homelessness How might the three emotional regulation systems be influenced by the experience of being street homeless?

43. Time to practice In triads of worker, client and observer, practice talking through the 3 systems role playing a client that you are currently working with.

44. Consider what might be in each area: e.g. in a threat mind-set where would your attention be? How the threat system organises our mind Attention Thinking and reasoning Emotional experience THREAT: ‘I’m in danger!’ Imagery and fantasy Motivation Behaviour

45. Consider what might be in each area: e.g. in a drive mind-set what would your motivation be? How the drive system organises our mind Attention Thinking and reasoning Emotional experience DRIVE: ‘I want that!’ Imagery and fantasy Motivation Behaviour

46. Consider what might be in each area: e.g. in a soothing mind-set what would your emotional experience be? How the soothing system organises our mind Attention Thinking and reasoning Emotional experience SOOTHING: ‘I am valued and connected’ Imagery and fantasy Motivation Behaviour

47. Soothing Rhythm Breathing • Soothing rhythm breathing is the basis for many of the compassion exercises we will learn. • Soothing is linked to feelings of safeness. • We can use these feelings to help manage threat based emotions such as fear, disgust and shame.

48. Case example: Macey • Anger – feels incontrollable and frightened by lack of control. Verbally aggressive towards boyfriend and family and physically violent towards objects. • Low mood – described feeling less and less optimistic that she could change her behaviours. Triggered by self-critical thoughts, also highly sensitive to perceived criticism from others. • Social anxiety – self-monitoring/self criticism in social situations • Current relationships – on/off boyfriend of two years. No contact with father. Strained relationship with mother • Has some close girlfriends but feel guilty for overburdening them with boyfriend problems. • Strengths – intelligent, good career prospects. Loves music and having musical people around her. Writes music and poetry as emotional release but lacks confidence to share • Anger and violence reinforced through observational learning (father, mother’s partner’s) and operant conditioning (negative reinforcement anger and aggression stopped the worst excesses of mother’s boyfriend’s behaviour). • This strategy was effective to keep Macey safe in childhood but was no longer helpful. “Not your fault” emphasis. • Toxic environment led to beliefs that others were dangerous, attacking and unpredictable, the world as chaos and self as defective and unlovable. • These beliefs hypothesised to feed the self-criticism and shame.

49. Case example: Macey

50. Safe Place Exercise Now I want you to let come to mind a place that is very comfortable and peaceful to you. It could be a place you have been to, a place you would like to go, or a place that is purely of your imagination. When a place like this begins to come to mind, I want you to raise one hand to let me know.