2 慈悲与心理灵活性

2 Compassion and Psychological Flexibility Although compassion in itself has yet to be integrated as a formal component of the ACT process model, ACT practitioners and researchers have been explor- ing the role of compassion and self-­compassion in psychotherapy for some time now (Forsyth & Eifert, 2007; Hayes, 2008c; Luoma, Drake, Kohlenberg, & Hayes, 2011; Schoendorff, Grand, & Bolduc, 2011; Tirch, 2010; Van Dam, Earleywine, & Borders, 2010). In order to approach an understanding of com- passion from an ACT perspective, we need to spend some time examining rela- tional frame theory (RFT; Hayes et al., 2001), the underlying theory of cognition within CBS and the foundation for ACT. RFT provides us with an approach to understanding how human beings think and feel, based in the most basic behav- ioral principles. One advantage it offers is that, by building our knowledge about the basic units of mental functioning, we can develop and scientifically test new ways of addressing the complex problem of human psychological suffering. RFT describes the processes of mindfulness, self-­ development, and perspective taking, among many other mental phenomena. RFT also provides a useful way of considering how humans may develop a sense of self and a sense of others and how we frame our experience of time and space (Barnes-­Holmes, Hayes, & Dymond, 2001; Törneke, 2010).

After just over a decade of widespread dissemination, RFT has become the foundation for a worldwide research initiative. This exploration of the funda- mentals of cognition and language from the ground up is one of the most active research programs in behavioral psychology today. One of the central concepts involved in this field of study is a process called relational framing, or derived relational responding, which aims to provide a thorough account of exactly what takes place in human symbolic thinking. As we will discuss, all of this has particular relevance for understanding the emergent, applied science of ­compassion.

compassion.

When training therapists in these theories that ground our work in a con- textual understanding of language, we often invite our colleagues to look at the theory as something more than an academic exercise and see these concepts as essential and dynamic pieces of a vital psychotherapeutic process. Our assump- tions inform how we view our clients and ourselves, and having a clearer under- standing of the foundations of thoughts, feelings, and action will help us develop case conceptualizations, provide clear targets for interventions, and influence the style and flow of our conversations. Say that you are a more traditional psy- choanalyst and your assumptions about how the therapy will work involve the resolution of a transference neurosis; everything from your facial expression to the degree of self-­disclosure in the room will be influenced by those assump- tions. Your aims will influence the directions that you suggest in the flow of the therapeutic discussion. Alternatively, if you are a Beckian cognitive therapist, interested in helping clients identify and directly change dysfunctional cogni- tions, you will have a different set of assumptions, and they will create quite different directions in relating to clients. By taking the time to explore the evolutionary roots of our affiliative emo- tions and increase our understanding of the behavioral principles involved in cognition and language, we are opening ourselves to new assumptions and new possibilities for assessment, case conceptualization, and treatment planning. We are also bringing new dimensions of ourselves to the therapeutic relationship in the process.

Derived Relational Responding and Perspective Taking As many ACT practitioners know, “derived relational responding” is a term used in RFT to describe verbal learning. Simply put, derived relational respond- ing involves a person’s ability to derive relations among stimuli, and as these relations are derived, the functions of the related stimuli can be transferred and transformed. For our purposes, when we say the “function of a stimulus,” we mean the way that an experienced change in an environment (stimulus) can predict and influence the behavior of a person. For example, deriving a relation of equivalence between the word “dog” and the word “txakur” (“dog” in the Basque language) may transfer the functions of the word “dog” (appetitive or aversive, depending on one’s experience with dogs) to the word “txakur.” If someone were then to tell you to take care of your txakur because it was pacing by the back door and walking in circles furtively, you would know what to do. This form of learned relational responding depends upon contextual cues and derived relationships among stimuli that are not dependent upon formal prop- erties of the stimuli (such as the sensory appearance qualities) or direct experi- ence of them. For example, neither the word “dog” nor the word “txakur” is in any way similar to the direct experience of the animal, but both of these words, when serving as a stimulus, can have the effect of bringing to mind for the lis- tener a host of associations and inner experiences related to dogs. At this point, hundreds of studies have demonstrated derived relational responding’s role in verbal learning and cognition (Dymond, May, Munnelly, & Hoon, 2010). Essentially, RFT suggests that derived relational responding is the fundamental building block of thinking, knowing, and speaking. As we explore the science of compassion for ACT practitioners, it is clear that an RFT account of compassion could help us better understand how compassion may function, how we may be able to develop methods to predict and influence compassionate behaviors, and how we can come to understand compassion with increasing precision, depth, and scope.

Relational Frames Derived responding can involve different kinds of relations, which are some- times referred to as relational frames, giving us the name for RFT. Here are a few examples of different kinds of relational frames: • Comparative relations: for example, bigger/smaller and faster/slower • Spatial relations: for example, above/below and behind/in front • Hierarchical relations: for example, this is a part of that • Perspective relations: for example, here/there, now/then, and I/you In RFT, and therefore in ACT, the abilities to experience empathy, compas- sion, a sense of common humanity, and even a sense of self all are viewed as involving our learned capacity for creating perspective relations, a process known as flexible perspective taking (Hayes et al., 2012; Vilardaga, 2009). This is to say that, in RFT terms, the experience of self emerges from a particular form of learned derived relational responding that establishes a perspective—­a point of view that is situated in time and space relative to other points of view. This form of verbal behavior is described as framing deictic relations, with the term “deictic” simply meaning “by demonstration.”

When we use the language of behavior analysis, we can say that these deictic relations are trained relational operant behaviors shaped by ongoing social interactions (Barnes-­Holmes et al., 2001). But because not everyone has a com- fortable background in that kind of language based on behavior analysis, we will also simply say that deictic relations are the fundamental elements of how we mentally represent and experience the world, ourselves, and the flow of time. RFT posits that the language training humans undergo in childhood results in our experience of having a self, which gradually develops through our inter- actions with others in our verbal community: our family and society in general. For example, a parent might ask a young child what she just did, or even who she is or what she will be doing tomorrow. Children might also be invited to contrast themselves with others. For example, a parent might say, “You were a very good girl today! Thanks for cleaning up your toys right away. Some girls at the party didn’t even listen to their parents. Good job.” RFT asserts that in order to establish consistency in our verbal communication, it’s absolutely nec- essary for children to create a frame of reference and point of view, and hence a perspective. Over time, this perspective is experienced as a sense of self (Hayes et al., 1999; Törneke, 2010).

In RFT and ACT, deictic relations that involve I/you, here/there, and then/ now all are viewed as involving perspective taking and represent the elemental processes that bring our experience of self into being. Furthermore, in order for the concept “I” to have any meaning, there must be a “you” involved. Similarly, in order for “here” to have meaning as a point of view, there must be a “there.” Our sense of a self arises from this perspective taking, an experience of “I-­here-­ now-­ ness” that emerges in the context of “you-­ there-­ then-­ ness.” We can represent these perspectives symbolically in a number of ways. For example, we can imagine our perspective relative to another perspective: How would I feel if I found myself having to raise that child on my own like she did? or What would it be like to be a soldier at war? We can also imagine our perspective relative to all other perspectives: I feel like I’m the only person in the world who feels this way! Thinking from within the ACT model, the self is less a thing in itself and more a flow of experience. It might even be more accurate to say that we “engage in selfing” than that we “have a self.”

Self-­as-­Context When people are asked who they are, they often respond by telling some form of life story, or self-­narrative. And these kinds of responses, such as “My name is Fred, I’m from Texas, and I’m an attorney,” make perfect sense. From an ACT perspective, this sense of self is known as self-­as-­content. However, mindfulness and compassion allow for experiencing a different kind of self. This self exists as a sort of observer, a silent “you” who has been watching your expe- rience, moment by moment, for a very long time and is always doing so “now.” Throughout history, many of the wisdom traditions that prescribe the culti- vation of compassion as a method for alleviating human suffering also outline ways that meditators and other practitioners might access a transcendent sense of self. This sense of self has been referred to many ways, including “the observ- ing self,” “the clear light,” “the ground of being,” and “big mind.” It is an experi- ence that has been difficult to express in conventional language, let alone technical, scientific concepts. In ACT, this sense of self is seen as emerging from an experience known as self-­as-­context (Hayes et al., 1999). Self-­as-­context has been described as a convergence of major classes of deictic framing that results in an experience of the “I-­here-­now-­ness” of being alive and an observing self.

How is it that this observing self, distinct from a narrative self, arises? In order to understand this, let’s return to ACT’s roots in research on human lan- guage and cognition—­RFT. As discussed, part of human relational responding involves trained capacities for perspective taking. Through these processes, our experience of being includes a sense of ourselves as a point of perspective before which the entirety of our experience unfolds throughout life. In ACT, this sense of oneself as an observer is referred to as self-­as-­context because it is an experiential sense of self that does indeed serve as the context within which our experiences are contained (Hayes et al., 1999). As we respond to our own responding, this sense of an observing self is important because, while this observer can notice the contents of consciousness, it is not the same as those contents. Just as we have arms but are more than our arms, we have thoughts, but we are more than that experience. Emotions don’t feel themselves, thoughts don’t observe themselves, and physical pain doesn’t experience itself. Throughout our lives, we can notice the presence of an observing self—which may be aware- ness itself—before which all of our experiences arise, exist, and, in time, disappear.

This sense of self-­as-­context is particularly important with regard to com- passion. For example, it clearly links with the components of self-­compassion as defined by Neff (2003b): mindfulness, self-­kindness, and common humanity. Looking at the relationship between self-­as-­context and self-­compassion in detail, we can see that returning to an awareness of self-­as-­context offers a non- attached and disidentified relationship to our experiences. In this way, Neff’s self-­compassion components of mindfulness and a sense of common humanity appear to represent the activation of the ACT process of flexible perspective taking that underlies the self-­as-­context mode of experiencing, as well as defu- sion (or disidentification) from our ongoing self-­narrative, or self-­as-­content. The activation of these processes and the accompanying experience of self-­ compassion can help loosen the habitual influence that painful private events and stories hold over us. Furthermore, from the perspective of the “I-­here-­now-­ ness” of being, we can view our own suffering as we might view the suffering of others and be touched by the pain in that experience without the dominant interference of our verbal learning history, with its potential for shaming self-­ evaluations (Hayes, 2008a; Vilardaga, 2009).

When you remember clients who described being really stuck in their psy- chological problems—­perhaps those who were mired in rumination and worry and waiting for their lives to start—­what stands out about their experience? Do you recall how isolated they felt and how identified they were with their stories? In a recent session, one of our clients said, “I’ve been like this all my life. I just can’t stop worrying about my health. I know I’m some kind of crazy person, and I wish I could be like the other people in my office, who have their stuff together.

On top of that, it really, really feels like I’m going to get a brain tumor—­that it’s only a matter of time. This is too much for me.” Under conditions of intense anxiety, people often have difficulty adopting a flexible perspective and step- ping out of identification with their stories. For this client, obsessive worries related to contamination, radiation, and brain tumors didn’t affect him as thoughts in his mind, but as genuine, looming threats in the world. He felt he was alone, bizarre, mentally and physically ill, and stuck in a place of perpetual anguish. He was his self-­story and identified with it deeply.

When working with such clients, an ACT therapist, who is trained to notice obstacles to psychological flexibility and compassion, might make the following types of observations: • The difficulty the client is having with flexible perspective taking • How identified and fused with his self-­narrative the client appears to be • How persistent self-­comparisons and lack of a sense of common human- ity contribute to feelings of shame, dread, and difficulty in engaging with life • How emotionally moving it can be to deliberately witness the pain of the client as he experiences a physically healthy phase of life as if it were a time of catastrophic illness All of these processes are highly relevant to the cultivation of self-­compassion, and all of them can be viewed through an ACT-­consistent lens and approached through ACT-­consistent therapeutic moves.

Emerging from the CBS and ACT literature as a set of evidence-­based psycho- therapy processes, psychological flexibility involves the development of expand- ing and adaptive behavioral repertoires that can be maintained in the presence of distressing events that typically narrow behavioral repertoires. Psychological flexibility has a strong negative correlation with depression, anxiety, and psy- chopathology and a high positive correlation with quality of life (Kashdan & Rottenberg, 2010). Furthermore, psychological flexibility has been demonstrated to serve as a psychotherapy mediator in a large number of randomized con- trolled trials, and its component processes have been identified and supported by behavioral research, as well as neurophysiological research exploring the neural correlates of those components (Ruiz, 2010; Whelan & Schlund, 2013). While psychological flexibility is a model of six elements (values authorship, commitment, self-­ as-­ context, defusion, willingness, and contact with the present moment), the model can be divided into two major areas of emphasis.

The first area involves mindfulness and acceptance processes (self-­as-­context, defusion, willingness, and contact with the present moment). The second area involves the authorship of and engagement in valued patterns of action that contribute to living a life of meaning, purpose, and vitality (which inherently entails the processes of self-­as-­context and contact with the present moment). Although in ACT values are freely chosen and not prescribed, ACT cofounder Steven Hayes (2008c) has suggested that compassion may, in fact, be a value that emerges inherently from the psychological flexibility model—­and the only value that does so. According to Hayes, the roots of both self-­compassion and compassion may emerge from the six core processes that comprise psychological flexibility, sometimes known as hexaflex processes (Hayes, Luoma, Bond, Masuda, & Lillis, 2006), as illustrated in figure 1.

Present Moment Acceptance Values Psychological Flexibility Commitment Defusion Self-as-Context Figure 1. The hexaflex: Interacting processes in psychological flexibility.

Given your interest in this book, you may well be familiar with these pro- cesses and the growing body of interventions and techniques they inform.

However, each component has a particular relationship to aspects of compas- sion and self-­compassion, with implications for assessment, intervention, and treatment. And as we begin to explore these relationships, it is worth noting that these six processes work together interactively to several ends: • Bringing people into direct experiential contact with their present-­ moment experiences • Disrupting a literalized experience of mental events that may narrow the range of available behaviors • Promoting experiential acceptance • Helping people let go of overidentification with a narrative sense of self, or self-­as-­content • Assisting in the process of values authorship • Facilitating commitment to valued actions and directions If we allow ourselves to mindfully reflect on what these processes represent and realize what it would mean to actualize them, we can approach a felt sense of how the ACT model encompasses and complements sensitivity to the suffer- ing we encounter in the world and the motivation to alleviate that suffering. By examining how current conceptualizations of compassion relate to psychologi- cal flexibility, we can discover the foundation for the development and integra- tion of a contextual and compassion-­focused behavior therapy.

Self-­Compassion, Mindfulness, and Psychological Flexibility Both psychological flexibility and Kristin Neff’s (2003a) conceptualization of self-­compassion are multidimensional constructs that involve mindfulness, the experience of an expansive sense of self, and a commitment to serve specific valued aims. In the case of self-­compassion, the alleviation of one’s own suffer- ing is an explicit aim, and in the case of psychological flexibility, a broader value of alleviating suffering and promoting life-­affirming action is inherent. As we consider the role of self-­compassion in ACT, there is a temptation to find a way to fit self-­compassion into the hexaflex model. Both psychological flexibility and self-­compassion are constructs that have demonstrated clinical utility across a wide range of outcome and process studies (Neff, 2011; Ruiz, 2010). For example, controlled outcome research on mindfulness-­based cogni- tive therapy has suggested that self-­compassion may account for more variance in psychopathology than mindfulness alone (Kuyken et al., 2010). Similarly, Van Dam and colleagues (2010) found that self-­compassion accounted for as much as ten times more unique variance in psychological health than a measure of mindfulness did in a large community sample.

Despite the natural pull to reduce or integrate self-­compassion and the hexa­ flex in a seamless way, it is important to remember that neither self-­compassion nor psychological flexibility is a technical term in the strictest sense of behavioral science. Neff’s definition of self-­compassion is an operationalization based on a reading of Buddhist concepts of compassion (Neff, 2003a), and the construct of psychological flexibility is based upon processes derived from basic RFT research on language, cognition, and rule-­governed behavior. However, the hexaflex con- ceptsconcepts are meant to be clinically applicable, middle-­level terms for describing the underlying principles of RFT in somewhat everyday language. The hexaflex components are useful descriptors, but they need not represent everything that is involved in human well-­being and psychological flexibility. What distinguishes CBS is the application of fundamental behavioral principles in accounting for the prediction and influence of human behavior. As we will describe, further CBS research may help identify more effective ways of working with the powerful psychotherapy process variable present in compassion for self or others. Similarly, compassion-­focused techniques may expand the technical base of ACT in ways consistent with its theoretical underpinnings.

Relating self-­compassion to psychological flexibility reveals both explicit and implicit levels of interacting processes. In terms of overt relationships between the models, we can see that the first component of self-­compassion, mindfulness, is represented in the hexaflex as a form of flexible and focused attention that encompasses contact with the present moment, acceptance, defusion, and self-­as-­context (K. G. Wilson & DuFrene, 2009). The second component of self-­compassion, common humanity, clearly relates to the experi- ence of self-­as-­context, emerging as a function of flexible perspective taking. In terms of psychological flexibility, we can imagine a sense of common humanity arising with a shift from a narrow focus on the individual, narrative self to the sense of “we-­ness” involved with being a part of the interconnected web of human experience (Gilbert, 1989; Hayes & Long, 2013). The third and final component of self-­compassion, self-­kindness, relates to treating oneself support- ively and with sympathy and includes “internal dialogues that are benevolent and encouraging rather than cruel or disparaging” (Neff & Tirch, 2013, p. 79). In the hexaflex, this type of deliberate engagement of warm regard and kind behavior toward the self is represented in the processes of authorship of freely chosen values and patterns of committed action to serve valued aims. This model of the relationship between self-­compassion and psychological flexibility is illustrated in figure 2.

Mindfulness Self-Kindness Present Moment Acceptance Values Psychological Flexibility Defusion Commitment Self-as-Context Common Humanity Figure 2. Self-­compassion and psychological flexibility.

Beyond these obvious functional similarities between given processes, both models stress relatedness among their individual components. Accordingly, the relationships between self-­compassion and psychological flexibility also contain subtleties and inherent relationships across processes. For example, while self-­ kindness appears to be more clearly related to values authorship and committed action, the very act of construing a self and regarding that self with the kindness we might extend to another is an act of flexible perspective taking and therefore related to the process of self-­as-­context. Similarly, for a person to con- sciously bring self-­kindness to her flow of experience, she must be sufficiently in contact with the present moment to have the opportunity to facilitate such a shift. As a result, when working with self-­compassion-­based interventions, ACT practitioners can use their own clinical wisdom and insight to note the corre- spondences and relationships they discern in the lives of their clients.

The CFT Model and Psychological Flexibility The model of compassion presented in CFT derives many of its constructs from research on developmental psychology, empathy, and affective neurosci- ence. Nevertheless, in CFT the core of the definition of compassion has its roots in ancient wisdom traditions. About 2,600 years ago, during the time of the historical Buddha, Siddhartha Gautama, there was a proliferation of con- templative traditions throughout the region along the Silk Road. These schools of thought emphasized the alleviation of suffering through meditative practices with a focus on the importance of cultivating compassion. Synthesizing these methods and innovating new perspectives and techniques, the Buddha devel- oped a program for personal liberation from suffering that involved specific training in compassion. Since then, there have been many discussions of what compassion actually is and what it means, but a fairly standard definition has emerged, and it is used in CFT: sensitivity to the presence of suffering in oneself and others, with a commitment to try to alleviate and prevent such suffering.

The definition points to the two basic psychologies of compassion discussed earlier: • The psychology of engagement, which involves opening up to and working with suffering • The psychology of alleviation, which involves working to develop the wisdom and skill necessary to alleviate or prevent suffering and its causes Within the CFT model, these two central aspects of compassion each include several subcomponents, as shown in figure 3, where “Attributes” corre- sponds to the psychology of engagement, and “Skills Training” corresponds to the psychology of alleviation.

Multimodal Compassionate Mind Training SKILLS TRAINING Imagery Warmth ATTRIBUTES Attention Sensitivity Care for Well-Being Reasoning Sympathy Compassion Nonjudgment Feeling Warmth Warmth Distress Tolerance Empathy Behavior Sensory Warmth Figure 3. The compassion circle. (Reprinted from Gilbert, 2009a, with permis- sion from Constable and Robinson.)

The psychology of engagement involves identifying and cultivating specific competencies, labeled as Attributes in figure 3: accessing the motivation to be caring, sensitivity to distress, sympathy, distress tolerance, empathy, and non- judgment. These attributes are drawn from research on caregiving and altruis- tic behaviors, and they appear to be the foundational elements of a compassionate orientation (Gilbert, 2010). The psychology of alleviation (or prevention) involves further competencies for appropriate reflection and action, labeled as Skills Training in figure 3: attention, imagery, reasoning, behavior, sensory, and feeling. CFT uses a systematic approach to train and cultivate these capacities and skills and thereby develop compassion. The subcomponents of the two psy- chologies—­of engagement and alleviation—­are outlined below.

Components of the Psychology of Engagement Importantly, the components of the psychology of compassionate engage- ment are interdependent. For example, the more we develop distress tolerance, the more willing and motivated we might be to develop compassion. Likewise, the more empathy we have, along with an ability to understand our own minds without judgment, the more we may be able to tolerate distress, increasing moti- vation. On the other hand, if any of these attributes falter, compassion itself may also falter. For example, it will probably be difficult to summon compassion if emotional engagement (sympathy) is low or distress tolerance or empathy are lacking.

Motivation to care for well-­being. Although all of the components of the psy- chology of engagement are interrelated, in CFT we start by recognizing that motivation to be caring and try to alleviate or prevent suffering in oneself and others is central to the compassion journey. There are many reasons why clients may not be motivated to engage with suffering or interested in cultivating com- passion. They may think that it will not help them, that it is weak, that it is undeserved, or that when they engage in compassion they will have overwhelm- ing feelings of sadness and fear (Gilbert et al., 2012). Also, certain clients may have obstacles to motivation that are artifacts of their learning history and thus outside of their conscious awareness. Nevertheless, in CFT the experience of the compassionate mind begins with motivation to alleviate suffering as it is encountered and contribute to the welfare of living things.

Sensitivity. In CFT, sensitivity refers to how we pay attention to suffering, both our own and that of other people: how we come to notice it and hold it in our attention without turning away or trying to avoid it. This sensitivity involves present-­moment awareness that is intentionally focused upon the presence of suffering as we encounter it in the world or in ourselves.

Sympathy. In CFT, sympathy refers to a reflexive and responsive emotional connectedness with suffering derived from the automatically engaged capacity to be emotionally attuned. For example, if you see a child stumble and hurt himself, this could trigger immediate unpleasant feelings within you. You might wince or feel compelled to act. This sympathy can also be directed within. When we pay attention to our own suffering, it is not an emotionally neutral experience; it comes with a feeling component, and the compassionate mind is capable of feeling into the pain.

Distress tolerance. Being motivated to engage with suffering, sensitive to the presence of suffering, and attuned to suffering with sympathy requires the ability to tolerate the difficult emotions, thoughts, and bodily sensations that arise. As described by Gilbert (2009a), this capacity for distress tolerance is closely related to acceptance: “Linked with but not identical to acceptance, tolerance is the ability to stay with emotions as they happen… Acceptance can involve toler- ance, but it is also a deep philosophical orientation to one’s difficulties. It’s a coming to terms, ‘letting it be,’ not fighting or struggling any longer” (pp. 200–­ 201). Neither acceptance nor distress tolerance is submissive resignation; rather, both speak to an intentional willingness to remain in the presence of challeng- ing experiences in the service of compassionate aims.

Empathy. One of the more complex elements of the psychology of engagement is empathy, as it is both an intuitive process and a more deliberate approach (Decety & Ickes, 2011). For example, you might deliberately imagine what it would be like to find yourself in another person’s shoes, as when viewing a cli- ent’s sadness from an empathic perspective. However, empathy might also be implicit, such as having a discussion with a friend, simply noticing that he seems anxious, and having a hypothesis about his concern pop into your mind. Empathic responding has been described many ways, including theory of mind (Premack & Woodruff, 1978), mentalization (Fonagy, Target, Cottrell, Phillips, & Kurtz, 2002), and, as discussed, perspective taking (McHugh & Stewart, 2012), a central contextual behavioral concept. We may be better able to empa- thize with others when we are open to and aware of our own processes. For example, individuals who are frightened or avoidant of their own feelings (e.g., intense rage) or fantasies may struggle to understand or empathize with others in those states.

Nonjudgment. The final component of compassion is the ability to allow oneself to experience certain emotions and mental events without falling under the control of condemnation, judgment, or shaming. Nonjudgment doesn’t mean indifference or apathy; rather, it represents a recognition that harsh eval- uations, shame, and self-­criticism can drive avoidance, contribute to emotional pain, and exacerbate suffering. So in CFT, we aim to “engage with the com- plexities of other people’s and our own emotions and lives without condemning them” (Gilbert, 2009a, p. 205).

Components of the Psychology of Alleviation The psychology of alleviation (which includes prevention) involves a set of skills that can create the potential to alleviate suffering in the context of psychotherapy and in daily life. A number of CFT interventions involve specifi- cally training these skills to develop compassionate mind. These interventions include chair work, guided imagery, mindfulness training, compassion-­focused exposure and response prevention, and working with compassion within the therapeutic relationship (Gilbert, 2009a; Tirch, 2012). Importantly, just as the attributes of compassionate engagement are interdependent, the skills of com- passionate alleviation build upon one another. For example, compassionate behavior involves the wisdom of compassionate reasoning and can be guided by mindful, compassionate attention.

Attention. Training in focusing, guiding, and modulating attention is a signifi- cant element of CFT (Gilbert & Choden, 2013). Much of the preliminary atten- tion training in CFT involves mindfulness, as this focused, flexible attention allows for disidentification and the ability to guide and move awareness. Indeed, mindfulness has served as a context for compassion training for millennia (Tirch, 2010). Additionally, CFT provides instruction in how to direct attention to the experience of compassion. For example, an exercise might be to devote mindful attention to people who are experienced as helpful throughout one day. Another form of such training might be a meditation practice of mindfulness of gratitude. Building on a foundation of mindfulness, focused attention training, and training in coherent breathing (Brown & Gerbarg, 2012), CFT extends to include guidance in directing attention to psychological, physical, and emo- tional domains.

Imagery. Imagery has increasingly been acknowledged as a powerful therapeu- tic tool in cognitive and behavioral therapies (Hackmann, Bennett-­Levy, & Holmes, 2011). Imagery itself can stimulate a range of physiological systems and emotional experiences. In CFT, we share this insight with clients and point out that compassion imagery practices are designed to build the capacity for com- passion, in part by stimulating related physiological systems. CFT makes use of a number of imagery exercises, including construction of a compassionate version of the self, imagining a compassionate and safe place, and creating the image of an ideal compassionate companion (Gilbert & Choden, 2013). Reasoning. True compassion obviously isn’t an unintelligent option; therefore, being able to stand back and take a wise, balanced perspective on situations is an important skill in the psychology of alleviation. It is important to think as freely and clearly as possible when engaging with compassion, because thinking through difficult questions and applying adaptive reasoning is often what helps us choose to develop compassion for things we don’t like in others or ourselves (Loewenstein & Small, 2007). We may also take a compassionate perspective on our thinking itself and realize the ways in which thoughts can ensnare us in old, unhelpful patterns of action.

Behavior. Within the CFT model, compassionate behavior is basically any behavior that intentionally addresses people’s suffering and tries to alleviate and prevent it. Behavior, in this sense, refers to overt behaviors rather than private behaviors in the mind; it refers to what we can do with our hands and feet to act upon and realize our motivation and intentions for compassion. Of course, such behavior would be wise and skillful, not simply reflexive rescuing, which may not actually help the target of compassion. Commonly, the cultivation of compassionate behavior involves courage as we come into contact with our awareness of suffering. For example, for a person who is agoraphobic, self-­ compassion does not mean sitting at home and avoiding difficult feelings; it requires practice in going out and facing the anxiety (Tirch, 2012). In essence, compassionate behavior means engaging with that which is causing suffering, and it is, of course, linked to commitment and willingness to engage. Sensory experiencing. To some extent, the capacity for soothing through com- passion, as an affiliative process, operates through the parasympathetic nervous system (Porges, 2007). It is therefore useful to help clients engage in more devel- opment of the parasympathetic nervous system. To do this, we use exercises that involve various breathing techniques and body postures. We also teach clients how to use facial expressions and voice to stimulate feelings of compas- sion within the body, and we use method acting techniques to help people experience engagement with the process of compassion. For example, when clients and therapists alike are first learning to build an inner voice and image of a compassionate self, CFT trainers invite them to bring mindful attention to the physical experience of smiling as opposed to having a neutral expression. Similarly, they are instructed to bring attention to the experience of listening to a warm voice greeting them, as opposed to what happens when a neutral voice greets them. Sensory sensitivity can guide our moment-­by-­moment experience of compassion and can stimulate the emotional systems involved in the compas- sionate mind.

Feeling. For the most part, compassionate affective experiences are associated with emotions involving connection, warmth, and kindness, partly because these are affiliative and soothing emotions that activate an experience of safe- ness and contentment, which can create a secure base for action. Compassionate emotions can also involve a sense of courage and willingness to face difficult things. Furthermore, there are times when feeling anger or panic might trigger compassion. An example would be anger at seeing indifference to starvation, as happened in the 1980s when Bob Geldof and Midge Ure created the charity supergroup Band Aid to raise money for alleviating famine in Ethiopia. Likewise, panic can activate compassionate feelings and action, as when someone realizes a child is trapped in a burning house and rushes in to rescue her. Clearly, it’s not so much the quality of an emotion but its function and its link to the motivation to alleviate or prevent suffering that distinguishes the cultivation of compas- sionate emotions.

ACT Processes, the CFT Model, and Compassionate Flexibility Each of the processes involved in the CFT model of compassion can be related to the ACT hexaflex processes that together effect psychological flexi- bility. Just as with Neff’s model of self-­compassion (2003a), these processes are all middle-­level terms and do not precisely map onto one another. However, conceptually and technically integrating compassion and psychological flexibil- ity in this way provides opportunities for clinicians to create focused interven- tions designed to help clients live adaptive and compassionate lives. In this way, examining a model of compassionate flexibility orients us toward adaptive, evidence-­based processes and principles so that we can bring our clinical wisdom, creativity, and compassion to the human exchange we have with our clients.

Compassionate flexibility reflects a particular quality of engaged psychologi- cal flexibility. Drawing from previous definitions of relevant concepts (Dahl et al., 2009; Gilbert, 2010; Hayes et al., 2012; Kashdan & Rottenberg, 2010), we define compassionate flexibility as the ability to contact the present moment fully, as a conscious and emotionally responsive human being with the following qualities: • Sensitivity to the presence of suffering in oneself and others • Motivation to alleviate and prevent human suffering in oneself and others • Persistent adaptation to competing and changing environmental, emo- tional, and motivational demands and commitment to returning atten- tion and resources to the alleviation and prevention of suffering in oneself and others • The ability to flexibly shift perspective and access a broader sense of oneself and others, involving the experiences of empathy and sympathy • The ability to disentangle oneself from the excessive influence of evalu- ative, judgmental thoughts • Maintaining an open and noncondemning perspective on human expe- rience itself, thereby cultivating necessary and sufficient willingness to tolerate the distress encountered in oneself and others The following elaboration of compassionate flexibility (illustrated in figure 4) provides a conceptual walk through the key elements of compassion as for- mulated within CFT theory, illuminating the hexaflex processes they relate to most significantly and how such processes might be targeted in the consultation room.

Sensitivity Distress Tolerance Care for Well-Being Compassionate Flexibility Committed Action to Alleviate Human Suffereing Nonjudgment Empathy and Sympathy Figure 4. A model of compassionate flexibility illustrating some of the relation- ships between CFT processes and ACT’s hexaflex model of psychological flexibility.

Care for Well-­Being and Values In ACT, living a life of meaning, purpose, and vitality in the service of freely chosen values is the core driving principle within the model of psychological flexibility. In a sense, all of the other processes come together to further increase engagement in personally meaningful actions. As discussed in ACT, values are neither goals to be attained nor rules to live by; they are inherently rewarding behaviors. A large part of values work involves clarification and authorship of behaviors that can be described as embodied intentions for how we wish to act in the world. Of course, some of the degree to which a behavior is intrinsically reinforcing may be related to our species’s genetic history. Behaviors that have adaptive evolutionary functions, such as eating or having sex, are more likely to be reinforcing for most people than, say, vacuuming or watching paint dry. Similarly, the inherent adaptive, evolutionary nature of the caregiver instinct and cooperation has made motivation to care for well-­being an inherently rein- forcing and very strongly held value for most people throughout life.

The ACT literature stresses that values are freely chosen; however, as noted previously, compassion may be the one value that is inherent in the psychologi- cal flexibility model (Hayes, 2008c). In CFT, compassion begins with an emer- gent motivation to care for well-­being, both our own and that of others. This speaks to the importance of human caregiving in our species’s survival. CFT stresses the importance of evolved motives: values that issue from and are embedded in our deep evolutionary imperatives and embodied in evolutionarily ancient brain structures and functions. Motivation to care for well-­being is clearly a value in the hexaflex usage of the term, yet it is also clearly related to some of the oldest behaviors exhibited by complex organisms on this planet. Nevertheless, individual learning history can interfere with how we contact and act upon this motivation. When people have encountered trauma in associa- tion with their experiences of support and warmth, they may have obstacles to their compassionate motivation.

Several techniques for values authorship derived from ACT and its psycho- logical model are effective for enhancing awareness of and building compassion- ate motivation. These techniques include experiential imagery exercises in which the client envisions a day in the life of a future self who is living his values more fully. In another popular technique, the client imagines that she has died after living a full, rich life and is hearing what people offer as a eulogy for her, describing how she had realized a life of great personal meaning. These and other, similar techniques can bring clients into emotional contact with how they most wish to live their lives. When such work includes a compassionate focus, these practices can build the motivation to care for well-­being and perhaps to be loving and open to love. Furthermore, even when these techniques are used without explicitly emphasizing compassion, many people are likely to contact how important loving relationships are for them.

The Psychology of Alleviation and Committed Action Committed action represents an individual’s ability to consistently engage in behaviors that support valued patterns of meaningful life activity and promote the realization of valued aims that create an experience of meaning, purpose, and vitality (Dahl et al., 2009). Because behavioral change rarely proceeds perfectly in an unwavering direction, committed action also involves returning to valued patterns after lapses in traveling the path we have set for ourselves (K.G. Wilson & DuFrene, 2009). For example, if a person who has been in recov- ery from alcohol dependence for thirteen months has a glass of champagne at a wedding, committed action may include halting the lapse and returning to 12-­ step meetings.

Many evidence-­based therapy techniques, from exposure and response pre- vention to imaginal reliving, and from behavioral activation to practicing asser- tiveness, can be viewed as committed action steps in which people face difficult experiences in the service of their valued aims. In CFT, the range of techniques drawn from the psychology of alleviation are all committed behaviors that serve the value of cultivating compassion. Examples include compassionate imagery practice, engagement in refraining from addictive behaviors, compassion-­ focused exposure to fears, and developing authoritative, nonviolent assertive- ness skills, all of which are forms of committed action. These techniques may serve various values, such as being a kind parent or living a more healthful lifestyle—­values that in turn may serve the superordinate value of alleviating suffering where it is found, both in ourselves and in others.

Sensitivity and Contact with the Present Moment In CFT, sensitivity means present-­moment awareness that is directed toward engagement with the suffering we encounter in the world, which has an obvious relationship to mindfulness. As we cultivate greater present-­moment sensitivity, we may be better able to simply notice the presence of suffering as it arises, holding it within an accepting awareness that does not turn away out of anxiety or aversion. Such sensitivity can also help us increase our awareness of the subtle dimensions of emotions and emotional memories. In this way, we may become better able, and better prepared, to encounter suffering and challenging emotions, with an increased sense that we have time to respond.

In the psychology of alleviation, this concept of sensitivity is used in a way that is similar to the psychological flexibility process known as present-­moment awareness (Hayes et al., 2012). In fact, present-­moment awareness, which is sometimes referred to as self-­as-­process (Blackledge & Drake, 2013), can be defined as purposeful, direct attention to the contents of the present moment as they unfold. In the hexaflex, present-­moment attention also involves flexible awareness. Contacting the present moment means turning toward our experi- ence, whatever it may be, in the moment, rather than turning away from the moment in pain or shame or getting lost in narrative content.

As the literature on mindfulness and attentional training has demonstrated, it is possible to cultivate and enhance an individual’s capacity for flexible, focused attention to the present moment (Baer, 2003; Garland et al., 2010). Such attention can be trained using a number of present-­moment awareness exercises during psychotherapy sessions and as homework. These practices may begin with simple movement of attention to different focal points in the body, or even in the environment. In time, these attentional practices may extend to deliberately bringing receptive awareness to one’s experience during long periods of mindfulness meditation.

In classical mindfulness training, present-­moment awareness served the aim of cultivating wholesome mental states, including compassion (Rapgay, 2010; Tirch, 2010; Wallace, 2009). When we bring a focus on compassion to such training, the present-­moment awareness that is foundational to mindfulness serves as a context for cultivating states of mind conducive to compassion and well-­being through a deliberate compassionate intention that also includes com- passionate motivation and additional hexaflex processes involving the self and perspective taking.

Sympathy, Empathy, and Self-­as-­Context ACT’s psychological flexibility model holds that well-­being and adaptive responding to the challenges of life are served by developing an ability to connect with and inhabit an experiential sense of the self as an awareness of our own awareness (Hayes et al., 2012). Throughout the many changes that occur in our lives and the myriad of contexts that will unfold for us, we humans maintain a sense of the “I-­here-­now-­ness” of our experience. As mentioned, this sense of oneself as an observer of one’s experience, separate from the content of con- sciousness yet observing the flow of experience, is referred to as self-­as-­context in the hexaflex model of psychological flexibility. Cultivating self-­as-­context allows for an experiential mode of self-­reference that can serve as a foundation for the cultivation of compassion. In fact, this mode of self-­reference has a dis- crete neuronal signature and involves distinct processes that can be trained (Barnes-­Holmes, Foody, & Barnes-­Holmes, 2013; Farb et al., 2007).

Flexible perspective taking can also involve an individual’s ability to take the perspective of another and infer that person’s intentions and feelings, as is the case with theory of mind tasks and mentalization. This ability allows us to step outside of ourselves and psychologically view the world from the perspec- tive of another being, which may allow our painful mental events and emotional memories to hold less influence over us. Interestingly, at a preverbal level, tasks involved in flexible perspective taking are facilitated by efficient deployment of the parasympathetic nervous system, which is involved in relaxation and sooth-ing (Porges, 2007). So from the perspective of the “I-­here-­now-­ness” of being, you can view your own suffering as you might view the suffering of another and be touched by the pain in that experience, without being dominated by interfer-ence from your learning history, with its potential for shaming self-­evaluations (Hayes, 2008a; Vilardaga, 2009). The biological context that can best contain this experience involves the activation of affiliative emotional response systems, along with an implicit or explicit experience that can be described as safeness or stillness. Accordingly, when you stand as witness to your own suffering or even suffering in others, you may be moved to take action to alleviate that suf- fering. In this way, stillness begins the movement toward action.

In contextual behavioral terms, CFT clients learn how to observe their experience from the vantage point of self-­as-context and how to gradually dis- identify from their self-­stories and narrative, or self-­as-­content (Hayes et al., 2012). This process of disidentification, which is sometimes even referred to as “depersonalizing,” has been a central psychotherapeutic move in CFT for some time; but only now is it beginning to be conceptualized in contextual terms.

Importantly, two of the central attributes of the psychology of engagement— which is to say two of the primary components of our evolved capacity for com- passion—involve flexible perspective taking. These attributes are sympathy and empathy. These terms are used very differently from one another in CFT, though both involve dimensions of flexible perspective taking.

In CFT, sympathy is defined as a reflexive, emotional response to our aware- ness of the distress we witness in others or even in ourselves. When we are moved by the presence of suffering on a resonant emotional level, sympathetic responses occur, without elaborate cognitive analysis. This sort of emotional resonance is captured by eighteenth-­century philosopher David Hume, who compared the transmission of emotional responses between humans to the ­harmonic vibration of violin strings (2000). In sympathetic responding, we automatically and effortlessly adopt the emotional perspective of another, are moved by the suffering we experience, and are compelled to do something to respond.

In contrast, within CFT empathy is defined as a heightened, focused aware- ness of the experiences of another person that includes understanding, perspec- tive, and an ability to derive and construe what that person’s experience would be like.

CFT offers a range of imagery and contemplative practices, as well as in-­ session interpersonal exercises, that provides training in flexible perspective taking, sympathy, and empathy. The following clinical example illustrates a few of these approaches.

Clinical Example: Cultivating the Observing Self and Compassionate Intention Gene is a twenty-­five-­year-­old client who presents with depression and social anxiety. He hates himself for his shyness and displays high degrees of fusion with a conceptualized self. To create the conditions for Gene to experience compassion in the presence of his shame and self-­hostility, the therapist works within the relationship to facilitate flexible perspective taking and the emer- gence of some self-­compassionate intention.

Client: I’m shy. I’ve always been shy. In my family I’m known as the shy one—the weakling, if you will. Basically, I’m just a depressed loser who will never dare to do anything worthwhile. I can’t even get a girlfriend! Therapist: I’m sad to hear that you’ve been walking around with this notion of yourself as shy and weak. How long has it been like this? Client: For as long as I can remember. It’s not a notion; it’s who I am. Therapist: So for all this time, the thought of being weak and shy has pretty much summed up your sense of who you are. Client: I t is who I am. They used to make jokes about this in my family. Now they don’t dare joke anymore, but I know they still think it. In a way, that makes it even worse. Therapist: Ouch! That must hurt. Client: Yes. But they’re right. I am weak and shy. Therapist: So “weak” and “shy” are the two words that stand for who you are? Client: Yeah. Pretty much. (Looks down.) Therapist: That sounds so painful. (Pauses.) But can we look at these two words for a minute? Client: What do you mean? Therapist: (Writes the words on a piece of paper and holds it a few feet from the cli- ent’s face.) Can you notice them standing there, as it were? Client: Yes. Therapist: Can you notice them telling you that’s who you are? Client: Yes. Therapist: Can you notice how it feels to have your sense of self reduced to these two words? Client: Yes, it’s painful…and depressing. Therapist: I’ll bet. I can hear how much you identify with these words. When I see how much this causes you pain, I really wish for this suffering to cease. How about you? Client: Me too. Therapist: So you can notice that too. And can you also notice that there is a part of you noticing these words and how they make you feel? Client: Errr. …Yes, I think so… Therapist: Can you notice that you are here, and that these words and how they make you feel are, so to speak, there? (Holds the piece of paper a few feet from the client’s face again.) They are present, and they are painful, and you can also notice them being present and notice the pain that comes with them. Client: Yes? Therapist: So, there’s a part of you that notices and hears these words, an “observer” part of you. This “observer you,” the part of you that can notice both the words and the feelings the words evoke—would you describe this observer you as weak and shy? (Pauses.) Would you describe this observer you by the feelings that arise when it’s criti- cized by these words, such as anger or anxiety? Or would you describe this observer you in a different way? Client: mm. …That’s a weird question. …I guess I would say it’s different. H It’s somehow more distanced. Maybe it hurts less? Therapist: Uh-­huh. So you can notice the pain, notice your wish to make it go away, and also notice that you’re noticing it. There sure is a lot going on in our tricky brains. Could it be that at every moment, there’s a part of you that’s there and can notice whatever shows up, painful though it may be? Isn’t it the case that this observer you is just there, along for the ride, noticing and experiencing each moment, moment by moment? Client: Yeah. It’s just that I hate it. Therapist: As I look at you, I’m starting to realize how long you’ve carried this sense of yourself as weak, carried this pain around the word “weak.” (Exhales.) I’m wondering, when is it easier for you to bear this pain? Is it easier when you’re judging your suffering and fighting with it? Or is it easier when you’re simply noticing this emotional suffering and allowing some caring intention to be here now, allowing yourself this…wish that the pain might somehow relent? Client: I guess it’s when I stop the judging and just allow myself that wish. … Then the pain might fade. Therapist: That feels like warmth in your voice now…not forcing the pain away, but standing back and looking upon yourself with a kind intention. Client: Well. …I guess it does feel somehow warmer or softer.

Nonjudgment and Acceptance In the hexaflex model of psychological flexibility, the concept of acceptance is different from a conventional notion of acceptance as resignation, giving in, or giving up. Crucially, in ACT acceptance includes an element of willingness, defined as a voluntary choice to be in contact with difficult mental events and emotional experiences. This form of psychological acceptance is defined as “the adoption of an intentionally open, receptive, flexible, and nonjudgmental posture with respect to moment-­to-­moment experience” (Hayes et al., 2012, p. 77). In terms of compassion, this process of acceptance means choosing to remain open to our awareness of suffering as we encounter it in the world and in ourselves, even when it is difficult to bear. Of course, it is all too easy to engage in avoidance and control strategies when we encounter experiences that we don’t wish to face, yet experiential avoidance also drives much of our suffer- ing (Ruiz, 2010).

In order to help clients face their fears, their shame, and even their self-­ criticism, CFT aims to help them adopt a sensitive, nonjudgmental, and accept- ing awareness of the pain inherent in being human. This is not a white-­knuckle or masochistic striving to remain in the presence of suffering for the sake of suffering. Compassion is not about just sitting in the cold, dirty bathwater of life so you can “feel your feelings” or “be accepting.” As the psychological flexibility model suggests, acceptance in the service of compassionate motivation involves a willingness to be in contact with suffering as we encounter it (through the psychology of engagement), and a willingness to feel the pain involved as we begin to take action to do something about the suffering we encounter and move toward greater well-­being (through the psychology of alleviation).

Clinical Example: Cultivating Acceptance, Nonjudgment, and Compassion We return to the example of Gene for an illustration of how we can use a com- passionate therapeutic relationship to help train clients to disidentify from their thoughts and emotions, access their inner wisdom through a functional analysis of their inner critic, and move toward willingness from a place of self-­kindness and courage. Gene has been offered a gallery show for his paintings, but rather than work on this, he has been staying in bed, smoking marijuana, and binge-watching TV programs, bringing on a barrage of self-­criticism. He has been responding through profound experiential avoidance that has been keeping him from engaging in activities that give him a sense of meaning, purpose, and vitality. This session takes place a few weeks prior to Gene’s gallery opening, and Gene has been completely avoidant in the week preceding the session.

Client: o, I’ve been beating myself up all week again. I’ve hardly gotten out S of bed. I just smoke weed and play video games most days. I’m disgusting. Therapist: Well, this week has been very much like the rest of the month. You’ve been curling up and hiding. That’s very sad, really. Client: eah, I wish I were getting out to see my friends or to the studio, but Y I just feel like I can’t face it anymore. I can’t even think about painting. Therapist: What is your anxiety? Client: y anxiety? Hmm. I guess that I’m afraid that if I bump into anyone, M I’m going to remember that I suck, that everybody dumps me, and that I am not working hard enough. I need to get more done and get my work in for the gallery show, and I’m screwing up. Therapist: That part of you that tells you “you suck” and “you’re not enough”—­ what emotions show up when that part drags in that old story? Client: Ugh. You know how it is, Doc. Despair, misery, and total dread. Therapist: “Despair, misery, and total dread.” This is a pretty heavy trio you’ve got showing up. It’s tragic, really. (The therapist is clearly moved by this sadness but is half smiling in the presence of these emotions.) Sometimes this life just feels like shit, doesn’t it? Client: ( Laughs and allows a few tears.) Yes, indeed, it does. That’s why we’re talking. Therapist: Exactly. That is why we are talking. …Let’s dig into this experience a bit, shall we? (The client nods.) So let’s imagine that we had a magic pill like in the movie The Matrix—you know, the movie where everything that was going on was like an illusion in a computer? Let’s say we have this magic pill, and if you took it, the part of you that tells you that you suck would go away forever. You could walk right out that door and never have the ability to tell yourself “you suck” or “you’re not enough” again. What would you be most afraid would happen if you took it? Client: That would be great. Nothing bad would happen. Therapist: Well, okay, maybe that’s the case. But what would your anxious self be afraid of if you took this pill and left my office without that harsh inner critic telling you your flaws? Client: I see what you’re doing here. Okay, my anxious self would be most afraid that I would be lazy—­that I wouldn’t get out of bed or live up to my potential. Therapist: Okay, so that anxious self believes that the criticism is needed to keep you living your life effectively? Right? Client: Yes. Therapist: So, the critic is trying to help you to live up to your potential? Client: Uh-­huh. That critic is trying to protect me from failing. Therapist: I see. So we can imagine that this critic has an intention to help you. But, is it really helping you? Client: No effing way! This voice shows up telling me that I’m a piece of garbage, and I feel so exhausted by it that I just want to check out and cry. That’s the irony. I’m afraid that if the criticism would stop, I’d be lazy, but all it does is make me shut down and hide, which is basically the same thing. I feel so trapped in all of this. Therapist: “Trapped.” Your mind tells you that you’re trapped, that you can’t get out of bed. That is just so sad and so heavy. What part of that experi- ence of being criticized and trapped are you least willing to feel? Client: Least willing to feel? Hmm. Well, I think it would be feeling ashamed that I’m not working hard enough. That’s very tough. Therapist: It sounds like it is. It’s a feeling that’s led you to stay in bed and be very stoned, checked out, and all alone. That is tough. I hear you telling me that the part of this that you really don’t want to feel is this sense of shame for not doing enough. Please tell me, what would you have to stop caring about to not feel bad about ignoring your work? Client: What would I have to stop caring about? Okay. Well, if I were going to totally stop feeling ashamed of blowing off my art and my work, I would have to basically not care about being an artist. Therapist: Are you willing to do that today? Are you willing to leave this office and not care if you’re working on your art and your craft? Client: No. My art means everything to me. It really does. Therapist: Yes! It does. That’s a beautiful thing. So, if feeling sad and ashamed was a necessary part of carrying your life forward and being the version of yourself you wish to be—­being the artist you wish to be—­ would you be willing to feel sad and ashamed? Client: I ’m feeling sad and ashamed anyway! But, yes, if facing those feelings was a part of living my life and being the artist I can be, I guess I can feel them. Therapist: That, Gene, is compassionate courage. That’s acceptance and will- ingness. Can you feel what it’s like to touch that accepting part of you? Client: Yes. I don’t like to feel the dread and anxiety that show up with this criticism, though. It sucks. Therapist: What a leap you’ve made there, Gene. You’ve moved from “I suck” to “It sucks to feel so criticized”! You can feel bad without buying into the idea that you are bad. That’s a huge step. We’ve seen how much you care about being an artist and how you’ve learned to have an inner critic who keeps telling you that you suck and that you’re awful. And when we looked at that critic’s intention, we could sort of see how he was aiming to protect you from failure… Client: ( Speaks with animation, eager to join in.) And we also saw how all he’s doing is making me feel worse by telling me “you’re awful.” It’s funny how that part of me tries to get me moving and succeeding by telling me the same sort of critical crap that my stepmother told me for years. I don’t respond to that kind of abuse. It makes me just shut down. Therapist: That’s a remarkable connection. So the part of you that hears this criticism is like you were when you were a boy. That part tries its best to do what makes the critic happy while listening to relentless criti- cism. When we think of that boy, with all of his hopes and fears, what might we want to say to him from a place of compassion and strength? Client: I would want to tell him to just keep on going. I want him to get up and go to the studio, even when those voices are saying he’s shit. He doesn’t have to give in, and he doesn’t have to give up. Even if the critic keeps going on and on, he can do it. Therapist: That’s very moving. You’re finding a kind of bravery in your accep- tance and compassion. So, it seems you’re willing to carry this and live your life deeply. Client: Hey man, it’s easier said than done, right? But, yes, I definitely want to do that. Therapist: One last thing on this. That critical part of you that thinks it’s helping by badgering you and calling you names—­the part that’s really bringing you down? What would you want to say to that part from a place of wisdom, compassion, and strength? If you could, imagine what it would be like to speak from that compassionate courage and tell the critic what you want to say. Client: ( Sits up straight.) I would say this: “Listen, buddy, you’re going about this all wrong. I don’t respond to abuse, so if you want to help me get moving, you’ve got to speak to me like a human being. I know you’re trying to help, but could you just lighten up a little?” Therapist: That’s wonderful, really. How did it feel to say that? Client: I think I get it, Doc. I can get moving this week, even if the critic keeps it up. Phew! This is exhausting work today. Therapist: Yes, it is. But you’re doing it. You’re looking out for yourself. I’m glad you’re facing these things here. Client: I need to face them somehow.

Distress Tolerance and Defusion The evolved nature of human cognition, symbolic representation, and derived relational responding has resulted in a tendency to respond to the literal meanings and stimulus functions of our thinking in ways that strongly influ- ence our subsequent behavior (Blackledge & Drake, 2013). We will be getting into quite a bit of detail about this process as we continue. For now, we can note that imaginal events can exert control over everything from our biological systems to our overt behaviors. In order to tolerate distress, we must have suf- ficient freedom from the influence of mental events to be able to remain in the presence of painful experiences while engaging in freely chosen actions. In ACT’s model of psychological flexibility, defusion represents a trainable ability to disrupt or transform the effects of mental events, providing some liberation from being dominated and controlled by events arising in our evolved minds (Hayes et al., 1999). ACT offers many empirically supported techniques for facilitating defusion, which are present throughout the CBS literature. More recently, these methods have begun to be adapted into compassion-focused therapies for anxiety (Tirch, 2012).

The CFT concept of distress tolerance differs from defusion in many ways. In fact, distress tolerance is highly involved with acceptance and willingness (Gilbert, 2010). However, the capacity to stand back from the historically deter- mined influences that mental events may have upon us and act differently than we have habitually involves defusion from the functions of these events. For example, consider a client who experiences chronic shame and self-­criticism and needs to give a presentation at work. If his mind is telling him that he needs to stay home to avoid the anxiety he will face in public speaking, his ability to tolerate the distress he will feel when standing before his colleagues will call upon his capacity to defuse from the dominance of past events.

The relationship between defusion and acceptance is very close and interde- pendent, with the two processes combining to form what, in ACT parlance, is referred to as an open response style. In CFT, distress tolerance and nonjudgment interact in a similar way. As we are able to defuse from our habitual responses, ease the grip of self-­condemnation and judgmental thinking, accept the diffi- cult experiences that face us, and tolerate distress, we are better able to face suffering and take steps to alleviate it. Furthermore, activating our evolved capacity for affiliative emotions, centeredness, and compassionate motivation can enhance our ability to be accepting and open. In this way, these somewhat parallel processes in the psychological flexibility model and the psychology of compassion interact, in each case affording both new perspectives on how to relate to our experience and a range of methods for moving toward greater com- passion, flexibility, and well-­being.

Clinical Example: Training Acceptance and Defusion with a Compassionate Focus John is a sixty-­five-­year-­old man who complains of incapacitating attentional difficulties, though doctors haven’t found any evidence of cognitive impairment or attention deficits. He manages a well-­liked natural food store that hosts a number of community activities. He’s been involved in community projects all his life and genuinely loves being of service to others. Yet he often feels like a fraud and experiences significant social anxiety and fears of public speaking. Lately he has become acutely preoccupied with his “memory issues.” He feels so guilty about them that he finds it hard to pay attention to what others are saying and has become deeply depressed.

Therapist: How’s it going? Client: Bad. On my way here, I crossed to the other side of the street so I wouldn’t have to meet this lady I know from the shop. I couldn’t remember her name or what she talked to me about just yesterday! It was some upsetting family matter, but I can’t remember what. My damned memory! So I crossed the street to avoid her. I’m not sure if she saw me. I hope not! I feel like such a coward, and like such a fraud for the “emotional support” I gave her yesterday. If I can’t remember it now, it must not have been worth much. (Sighs heavily.) Therapist: It’s really tough to feel so bad and so preoccupied with the thought that you can’t remember what people tell you. Client: Yes, it’s hard. Therapist: I hope you can find relief from the weight of that. Client: Can I? Therapist: I hope you can. It would be a relief because it’s so hard for you to be going through that. Client: Yes, and I feel it’s only getting worse. Therapist: I’m having an image of this painful thought, about not being able to remember, standing between you and the people you’re talking to. Where does it stand? (Raises his hand and holds it several inches from the side of his own head.) There? (Brings his hand closer to the side of his head.) There? (Brings his hand in front of his eyes so his line of sight to the client is blocked.) Here? Client: ( Raises his hand in turn and brings it in front of his eyes.) More like here. Therapist: Wow. I want to stop for a moment to acknowledge how painful it is for you to have this thought effectively blocking you from being fully present with other people. I know how important others are to you. Client: Yes, it’s really hard. Therapist: And you must feel so alone. It’s as if it’s cutting you off from others. Client: Yes. Even my wife can’t fully understand how I feel. Therapist: Maybe we can make some room for how terribly painful it is for you to have this thought stand in your way and isolate you so much. Client: How do I do that? Therapist: Well, John, I don’t think it makes you a fraud to have it there. I just think it makes life very hard for you. Client: It sure does. Therapist: So when life is so hard, what could help you most—bringing more harshness and judgment into the equation? Or do you need more kindness? Client: I guess kindness. But I’m not very good at being kind to myself. Therapist: Perhaps we can also make room for that as you learn how to be kinder to yourself and the difficulties you’re going through. Client: (Smiles.) I’d like that.

CBS, Compassion, and Buddhist Psychology Western science continues to advance our understanding of compassion and the central role it can play in human psychological growth, adaptive behav- ioral functioning, psychological flexibility, and wellness. The scientific method allows us to expand our understanding and test its applications. However, we can continue to find wisdom in the thousands of years of prescientific phenom- enological research conducted by contemplative traditions. In Buddhist psy- chology, several different aspects of compassion are discussed, and each reflects a nuance of the experience of compassion. For example, the concept of metta represents loving-­kindness and a desire for all beings to be happy and at peace. Another Buddhist aspect of compassion, bodhicitta, is very significant to an ACT formulation of compassion, as it provides an illustration of how an indi- vidual’s sense of self might be intimately involved in the experience of compassion.

Bodhicitta represents an altruistic aspiration for the end of suffering for all beings. It is said to arise among advanced meditators after they have recognized and encountered a sense of self that acknowledges and experiences the inter- connectedness of all things. If we were to view the prescientific concept of bodhicitta in the way we would view a scientific hypothesis, we might posit that ongoing mindfulness practice leads to a shift in the sense of self such that all mental phenomena become insubstantial. In addition, this shift in sense of self allows for recognition of the interconnectedness of all things and all beings, with all conceptual divisions and separations being merely verbal constructions and acts of relating symbolic events in the mind. In this way, the arising of bo­dhicitta may involve letting go of evaluative self-­concepts, which, by definition, place us in a position of opposition to others. Indeed, even the concept of a self may be viewed as an ongoing process of relating moment-­to-­ moment experiences to one another, creating a conceptual process of experi- encing reality that is actually based upon formlessness and sunyata, or emptiness. This shift of perspective is hypothesized to evoke a desire to alleviate all suffer-ing in all beings. Therefore, in Buddhist psychology, compassion arises from a fundamental shift in perspective away from a content-­based sense of self and toward an experience of self as a stream of bare attention. Clearly, there is a high degree of conceptual continuity between such a formulation and CBS con- cepts of flexible perspective taking, with the experience of self-­as-­context being crucial to liberation from suffering.

By shifting the focus away from a content-­based self and adopting a psycho- logically flexible perspective, the ongoing pursuit of high self-­esteem (and its attendant downsides in terms of narcissism and damaging social comparisons) can be avoided. This may help explain why the practice of self-­compassion leads to more beneficial outcomes than the cultivation of self-­esteem (Neff, 2009). Psychological flexibility obviates the need to judge or evaluate a content-­based self as good or bad, given that the self is seen as an experiential process rather than a reified entity. This may facilitate a reduction in shaming and blaming self-­talk and an increase in the ability to be kind to oneself in contexts of suf- fering. Psychological flexibility also allows individuals to commit to courses of action that align with their core values, perhaps helping to explain why self-­ compassion is linked to greater motivation. As was the case with exploring contemporary theories of compassion in applied psychology, exploring the rela- tionship between psychological flexibility and Buddhist psychology’s conceptu- alization of compassion also reveals a window of opportunity to further a science well-suited to addressing the problem of human suffering.