4 临床实践中自我慈悲的训练

4 Training Self-­Compassion in Clinical Practice Regardless of their theoretical approach, clinicians often notice that successful therapy leads to a profound sense of self-­reconciliation. We believe that compas- sion for oneself and one’s inevitable failings, past, present, and future, is a key element in such self-­reconciliation. Pierre Cousineau, a clinician friend of ours, likes to say that if he could give his clients only one skill, he would give them the skill to be self-­compassionate. Unfortunately, our evaluative and comparing minds make it so easy to fear or hate our selves, histories, thought patterns, emotions, behaviors, and the self-­concepts that inevitably come to filter our experience and seemingly limit our options. Yet when we are at war with ourselves or some part of ourselves, what could a victory possibly look like? Who would win and who would lose? What would become of the loser, and what would be left of the winner? From a compassionate perspective, nothing is to be gained by prosecuting a war against those parts of our experience or ourselves that evoke discomfort and stubbornly resist our attempts at change. It’s only natural to dislike aversive experiences such as fear, sadness, or self-­doubt. From there, it is only a very short distance to hating them and the vessel that contains them. Then comes hatred for the kind of person who feels or does such things; in other words, oneself. Our culture disparages weakness and negative experience and makes this dislike abundantly clear in myriad ways—including, quite often, through our early caregivers. As we learn how to relate to our private world from our early caregivers, we may adopt a hostile, dismissive, avoidant, or invalidating attitude toward difficult inner experiences, perhaps based on the assumption that we are supposed to think rationally and feel good, supposed to be confident and opti- mistic. We may believe we are expected to “just do it” regardless of inner obsta- cles. These messages are pervasive to the point where it can feel unsafe to publicly show any sign of weakness. When the evaluative mind enters the fray, these social processes become highly potentiated and the war against inner experience starts in earnest. If only we felt differently, if only we could see the good side of things, if only we’d had a different history; if only we had a less negative vision of ourselves, more self-­esteem, less self-­doubt, more of this, less of that…then we would finally be complete and whole. Verbal processes trap us in endless evaluative frames from which we nearly always emerge at fault. In this context, training self-­compassion can be seen as the overarching goal in therapy. If we all had the skill and courage to make space for our own suffer- ing and be kind to that part of ourselves that stumbles and sometimes falls, change would become so much easier. Through self-­compassion, mistakes cease to present us occasions to berate ourselves, shame dissipates, and we become our own best friend, coach, or ally, providing ourselves with whatever support we need to make it through and move toward what really matters to us. This chapter explores the clinically relevant processes that make us hate ourselves, the forms they can take, and the functions they can serve. It then outlines a number of key skills that can assist clinicians in training self-­ compassion and briefly discusses psychological barriers to self-­compassion from a learning theory perspective. Then, through the lens of our clinical practice, we’ll explore the elements of the deep reconciliation that can arise from self-­ compassion and offer some clinical approaches that may be helpful in getting clients to engage in this process. The Ultimate Frontier in Self-­Reconciliation When therapy works at a deep level, it brings clients to a place of profound rec- onciliation. In that place, the past has not been erased, nor has pain disap- peared, yet clients’ resonance and relationship with the self are transformed. Of course, personal flaws, pain from past history, judgments of the evaluative mind, and scary emotions do not disappear, though they often become less intense. They still play out on the stage of our private personal experience; however, instead of igniting an inner war, they can now lead to a kind inclination of the heart and a softness born of taking the full measure of the struggle and its costs. Clients develop a new sense that they are able to speak to themselves in the way they need to be spoken to in order to provide the support that will allow them to move toward what is important in this difficult and beautiful life. In our clinical experience, one characteristic common to clients who have effected deep and lasting change in their behavior is a sense of having made peace with the parts of their experience and past that they had been warring against or fearful of. Their problems have in no way been magically solved, and they will assuredly know suffering again. Yet they seem to approach their entire selves with a new sense of kindness and reconciliation. At this point, names and tags fall away, and it is not uncommon for clients to even wonder about the diagnostic labels that have been applied to them, as they have come to see more broadly that suffering is an integral part of the human experience—­one that informs what is centrally important to us and can be held with the same kind- ness and willingness as our deepest values. What, then, would be the sense in trying to not have suffering, to dismiss it, avoid it, or somehow invalidate it? Clinical Example: Holding Yourself in Kindness Below is a dialogue with Carl, who has come to the end of a twelve-­session course of ACT. When Carl started ACT, he was forty-­two and came with a twenty-­year history of therapy, sometimes in inpatient facilities. He had at various times been diagnosed with depression, generalized anxiety disorder (GAD), and obsessive-­compulsive disorder (OCD). From his point of view, his main difficulties were anxiety and a lack of self-­esteem. After ten weekly ses- sions, he took a break from therapy and came back three months later, then once again three months after that. Below is an extract from that twelfth session. For the past six months, he’s been gradually improving. Therapist: So, how do you feel about our work? What has changed? Client: ell, it’s strange to say, but the main thing for me is how I’ve stopped W being so hard on myself. Therapist: How so? Client: I used to constantly judge myself and feel ashamed because of my anxiety. Then I would judge myself for making lists, seeking reassur- ance, and doing my rituals. Of course, I would judge myself for having OCD, depression, and—what do they call it again? DAG, AGD, GAD? Who cares about these labels anyway? Then, after we started our work together, I would judge myself for judging myself! I basically used to hate the Carl that did all this. Therapist: Ouch! Client: eah. Well, I wanted to be someone else, someone better, someone Y without anxiety. Now I see that I was at war with a part of myself. How could I win against myself? Now what’s important to me is to move in directions I care about. Of course I’ll stumble and even fall. And that will be hard. But it’s okay, because when I fall, I now know not to treat myself so harshly. Everybody stumbles sometimes, right? So yeah, I’d say the main change is I’ve made my peace with myself. Three years later the therapist met with Carl again. He’d made the choice to end his relationship of ten years with his partner. Most importantly to him, he’d changed jobs, moving out of banking and into providing support to teenag- ers who were struggling in school. He’d also stopped smoking and started exer- cising. The job change was tough and money was tighter, but he loved his new job, working in a school and helping troubled kids, and he was good at it. The dialogue below is from that follow-­up session. Therapist: How did you manage to make these difficult changes? Client: ecoming kinder to myself allowed me to follow my heart, even B though I knew it would be difficult and scary at times. Therapist: And was it? Client: 86 ( Laughs.) Oh yes! But nowhere near as bad as the stories my mind used to sell me! What I do now is just proceed, knowing it may be hard. And when it is, I give myself gentle encouragement. I guess I speak to myself a bit like I wish I’d been spoken to as a kid—­and, come to think of it, a bit like I speak to those kids I work with. We contacted Carl again as we were writing this chapter. It has been six years since he was last in therapy. He has a new partner, and they’re in the process of buying a house together. He still loves his job helping teenagers. On the occasions when he feels down, he goes back to the observer perspective and practices receiving his distress with kindness. There is no question that he is finally leading a rich and meaningful life. Carl’s story is evocative. It is particularly interesting to us in that, more than six years after a brief treatment that helped him get unstuck from over twenty years of struggling with obsessions, compulsions, worry, and poor self-­esteem, he reports three skills as being central to maintaining the gains of treatment: an ability to take an observer perspective on his experience, choosing directions rather than rigid goals, and receiving with kindness the experiences he cannot change. In other words, though Carl does not specifically name compassion and his therapist did not engage in explicit compassion work, Carl has learned to be self-­compassionate. What Makes Us Hate Ourselves? From an ACT perspective, fusion with self-­as-­content can be one of the most potentially damaging processes we face. Indeed, long histories of punish- ment for a wide array of behaviors, augmented by the attendant verbal punish- ment that minds deliver, can result in people becoming fused with self-­critical or self-­shaming constructions their minds insist are their true selves. Clients (and if we are honest, most of us) therefore walk around with fused notions of who or what they really are, and more often than not hate or shame themselves for it. Depressed, anxious, shy, ugly, socially inept, unlovable, complicit in abuse, ne’er-­do-­well, coward, idiot, misfit, defective, and so on—­the list is endless. But whatever particular set of epithets the vagaries of our personal history have led us to fuse with, one thing most of us share is that we intensely dislike and often criticize ourselves for whatever self-­concept we hold. Derived relational responding is the driving force in this dynamic. Most of these labels arose from painful moments in our history. Through the transfor- mation of stimulus functions that lies at the heart of relational framing—a largely involuntary process—the pain, and often shame, that these events elic- ited became attached to the memories of the events and the labels our behavior, experiences, or entire self received on those occasions. When that content is, in turn, put into a frame of equivalence with the self, then our very notion of self becomes aversive—­something to move away from. This can lead to self-­hatred and self-­shame and take many forms, including suicidal ideation, self-­harming behavior, self-­chastising or self-­aggrandizing talk, putting on a mask and pre- tending, ruminating, self-­shaming, and dissociating. Fusion of our sense of self with content or labels of experience is often prompted and reinforced by caregivers or peers, through statements like “Little Joe is such a shy boy,” “You asked for it!” “You’re such an idiot for not seeing this,” “You’ll never amount to anything,” “Look at this big baby crying again,” and so on. Soon enough, that other-­initiated talk can turn inward and become self-­sustained disparaging self-­talk. Is it any wonder that deep-­set self-­hatred is so prevalent? Because of this dynamic, it is clinically crucial to promote a more flexible sense of self that can help clients disentangle themselves from rigid self-­ concepts and the limitations they impose on behavior. Learning History and Emergence of Sense of Self As mentioned, our self-­concepts are largely the products of our learning histories, especially in relation to our caregivers and attachment figures. From a functional contextual point of view, the self is a function of verbal behavior and emerges as a product of becoming a verbally competent human (Hayes, 1984; Kohlenberg & Tsai, 1991). Developmentally, the acquisition of verbal behavior goes through a number of phases. At first children learn to name objects, then subjects and actions, often as whole functional units containing all three: “Baby eats apple.” “Baby sees doggy.” “Daddy reads book.” As children grow more sophisticated in their use of language, the functional units become increasingly smaller, separating subjects from objects (baby from apple) and objects from actions (apple from eating). In normally developing children, this process is relatively straightforward as regards publicly observable objects and actions. Most children are presented with a great many opportunities to use and respond to functional verbal units and get fairly consistently reinforced for correct uses and responses. This is a form of multiple exemplar training that is ubiquitous, and a consistent history of reinforcement is a central condition for successful multiple exemplar training. Early on, children have no more language for their inner experience than they do for the experience of their senses. And whereas learning to orient to sensory experience is necessary for physical survival, the world of inner experi- ence, as Skinner (1974) noted, only acquires significance because it is important to other members of our verbal community. In this way and through social inter- action, we learn modes of interacting with our inner experience. This is why it is so common for people to recognize their caregivers’ voices in their self-­talk. How does the individual learn to recognize and name that part of the universe that only he can observe? How do we learn to name what we feel when no one can see it? Because our caregivers do not have direct access to the objects or actions involved (bodily states and sensations), a certain amount of guesswork is necessary, often based on what can be observed of the child’s behavior. This means that, even at best, our descriptions of private events can never have the precision of our descriptions of publicly observable objects or events (Skinner, 1974). A consistent learning environment requires that caregivers devote exquisite attention to subtle cues, and that they flexibly adapt to new information avail- able from further observation. When caregivers are stressed, absent, overworked, avoidant of or overcome by emotion, or themselves the product of an inconsis- tent learning history, chances are they will not respond in ways most conducive to children learning how to recognize and name their inner experience and accept it as normal. Under these conditions, children might be told that they are angry when they are in fact hungry, that they are hungry as the clock strikes noon, that they are not (or should not) be sad when they are feeling sad, that they want ice cream when in fact their caregiver wants ice cream, and so on. Repeated such experiences during early development may lead to children having difficulties in learning to name what they feel or want with any precision and under the control of internal stimuli (i.e., what they really feel, think, or want). Instead, they may have to take cues from others to know about their “own” thoughts and feelings. Their inner experience might have received so little attention that they have no words to describe it. In many cases, they will have learned to fear, deny, or judge their inner experience rather than notice and accept it as one may notice and accept the changing weather. In extreme cases, such as when early attempts to name feelings, thoughts, and desires have been consistently or unpredictably punished, they may present with a veritable phobia of experiencing or expressing their inner experience.

The world of inner experience can thus become an unfamiliar, unstable, treacherous territory, full of darkness, threats, and defects. And that, in turn, will further feed self-­hatred, shame, fear, and a sense of unrelenting inner con- flict. Clinically, clients may say that they do not know how they feel or think. They might be unable to describe inner sensations or name their emotions, perhaps only locating feelings in their heads; or they may react aversively to any attempts at helping them contact inner experience, such as through eyes-­closed mindfulness exercises. Attachment and Self-­Compassion in Context How caregivers respond to a child’s instinctual bids for affiliation can also have a profound impact on affiliative behavior. Whether those bids have been consistently reinforced, ignored, punished, or responded to inconsistently (at times reinforced, at times punished or ignored) can contribute to the develop- ment of the child’s attachment patterns (Mansfield & Cordova, 2007). A history of consistent reinforcement for affiliation bids could result in a secure attach- ment style. A history in which such bids were consistently ignored may lead to an avoidant attachment style. A history in which those bids were consistently punished could produce an attachment style that’s fearful. And because few learning histories are perfectly consistent, different combinations of reinforce- ment, punishment, and ignoring could lead to a mixed attachment style with either a dominant style or, in cases where inconsistency is the norm, a disorga- nized attachment style. Because we learn our relationship with our inner expe- rience and concepts of self largely from our attachment figures, these styles could in turn be reflected in individual styles of relating to inner experience: secure and accepting, avoidant and dismissive, fearful and critical, or disorga- nized and unaware. Of these, only the first style would naturally incline the individual toward self-­compassion. The others would naturally fuel different forms of self-­hatred, self-­shame, and inner conflict. It thus takes a specific learning history and a deliberate verbal context and community to build an accepting and kind relationship to one’s own experience and self-­concept—­a relationship that consistently reinforces compassion for one’s own aversive experiences and those of other people. It makes sense that when that history is missing, a healing relationship, such as the therapeutic relationship, might provide a privileged context for building a new learning history that fosters and reinforces affiliative responding and self-­compassion skills, something we’ll discuss in detail in chapter 6. In this way, the therapeutic relationship offers a setting in which a different approach to the self and one’s own experience becomes possible. This can range from helping clients learn to receive their negative self-­concepts with strength, wisdom, and kindness to helping them transform a sense of self that is unstable or disorganized. Within this context, clients can also adopt a more flexible sense of self. Verbal Processes and Self-­Compassion We have discussed how the verbal community is central to learning one’s relationship to one’s own private experiences, thoughts, and emotions. Now we will briefly look at the influence of verbal processes on self-­criticism and self-­ compassion. Understanding the verbal processes that lie at the root of self-­ hatred and reinforce it can help clinicians devise targeted interventions to gradually undermine self-­critical behavior and foster a more compassionate approach to how hard it is to live in this world. This approach highlights the importance of being kind to oneself in order to have a chance to move toward what is important in life, even in the face of deep-­seated and painful inner obstacles. As previously noted, fusion with the content of one’s experience and verbal constructions is the process that fuels self-­criticism and self-­hatred. The fruit of derived relational responding and the transformation of functions, cognitive fusion is ubiquitous and constitutes the normal mode of mind. Through derived relational responding, inner experience acquires the aversive or appetitive func- tions of sensory experience. Though it is useful and at the root of our ability to think abstractly, fusion makes it highly probable that individuals will define themselves by the content of their experience. From there it is natural to evalu- ate one’s self-­concept and classify it as aversive. Thus, clients will judge them- selves as bad because of what they have experienced (for example, trauma) or still experience (anxiety, sadness, fear, doubts). They may condemn their present selves for past actions. They may feel ashamed of having intrusive ego-­dystonic thoughts. They may fear their inner experience and equate their feelings of emptiness with proof that they are somehow less than others.

Self-­Compassion Versus Self-­Esteem Whereas traditional cognitive approaches may recommend helping clients reevaluate their self-­definitions more rationally, from an ACT perspective the problem with self-­hatred does not arise from the content of one’s self-­concept, which would prescribe changing the problematic content, but from excessive fusion with one’s self-­concept, or self-­as-­content. If the problem is not primarily how one evaluates the content of one’s self-­definition, then trying to move eval- uative constructs, such as self-­esteem, might not prove most helpful. From an ACT perspective, trying to directly modify one’s self-­evaluation (i.e., improving one’s self-­esteem) runs the risk of investing self-­evaluations with excessive importance. Then, through derived relational responding, the risk of increasing or strengthening negative self-­evaluations arises. A positive evalua- tion marshaled in the service of weakening a negative sense of self might serve to put both in a frame of coordination that can result in the aversive functions of the original evaluation being transferred to the proposed alternative evalua- tion. Thus, the intended positive self-­evaluation becomes associated with the same experience of suffering as the original negative self-­evaluation. Furthermore, high self-­esteem in itself is not necessarily correlated to better social or general functioning. When insensitive to context and attached to one’s self rather than one’s actions, positive evaluations are liable to lead to higher degrees of narcis- sism and lower levels of prosocial behavior (Morf & Rhodewalt, 2001). In addi- tion, such artificially inflated, conditional self-­esteem is fragile. A potentially more fruitful approach to dealing with negative self-­evaluations, and one that carries fewer risks of unintended side effects, would be to cultivate compassion for aversive self-­concepts. In this work, the key processes are defu- sion, acceptance, and fostering experiential contact with a sense of an observer self, or self-­as-­context. The central focus is on cultivating the ability to take perspective and receive one’s suffering and negative evaluations as they arise. Establishing an Effective Context for Training Self-­Compassion We believe that effectively training a more self-­compassionate approach to one’s suffering is greatly enhanced by various prerequisites and key skills. From a contextual point of view, it is crucial to establish a context that will prove most effective in fostering compassion. Foundational elements for establishing such a context include a deliberate focus on acceptance in the therapeutic relation- ship, the skill set of the therapist, presentation of a rationale for the work, estab- lishing a functional contextual point of view, and orienting to function and workability rather than form. Establishing an Accepting Relationship In psychotherapy work, the therapeutic relationship is the primary context in which change takes place. We believe it is essential for the relationship to be based on acceptance, kindness, compassion, and reciprocity. As suggested by the promoters of functional analytic therapy, the therapeutic relationship can be established as a sacred space that can compassionately hold everything clients think and feel, along with all of their history and the whole of who they are (Tsai & Kohlenberg, 2012). It can also become a model of a truly intimate rela- tionship, which, in the definition offered by Cordova and Scott (2001), is a relationship in which behaviors that are liable to be socially punished, such as sharing vulnerabilities, opening up to one’s hopes and dreams, or showing one’s soft side, are not only not punished but in fact reinforced. Such a relationship can offer a supportive environment for the cultivation of self-­acceptance and self-­compassion. In chapter 5, we will further detail how to use the behavioral tools of functional analytic therapy to promote such a relationship. Cultivating the Therapist Skill Set ACT has its roots in a model of normal functioning in which evaluative verbal processes inherently feed cognitive fusion and experiential avoidance and can lead to unclear values and lack of contact with the present moment. In turn, fusion with the self-­judgments that the interactions of these processes can create is a universal human experience. And just as ACT clinicians are all the more effective when they embody compassionate flexibility around their own fusion and values, training self-­compassion is best done by clinicians who prac- tice self-­compassion around their own struggles, self-­judgments, and shame.

To effectively foster curative relationships, clinicians must themselves possess a flexible repertoire for intimate relating, including the skills or behaviors they seek to train in their clients. Direct experiential work is key. This can be accom- plished by working through the clinician exercises proposed in this book, and by attending experiential training workshops in ACT, CFT, and FAP. Clinical supervision or participating in a peer consultation group with like-­minded clini- cians can also be helpful in developing these skills in both personal and profes- sional life. Beyond the clinic, practicing deliberate acts of kindness with loved ones and strangers, keeping a log of compassionate interpersonal risks and acts of self-­ care, cultivating mindfulness, and engaging in compassion-­focused imagery practices can all contribute to learning to stay within a mindful, compassionate space. Mindful movement practices, such as yoga or tai chi, can also be helpful. Presenting an Overall Rationale for the Work A key aspect of creating a context for compassion-­focused work and enhanc- ing client motivation is presenting a rationale for the work. While there are a number of ways to do so, we believe that an effective rationale stems from the functional contextual point of view and includes several key elements. The first step is to establish mindfulness—­a focus on what happens in the present moment—­as the favored arena for training and learning new skills. Following from that, the therapeutic relationship can be presented as a context in which familiar difficulties can and will show up, providing precious opportunities for present-­moment work. Drawing clients’ attention to this dimension of the work can help normalize emotional and affective issues that will arise in or about the therapeutic relationship. It also provides the groundwork for the clinician to turn to clinically relevant behavior when it shows up in session. As defined by FAP, and as we will detail in chapter 5, clinically relevant behavior is problem- atic or improved behavior that occurs in session and in the therapeutic relation- ship and that is an instance of problematic or improved client behavior outside of session (Kohlenberg & Tsai, 1991). Establishing a Functional Contextual Perspective on Compassion The functional contextual viewpoint on compassion can be set forth by presenting psychological flexibility as becoming able to do what is important even in the presence of inner obstacles such as unpleasant or painful emotions, thoughts, or self-­judgments. This can be presented in a number of ways, such as through a metaphor suggesting that we cannot control the waves of our emo- tions but can learn to surf them. Another effective way to present the func- tional contextual viewpoint on developing compassion is through the ACT matrix (Polk & Schoendorff, 2014). Intervention: Presenting the ACT Matrix The ACT matrix, shown in figure 7, is a diagram that helps orient client and therapist toward increased psychological flexibility and compassion. It can provide an effective way to establish a functional contextual point of view with clients in everyday language. The matrix can be introduced in a number of ways. External Experiencing (Five Senses) Values: Family Intimate Relationships Parenting Away Toward Friends Education Work Recreation Spirituality Citizenship Health Internal Experiencing (Inside the Skin) Figure 7. The ACT matrix. (Reprinted from Polk & Schoendorff, 2014, with permission from New Harbinger Publications.)

One effective way of presenting it is to invite clients to name who or what is important to them and ask them to note it in the lower right quadrant of the diagram. Common responses include family, children, spouse, work, or health. Whatever clients may name, it is written down. Next, ask if they always do what would move them toward who or what they identified as important. In other words, do they always embody their values? Of course, none of us do; there are always obstacles that stand in the way. Take a moment to differentiate between external obstacles (material circumstances, other people, or both) and internal obstacles (thoughts, emotions, bodily sensations, and memories, some of which may arise in the presence of external obstacles), then invite clients to list some of their inner obstacles to moving toward who or what is important and place them in the lower left quadrant of the matrix. Common obstacles include fear, anxiety, guilt, shame, pain, painful memories, and thoughts of being unworthy, stupid, not good enough, and so on. Next, invite clients to list some of the things they can or could be seen doing (if, say, a video camera recorded their actions) to move away from these inner obstacles—­behaviors that they usually engage in response to these obstacles or to cope with them—­and place them in the upper left quadrant. These are often resistant or avoidant behaviors and commonly (but not always) stand in opposi- tion to behaviors that would move them toward what really matters. Typical away moves include avoiding, drinking, taking drugs, distracting with television or video games, shopping, working, arguing, seeking to be right, blaming, com- pulsions, doing sports, cleaning, seeking reassurance, and so on. Finally, ask clients what they can or could be seen doing (on the video camera) to move toward who or what is important to them and list these responses in the upper right quadrant. Common toward moves include spend- ing time with loved ones, playing with one’s children, going on date nights, planning a vacation, reconciling, exercising, and doing sports. As the examples we listed illustrate, some behaviors can be considered either toward or away moves depending on whether they are under aversive control of unwanted inner experience or appetitive control of values. For example, you could go to the gym as a move away from anxiety, a move toward health, or a bit of both. And just as only clients themselves can notice who or what is impor- tant to them and what they don’t want to think or feel, only they can tell if a particular behavior is more of a toward move or an away move. When clients are unsure, asking them to ascribe percentages to toward and away can be useful. Through skillful questioning, you can orient a client toward experienc- ing the perspective of an observing self that can notice inner experience and whether behavior is performed in the service of moving away from unwanted inner experiencing (or at times moving toward wanted feelings, such as when using substances) or toward values. Once the matrix has been set up and clients are noticing that the self, or “I,” lies at the center of the matrix—­and the therapeutic process—­you can ask which life clients would choose if presented with two options: doing more things to move away from what they don’t want to feel or think, or doing more things to move toward who or what is important. Thus far, every single one of our clients has voted for the option of moving toward life and what is important. You can then wrap up the process by explaining that the work in therapy will be about becoming better able to choose moving toward who or what is impor- tant, even in the presence of inner obstacles—­a definition of psychological flex- ibility that’s accessible to the layperson. Presenting the matrix sets up a context for therapy under clear appetitive control of values (i.e., moving toward). In this respect, the functional contex- tual approach differs radically from other approaches, which largely seek to help clients move away from aversives, either by reducing the occurrence or intensity of aversive thoughts and feelings, or by helping them change their behavior to escape aversive consequences (such as when promoting abstinence from alcohol and other drugs). We believe that setting up an appetitive context as explicitly as possible is crucial for establishing long-­term motivation that can last beyond the removal of aversive consequences and reductions in distress. Furthermore, it provides an ideal basis for fostering more approach behavior toward aversive inner experience and self-­concepts, which is a key element in training compas- sion clinically. Orienting to Function and Workability Behavior cannot be understood in isolation from its context. For example, looking at different options may be useful before engaging in a course of action but not so helpful once action has been taken and there is no possibility of changing course or outcomes. Whereas other cognitive and behavioral approaches tend to focus on the content of clients’ thoughts, a functional contextual approach seeks to orient to the function of a particular thought or behavior in a given context. Orienting to function involves looking at the effects of behavior, thoughts, emotions, and memories in a given context. Do thoughts of being hurt in the past that arise in the context of meeting a new potential partner serve as obsta- cles, or do they facilitate opening up? Does the behavioral response to these thoughts and feelings serve to move toward valued ends? These two questions—­ what behavior follows a particular inner experience (thought, emotion, memory, or image) and whether this behavior represents a move toward a valued direction—­help orient to function. Orienting to function can prevent clinicians and clients from getting trapped in the content of inner experience and the often futile attempts to change that content. From an ACT perspective, once the unworkable function of a particular inner experience has been identified, defusion and acceptance strategies, along with orienting toward values, are the preferred means of changing the verbal context and increasing the workability of behavior. Validation of the Struggle Self-­ compassion implies unconditional validation of one’s own aversive experiences and feelings. It involves opening up to the entirety of one’s experi- ence and having the wisdom to know that one’s emotions and thoughts are valid. Many clients struggle with self-­validation. Deeply understanding and acknowledging inner experience, particularly emotional experiencing, is a sin- gularly uncommon skill. Even clinicians, who are professionally trained in vali- dating clients’ experiences and emotions, may struggle with this process when turning it inward. Analyzing the Workability of the Struggle From an ACT perspective, an effective first step toward validation includes a functional analysis of clients’ struggles to move away from unwanted inner experiences. In such an analysis, the clinician invites her client to consider how effective his away moves have been, in both the short and the long term, and whether they have served to help him move toward who or what is important. Often clients report that away moves are effective in the short term. This pro- vides an opportunity to validate the fact that the client engages in them. After all, they do work; they are valid, even if not the most effective approach in the long run. Indeed, most clients report that their away moves are ineffective in the long term, causing negative consequences or even making unwanted inner experiences more frequent, more intense, and generally more important in their lives. This provides a further opportunity for clinicians to validate clients’ expe- riences of being stuck in away moves. Finally, asking whether away moves have been effective in helping clients move toward who or what is important helps reorient the work toward their freely chosen values. As mentioned, some behaviors can be either away moves or toward moves, depending on the context. For example, clients can go out with friends or engage in physical activity as a move away from loneliness or anxiety. Yet if friendship and health are important to them, they could also do the same behaviors under appetitive control of their values. This insight can help clients appreciate the potential for increasing the appetitive control of many of their away moves. Here, the power of derived relational responding can come into play, gradually bringing a range of hitherto aversively controlled behaviors under appetitive control. For example, say the compulsive away moves of a client presenting with OCD are running, reading, calling family and friends, cooking, and doing crossword puzzles. As the client comes to see that these are all also moves toward values, he can gradually begin to engage them under the appetitive control of values, rather than the aversive control of anxiety and obsessions. Indeed, we had such a client once who, by the end of treatment, did not meet criteria for OCD anymore while still engaging in largely the same range of behaviors; the difference was that he did so now under the appetitive control of values (Schoendorff, Purcell-­Lalonde, & O’Connor, 2014). Through this kind of analysis of the way clients have struggled—often referred to as creative hopelessness in ACT texts—clients can learn how addic- tive and powerful away moves can be and how they result in people feeling stuck, unable to free themselves from entrapment. The first step toward freedom is to acknowledge this valid experience of being stuck. The next step is to stop struggling with the trap itself—­in other words, defusing from rigid interaction with language.

Defusion from Self-­as-­Content Fusion with negative self-­concept is a major obstacle to fostering a more self-­ compassionate stance. If clients take the negative self-­conceptions their minds produce literally—­self-­conceptions that often echo the words of developmen- tally influential figures—­self-­criticism and self-­invalidation can become their default behavior. By presenting the mind as an evaluating organ, useful for judging whether things fit in the world of five-­senses experiences but not so useful when it comes to controlling inner experiences, the clinician can create more space in which clients can start gaining some distance from what their minds tell them. Clinical Example: Targeting Self-­Judgments and Criticism Given how common negative self-­evaluation is, it may be possible fairly early in treatment to zero in on negative self-­judgments and criticism as they appear in the moment. Asking clients how effective self-­berating has been and how they would like to be able to behave toward themselves instead can help. The dia- logue below, which occurred in the second session of therapy, illustrates such an intervention. Ted is a thirty-­two-­year-old man presenting with depression, pro- fessional difficulties, and a high level of marital conflict. Therapist: So, Ted, what did you notice in your matrix over the past week? Client: I t looks like it’s been mostly away moves. I am just such a loser. I don’t know why you bother with me. Therapist: Ouch! First let me congratulate you for noticing away moves. Minds generally don’t like it when we start noticing this, and one thing they often do in reaction is beat us over the head with the fact that we’ve noticed away moves. Could this be what has happened? Client: Yeah. (Sighs.) Therapist: That must have been really painful. Is it something new, or is this something your mind usually does, judging you harshly and calling you names? Client: 100 Oh, I’m used to it. I’m just a loser anyhow. Therapist: It sounds to me that it’s almost as though “I’m a loser” stands guard to stop you from going anywhere beyond where it’s kept you all these years. Client: What do you mean? Therapist: Well, here you are doing something new: noticing toward and away moves. Yet “I’m a loser” won’t let you do it. It picks up the away moves you notice and tries to use them as sticks to beat you back into the “I’m a loser” corner. Client: Yeah. That’s exactly it. Therapist: I wonder if that’s what you need? Do you really need to be more beaten down? Client: Well, no. But what else can I do? Therapist: How would the person you want to be handle this? By calling you a loser? Or would some other words help? Client: I guess I’d need more encouragement. Therapist: Great! Let’s start by encouraging you to notice when your mind wants to pick up the loser stick and beat you with it. That’s kind of like level two of noticing. The client is fused with the negative self-­concept “I’m a loser,” which func- tions to limit what he can do in a given context. The clinician works on making apparent to the client how fusion with this negative self-­concept determines his behavior, picking up on the self-­judgment and helping the client defuse from it by pointing to its function: beating the client into a corner. Making that func- tion apparent provides the space in which the client can identify an alternative, more compassionate behavior: offering himself encouragement. Intervention: The Mother Cat Exercise Self-­blaming and a harsh approach to our inner distress can become the default mode of interacting with the self-­judgments and other parts of our inner experi- ence that we dislike. Noticing how we receive our aversive inner experience can help lay the foundations of a more compassionate approach to our suffering. The following exercise in discrimination can be very useful in helping clients develop a more compassionate stance toward their experiences, behavior, or past. The exercise builds on a number of aspects of compassion-­focused work and starts with a little story. Imagine you’re observing a mother cat tending her litter of six kittens in a box. Of the six, one is black and white, and from the moment it opened its little eyes, it has shown itself to be more adventurous than its siblings. One day, as the mother cat is nursing her kittens, the little black-­and-­white kitten, who has ventured away from her line of sight, suddenly emits shrieks of distress. The mother cat instantly makes a beeline to where the black-­and-­white kitten is, catches it by the scruff of the neck, and carries it back to the box, where she drops it and licks it until it’s soothed. This mother’s behavior is not peculiar to cats; it’s present in some form in many species and nearly all species of mammals—­well, perhaps not quite all species of mammals. When it comes to humans, we may not always make a beeline for our little one in distress, perhaps saying, “I don’t have time for this now!” or “Wait until your dad gets home.” We may not immediately bring it back to a safe place, instead demanding explanations: “Why did you get into trouble again?” We may judge: “If you behaved there as you behave in the box, no wonder you came to grief!” We may invalidate: “You have no good reason to cry!” We may threaten: “Stop whining, or you’ll be sorry!” We may mock: “Look at that big baby crying again—­not such a brave adventurer now!” We may turn away: “Don’t come near the box. I only want happy kittens here!” In short, unlike a mother cat, we humans may display a large palette of behaviors other than instinctively approaching a young one in distress, bringing it to a place of safety, and comforting it until it is soothed. What stops us from approaching distress and providing comfort? Getting hooked by the mind’s judgments. We all learned how to receive and respond to our own distress by witnessing how distress, both our own and that of others, was received by those giants we grew up amongst. How about you? When your own kittens of inner distress start shrieking in the distance or when your self-­judgmental thoughts start rumbling from afar, when that long-­ago child starts hurting again, what do you do? How do you receive that kitten or that child? Do you turn toward it with an open heart and an intention to soothe the pain, or do you turn away, push away, ignore, belittle, argue, demand explanations, invalidate, scrutinize, mock, or engage in any number of behaviors other than approaching and receiving your inner distress with compassion? Just notice. And then notice if you can find some space to give that hurt part of yourself, that painful self-­judgment, doom-­laden prediction, or panic-­stricken feeling, some of the mother-­cat care it needs. This exercise can be helpful for both therapist and client. It promotes dis- crimination between two modes of relating to aversive inner experience, whether those experiences are thoughts, self-­stories, judgments, memories, or emotions. Often, when clients simply notice how they receive their inner experience, it can allow them to gradually notice the unworkability of not comforting their suffering. We like to invite clients to try to identify the attachment figures from whom they might have learned their nonsoothing behavior. To aid in this, we volun- teer our own experience, such as hearing a parent’s voice loudly disapproving of our behavior when we make even a minor mistake. We observe that sometimes the blaming words in this tone of voice come so fast that there is little to be done about them other than noticing them as a hook and validating how painful it is to have this experience. Clinical Example: Using the Mother Cat Exercise with a Depressed Client Below is a dialogue with Ted that illustrates use of the Mother Cat exercise. Therapist: So, over the past week, were you able to notice how you received your inner distress when it showed up? Client: It’s strange, but I could really see it as the little Ted getting so angry and frustrated about not being listened to. Therapist: And how did you meet him—like the mother cat, or in some other way? Client: y first reaction was to try to push him away and…I guess shame M him in some way. Like, Look at you, little so-­and-­so, feeling pissed off again! Can’t you just stop it? Therapist: Ouch! That feels harsh. Client: It is. And I could almost hear my mother’s voice talking to him. Therapist: Wow! What did you do? Client: I t’s strange, but when I noticed it, I thought of your mother cat image and was able to approach him with more kindness, to not meet anger with anger. Therapist: I find this really touching. Client: es. But you know, I didn’t make those calls to potential employers Y we discussed last week, and I lashed out at my wife when she tried to remind me. Therapist: What’s showing up for you now? Client: hat I’m useless and not a good client. (Pauses.) I feel ashamed and T angry. Therapist: That must be hard, and it’s hard for me to see you like this. I wonder how you’re receiving what you’re feeling and thinking right now. Is it more like a mother cat or in some other way? Client: (Laughs.) I guess more the other way! Therapist: And what would the Ted you want to be do with that little kid showing up in anger and shame? Client: Be more like a mother cat. Therapist: I wonder what your mother cat would do right now. Client: I guess she would say that it’s tough to feel this way and that she’s going to just be there for me. Therapist: Yes, and I will be there for you too. In this dialogue, after the client reports having practiced the discrimination introduced the previous week, the therapist catches an in-­session moment when the client veers back toward self-­judgment and self-­shame. In response, she invites him to practice the discrimination in real time. This exercise is an example of how offering clients a values-­based discrimination, such as the one conveyed by the Mother Cat metaphor, can help them recognize and change unhelpful patterns of relating to their inner experience. In the course of therapy, it is not uncommon for clients’ minds to turn the therapeutic tools or exercises they receive into a way to feed the self-­judging machine, as Ted did. In our expe- rience, guiding clients to notice when their minds turn on them and gently shaping a more compassionate approach to old wounds and judgments can greatly speed progress. Training Self-­Compassion More Directly The war against ourselves that our minds convince us to prosecute cannot be won. Accepting what we dislike about ourselves is the only basis for deep self-­ reconciliation. Clinical experience suggests that making peace with oneself is a hallmark of deeply transformative therapies. Peace is not about the end of pain; it is about not going to war against pain and suffering and instead receiving these experiences as they are, with a kind inclination of the heart. By promot- ing defusion and acceptance and orienting clients toward their values, ACT can serve to promote this kind of compassionate peace effectively. Cognitive fusion, which from an ACT perspective plays a central role in many pathological processes, also affects self-­conceptions and can result in highly aversive self-­constructions. The resulting behaviors of self-­judgment and self-­shaming are fundamental to the verbal entanglements that narrow people’s life choices and unduly increase suffering. The emergence of a sense of self is a verbal product of our early interactions with our caregivers. Central to this process is the ability to recognize and name inner experiences. This learning requires a caring, consistent, and accepting social environment, which is rarely the case due to the vagaries of both family and cultural environments. In addition to purely verbal processes, our history of reinforcement or punishment for affiliation bids can impact our relationship to our own experience and our capacity to provide ourselves with the comfort we need. Within this context of verbal and attachment history, people can become fused with particularly painful and rigid forms of self-­evaluations and self-­shame. Rather than trying to change the content of such evaluations and emotions, it may be more fruitful to foster a more compassionate relationship with them. Because the relationship we have with our inner experience was learned in the context of relationships with our closest caregivers, a close and intimate thera- peutic relationship can provide a context ideally suited to helping clients foster a more accepting and compassionate relationship with their inner experience and self-­evaluations. Some key elements of working on compassion clinically include establishing a validating, accepting, and intimate therapeutic relationship; presenting a cogent therapeutic rationale; establishing a functional contextual point of view; and focusing on the function rather than the form of inner experience and behavior. The ACT matrix can be an effective tool in establishing a functional contextual point of view. An integral part of this work is validating clients’ struggles against their own experience, helping them see that it is often effective in the short term, and also orienting them to its long-­term unworkability, both in terms of reducing their suffering and, crucially, in terms of moving toward a valued life.