Compassion Focused Therapy Derby December 2008

1. Compassion Focused TherapyDerby December 2008 Paul Gilbert PhD FBPsS Mental Health Research Unit, Kingsway Hospital Derby p.gilbert@derby.ac.uk Mary Welford Greater Manchester West Mental Health NHS Foundation Trust mary.welford@gmw.nhs.uk Ken Goss, Ian Lowens, Chris Gillespie & Chris Irons www. compassionatemind.co.uk If you wish to use this material please respect sources

2. Warm-up Exercise • In threes or small groups introduce yourself and then consider clients whose shame and self-criticism have been hard to work with • What was the nature of the ‘stuckness’ how did you formulate this, and how did you try to resolve it? • What might have helped you

3. Workshop Outline First leg • Introduction to the model • Our Basic Threat-Defence Systems • Safeness: A Missing Component • Key Shame Concepts • Identifying Critical Dialogues & Associated Affects • The Diagrammatic Model / Formulation

4. Key Targets of Therapy Attention Imagery Thinking Reasoning Behaviour Motivation Emotions Evolved Dispositions and Designs

5. Basic Philosophy and Model To derive models of psychopathology based on the science of mind To derive models of psychotherapy based on the science of mind To derive models of both that integrate all the relevant sciences e.g., genetic neuroscience, development, cognitive psychology through to social and political psychology and beyond Contextualise mind in it’s environment

6. Innate and Acquired (v) Genotype  (v) Environment = (v) Phenotype Genotypesare potential competencies for - Examples: Language, symbolic thought, attachment, defensive behaviours Phenotypes are the expressed or manifest traits/outputs that are observable or measurable Examples: Styles of language, attachment

7. Basic Evolutionary Orientation Phenotypic vulnerabilities Normal reactions to abnormal/hostile’ environments e.g.,: abusive environments develop threat focused phenotypes Safe environment develop trust, openness phenotypes Multiple systems specialised ‘trying to do their best’ thus protective but can conflict Population variation Co-constructions

8. The Challenges Old brain Motives: Safeness, food, shelter, social Emotions: Anger, anxiety, sadness, joy, lust Behaviours: Fight, flight, withdraw, engage Relationships: Sex, power, status, attachment, tribalism

9. The Challenges Archetypes and Social Mentalities Innate tendencies for organising basic psychological processes (motives, emotions, attention, thinking and behaving) for the creation of social roles and relationships Consider their organisation for Care-seeking Care providing Cooperation Competition Sexual KEY POINT: Different social mentalities organise our minds in different ways

10. The Challenges Old brain Motives:Safeness, food, shelter, social Emotions: Anger, anxiety, sadness, joy, lust Behaviours: Fight, flight, withdraw, engage Relationships: Sex, power, status, attachment, tribalism 2. New Brain Imagination Planning Ruminations Integration of mental abilities What happens when new brain is recruited to pursue old brain passions?

11. The Evolved Brain Sources of behaviour New Brain:Imagination, Planning, Rumination, Integration Old Brain: emotions, behaviours, relationship seeking

12. Humans are an Evolved Species HumanSymbolic thought and self, theory of mind, metacognition MammalianCaring, group, alliance- building, play, status ReptilianTerritory, aggression, sex, hunting

13. The Challenges Curse of the self Aware and seeking to create a self-identity Self As: wants to be, does not want to be Shame, sense of personal failure, alienation What you think about me Mammal brain requires nurturing, caring and kindness Affects brain a maturation Experience of safeness and pro-social behaviour Physiological regulating Health and well-being

14. The Challenges 5 Interconnectedness and interdependency Co-operation, sharing, training Tribalism, group loyalties, Submissive following 6. Individual differences Personality Gender Talents Ethnicities 7 Self-to-self-relating Imagination Thinking Self-reflections

15. Stimulus-Response Sexual Bully-threat Meal Sex Meal Bully- threat Kind, warm and caring Limbic system Compassion Soothed Safe Stomach acid Salvia Fearful Depressed Arousal

16. The Challenges 8The Tragedies of Life Death, decay and an awareness of this Diseases, famines, droughts and wars Moralities Justice vs compassion Morality as feeling (and genes) Social conditioning Developmental stage Fear of compassion Weakness Indulgence Vulnerable

17. The Challenges So basic philosophy is that We all just find ourselves here with a brain, emotions and sense of self we did not choose but have to figure out ‘Not our fault’ – all in the same boat –clearly convey – de-pathologising

18. 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 Solutions

19. Key Targets of Therapy Attention Imagery Thinking Reasoning Behaviour Motivation Emotions Evolved Dispositions and Designs

20. Types of Affect Regulator Systems Content, safe, connect Drive, excite, vitality Affiliative focused Soothing/safeness Opiates (?) Incentive/resource focused Seeking and behaviour activating Dopamine (?) Threat-focused safety seeking Activating/inhibiting Serotonin (?) Anger, anxiety, disgust

21. Key Idea Various therapies have developed exposure and other techniques for toning down negative emotions but not fortoning upcertain 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.

22. 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.

23. What is Compassion Focused Therapy? 1. CFT draws on many branches of psychology (e.g., developmental social and evolutionary) and neuroscience science 2. It utilizes interventions derived from many western and eastern therapies. 3. The therapy is not technique driven but process driven. 4. The focus is on developing capacities for compassion and balancing the affect regulation systems

24. CFT Can Involve The therapeutic relationship,collaboration, guided discovery, personal meaning, Socratic dialogues, inference chains – (bottom line/catastrophe/major fear/threat), functional analysis, chaining analysis, maturation awareness, shared formulation, change through practice, behavioral experiments, exposure, developing emotional tolerance, mindfulness, guided imagery, expressive writing, reframing, generating alternative thoughts and independent out-of –session practice -- to name a few! There should be increasing overlaps in our therapies if we are being science based.

25. What is helpful Cognitive-Behavioural focused therapies help people distinguish unhelpful thoughts and behaviours - that increase or accentuate negative feelings - and alternative helpful thoughts and behaviours that do the opposite. This approach works well when people experience these alternatives as helpful. However, suppose they say “I can see the logic and it should feel helpful but I cannot feel reassured by them” or “I know that I am not to blame but still feel to blame.”

26. What is helpful This is called the cognition-emotion mismatch. In these cases, the problem may be that their soothing systems simply do not register the alternative thoughts as helpful i.e. the opiate / oxytocin system is insufficiently stimulated and thus they do not feel reassured. The emotional systems that give rise to feelings of reassurance are not active enough -- or the threats are so great that the threat system overrides them. Safeness can feel unfamiliar or dangerous

27. 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 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.(page 12)

28. What is the Point of Change? Clarify the ‘direction of travel’ and the destination: Symptom reduction, achieve a goal, transformation of one’s being - the re-organisation of one’s mind. Making a decision that suffering is not desirable – one’s own mind contributes to it (luxury flat) If we loose the sense of direction then change process can seem overwhelming and lost The importance of cultivation (wild vs cultivated garden) Knowing one’s mind – different levels and types of subject and objective knowing Change requires courage - purposeful vs purposeless suffering

29. Buddhist To investigate the nature of consciousness and reside there The light is not what it illuminates: Water is water whether it carries a poison or medicine Mindfulness helps us reside in consciousness and not content Making a decision to reflect on the nature of suffering, it’s nature and consequences

30. Compassionate KnowledgeSome Basic Themes Understand how our minds were designed If therapy involves psycho-education then what do we teach clients about how our minds work? Evolution-informed and functional and focus

31. Two Types of Processing System These systems interact but can conflict. Therapy should work with both systems and may require different interventions

32. Workshop Outline First leg • Introduction to the model • Our Basic Threat-Defence Systems • Safeness: A Missing Component • Key Shame Concepts • Identifying Critical Dialogues & Associated Affects • The Diagrammatic Model / Formulation

33. Self-Protection: A Design for Life All organisms are structured for self-protection: Safe --- Not safe

34. Better safe than sorry: Our Minds are designed to easily assume the worst -safer Threat NoYes Run Don’t Run Action

35. Self-Protection In species without attachment only 1-2% makeit 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 Over millions of years a variety of fastdetection and response systems have been built into animal and human minds to cope with a variety of threats and are the basis for UCSs and UCRs Threat responses need to match the stimuli and context

36. Menu of Defensive / Protective Strategies linked to Coordinated set of: Motives Emotions Behaviours Cognitive Processes

37. Self-Protective Motivations/Drives Get or stay safe Damage limitation vs enhancement Hold on to what one has Act to reduce future threat

38. Menu of Implicit Threat - Protective Emotions Anger –increase effort and signal threat Anxiety –alert to danger and select defensive behaviour Disgust –expel / keep away from noxious or undesirable Sadness –acknowledge loss, signal distress Jealousy –threaten and defend Envy –undermine / spoil benefits of the other

39. Menu of Defensive / Protective Behaviours Stop - Hyper-alert/ hyper vigilance – predict threat early Flight - Escape, prevent exposure (Cannon 1929) Fight - Protection or deterrent – subdue others / exert control Hiding and camouflage Tonic immobility – ‘play dead’ (Bracha 2004) Cut off - turning away from Demobilisation -- short-term and long-term Clinging ‘on to’ Help seeking - hyper activation of proximity seeking Submission - appease, comply

40. Menu of Defensive / ProtectiveCognitive Processes Better Safe than Sorry requires rapid decisions Selective attention - scan for threat Crude analysis Dichotomous thinking Over-generalisation Disqualify positive – can’t risk false hope Sensitive to nonverbal signals Helps select automatic appropriate defence (e.g., flight, submit or attack) May be into process before conscious awareness e.g., we find ourselves submitting and then make self-referent explanation

41. Neural Bases of Threat Processing (LeDoux, 1994)

42. Cerebral cortex Amygdala Hippocampus

43. The Complexity of the Threat System 1) Different processing systems active 2) Threat emotions can set up conflicts - The power of approach-avoidance conflicts 3) One protection strategy creates another 4) Emotional Conditioning

44. Threat – boss criticises your work 2) Threat Emotions can set up Conflicts Rapid access of safety strategies Angry-attack revenge Anxious - flee submit Cry want to seek reassurance Threat to self-identity and self as social agent in social role Fragmented and fragmenting, confused and secondary safety strategies at management of inner conflicts

45. Conflicts (e.g. Approach-Avoidance) Experimental neurosis – trigger two different behaviours at same time e.g., seek reward and avoid threat – Pavlov, Liddell & Cooke etc Incompatible decisions – choosing one violates another: Disorganisation of systems (also classic Sci-fi; Hale in 2001 a Space Odyssey and 2010 the Return) Dilemmas (e.g., risk change or trust vs stay safe); head heart Increase in stress arousal and inhibits abilities to think – dissociation. Confusing to client and therapist (Liotti..) Therapeutic task is to clearly articulate the conflict, explain how conflict affects the brain, and then brain storm – May take time to work through – resolution may not be easy – hard life decisions.

46. 4) One Protection Strategy Creates Another Express feelings Don’t express feelings Others angry Others ignore Reject my wishes Feel bad Feel bad

47. 5) Emotional Conditioning How emotions and desires can become non-conscious (Ferster 1973) Anger Punishment Anxiety Any emotion or motivation (urge) can become a CS of any other

48. Conditioning Care seeking Punishment Anxiety Care seeking systems can become conditioned to threat rather than safeness. If happens early, people may not recall specific memories but experience confusing feelings in close relationships

49. Conditioning Care seeking No response shut down

50. Own Behaviours as Threats Anxiety can be an alerting signal for not to do something –a ‘don’t’ signal. Brain can also automatically change the balance of emotional regulation as in Protest-Despair. Infants separated from caregiver first shows protest (pining and anxiety) but then becomes quite and withdrawn – this stops movement, getting lost, and attracting attention of predators Toning down of positive emotions most likely in poorly supportive, low pay off and/or risky environments – So what is the protective strategy underpinning low mood?