Compassion and Mindfulness in Cognitive Behavioural Therapy (CBT)

1. Compassion and Mindfulness in Cognitive Behavioural Therapy (CBT) Psychology and Religion in the Search for Personal Wholeness Johann Maree SummerSchool, UCT, Jan. 2012

2. What is Cognitive Behaviour Therapy (CBT)? • Formal definition: CBT is a form of psychotherapy based on cognitive therapy and behaviour modification, in which the client or patient learns to replace dysfunctional self-speech (such as “I knew I’d never be able to cope with this job”) with adaptive alternatives(“The job’s not going well, but I am capable of working out a plan to overcome the problems”).

3. Cognitive Therapy (CT) and Behaviour Modification (BM) • CT is ‘a form of psychotherapy aimed at modifying people’s beliefs, expectancies, assumptions, and styles of thinking, based on the assumption that psychological problems often stem from erroneous patterns of thinking and distorted perceptions of reality…’ • BM is a collection of psychotherapeutic techniques aimed at altering maladaptive behaviour patterns, the basic assumptions being that most forms of mental disorder can be interpreted as maladaptive patterns of behaviour, and that treatment involves the unlearning of these behaviour patterns and the learning of new ones.

4. The Origins of CBT • The emergence of CBT is ascribed to the American psychiatrist Aaron T Beck (b.1921). He developed it while treating people for depression. • Beck used to adopt a psychoanalytic approach towards the treatment of depression. He assumed the validity of its theoretical proposition that depression was due to a retroflected hostility, expressed as “a need to suffer”. However, during the second half of the 1950s he came to realise through empirical observation and study of his depressed patients that the theory was wrong. The treatment based on its assumptions did not work and the patients themselves expressed their problems differently.

5. Aaron Beck’s agonizing reappraisal • This ‘marked discrepancy between laboratory findings and clinical theory’ led Beck to an “agonizing reappraisal” of his ‘own belief system’. He came to the conclusion that depressed people had ‘a global negative view’ of themselves. • Consequently, Beck and his colleagues devised an interactive treatment with their patients in which the patients were set ‘homework’ which consisted of observing their automatic negative mental reactions and replacing them with positive responses structured as incremental steps that could be taken to deal with the observed challenges. This approach worked well and directly ameliorated the depression symptoms.

6. Increasing use of CBT • Since its development in the 1960s CBT has grown almost exponentially in its clinical applications. • It has proved its effectiveness with a range of personality disorders: • Anxiety including panic disorder • Obsessive compulsive disorder • Eating disorder • Bipolar disorder, and • Couples and family problems.

7. Compassion and Mindfulness • Two exciting developments in CBT over the past twelve years have been the introduction of compassion and mindfulness as two key practices. • They have the added advantage that they are available through self-help techniques. • There is evidence that training ourselves in compassion and kindness, with regular practice, can actually change our brains. • We shall explore how this is done.

8. Compassion • Paul Gilbert, Professor of Clinical Psychology at the University of Derby, describes compassion as follows: • ‘Compassion (which is an element of loving-kindness) involves being open to the suffering of self and others, in a non-defensive and non-judgemental way.’ • The focus of Western psychology on compassion is due to the influence of Eastern psychology and Buddhism which sees life as ‘full of threats and suffering (or dukkha)’ and that ‘all sentient beings seek to be free of suffering’.

9. Inner Compassion • For people suffering from depression Gilbert stresses the importance of developing inner compassion. He explains how this is achieved. • Firstly, a core belief is something that one thinks is basic to oneself, such as: “At heart I feel that I am useless” . • When core beliefs are activated they come with powerful feelings and emotions. • Depressed people have very negative core ideas about themselves, their ability to gain support, affection and approval of others.

10. Self-Bullying • Depressed people, but also others, can bully themselves in many different ways. For instance • Self-blame: “It is all my fault” when it wasn’t necessarily even due to any of the depressed person’s actions, or only partly due. • Placing too high an expectation or demand upon oneself: “I ought to be able to come top of the class, to have achieved this, etc, etc. ” • Calling ourselves names / Negative labels: “I am a fake, inferior, inadequate, worthless, etc, etc.”

11. The Compassionate Mind • Depressed people have to learn to develop a compassionate mind. • A compassionate mind – has empathy and sympathy for those who are in pain and hurting; - is concerned with supporting, healing and listening to what we and others need; -recognizes that life can be painful and that we are all imperfect beings.

12. How to develop a compassionate mind Core idea: negative Alternative thought • I can’t cope with the needs of my family. • I just want to run away from it all. • I am useless and a failure. • I am feeling exhausted right now which is understandable given the demands on me. • I need to create more space for myself, take some time out for myself if I can, and ask my family to help out more. • It is understandable that I am disappointed in myself.

13. Mindfulness • Mindfulness normally means taking thought or care, being heedful, keeping others’ circumstances in mind. • But in CBT the emphasis is laid on awareness, on paying attention. It involves ‘learning to pay and hold attention in the present moment with a specific focus.’ Gilbert explains: • ‘Many of the great teachers of meditation point out that we only exist in this moment – we are a “point of consciousness” passing through time. Our consciousness does not exist in the moment just gone nor in the moment yet to arrive – we only exist now. Mindfulness is learning how to bring us to be fully alive to the now of our conscious existence, the only place we actually exist.’

14. Becoming familiar with how our minds work • Gilbert links mindfulness with meditation which actually means becoming familiar. For us becoming more mindful is to become familiar with the contents of our minds and how our minds work. • The end result is to be able to direct and retain our attention on something here and now. Then ‘our conscious attention can be thought of as a spotlight that moves around. It is learning how to direct that spotlight, via our attention, which is key to mindfulness.’

15. Value of mindfulness • Our minds give us a range of thoughts, feelings and moods. Mindfulness can help us become aware of them without forcing them away, or being frightened of them. We learn to stand back and observe. • In mindfulness we are not trying to change thoughts, but change our relationship to our thoughts and feelings. • We can deliberately use mindfulness to practice stimulating emotion system that will give rise to brain patterns that create good feelings. Appreciation is one way of practising to do this, says Gilbert.

16. Evaluation of CBT • Appreciative: • CBT provides us with self-help techniques on how to love ourselves and, by extension, others, especially those who are suffering. • It also provides us with a way of being more aware of, and in touch with ourselves, our feelings and our bodies. • Critical: • CBT does not stress enough how difficult it is to achieve mindfulness by focusing our minds.