5 利用治疗关系培训慈悲

利用治疗关系培养同情心

想象一下，如果你想学习冲浪。你会选择那些只谈论你上周的冲浪尝试以及下周可以尝试做些什么不同的课程吗？还是会选择让你有机会在教练面前练习冲浪，以便她可以在你练习新动作时指导你的课程？此外，你会选择那些主要讨论冲浪理论的课程，还是大部分时间都用来实践的课程？最后，你会选择一个技术娴熟的冲浪者作为老师，还是一个读过许多冲浪书籍、观看过重大比赛并熟悉术语但从未能站在冲浪板上的老师？

在治疗中，就像冲浪一样，最好的学习是通过体验获得的，最有效的练习是在治疗师能够即时观察和指导的情况下进行的，而这位治疗师本身具备她被雇佣传授的技能。因此，在训练客户变得更加同情和自我同情时，疗程中的实践是关键，而治疗师自身的同情心和自我同情心也是必不可少的。

自我批评和自我羞愧是与自己和个人经历互动的有害形式。从接受与承诺疗法（ACT）的角度来看，它们是由各种不灵活性过程造成的。与自我评判性思维融合以及对厌恶体验的不接纳，会强化一种局限于过去和现在负面内容的自我感觉。难以接触价值观和参与有价值的行为也会削弱自我价值感，使客户更加陷入内心的挣扎，陷入无效行为、自我贬低和个人历史耻辱的痛苦循环中。通过增加灵活性，客户可以学会如何驾驭负面思想、厌恶体验和自我贬低故事的波涛，从而朝着有价值的生活方向前进。

在很大程度上，治疗过程中发生的事情都是在治疗关系的背景下发生的。正如上面冲浪的例子所示，无效行为最好直接观察，而不是通过客户重构的口头叙述来过滤。同样，有助于客户进步的技能最好在疗程中练习，让临床医生能够指导客户采取更加同情和自我同情的态度。这种对当下（治疗）时刻的重视非常适合运用操作性学习原则，这些原则侧重于提供即时的结果。本章将描述如何在疗程中使用操作性学习原则，帮助客户熟练地驾驭自我批评的思想和羞耻的自我导向情绪，以实现有价值的生活。

5 Using the Therapeutic Relationship to Train Compassion Imagine that you wanted to learn to surf. Would you choose lessons in which all you did was talk about your surfing attempts over the past week and what you could try to do differently in your next week of surfing? Or would you rather take lessons in which you got a chance to practice surfing in front of your coach so she could guide you as you practice new moves? Furthermore, would you choose lessons in which the teacher mostly talked about the theory of surfing, or in which most time was devoted to practicing? Finally, would you pick a teacher who is a technically proficient surfer, or one who has read numerous surfing books, been a spectator at major competitions, and knows the lingo but could never stand up on a board?

In therapy, as with surfing, the best learning occurs through experience, and the most effective practice is that which can be observed and coached in the moment by a therapist who herself possesses the skills she is hired to impart. Thus, when it comes to training clients to become more compassionate and self-­ compassionate, in-­session practice is key, and compassion and self-­compassion on the part of the therapist are a must.

Self-­criticism and self-­shame are damaging forms of interacting with one’s self and one’s personal experience. From an ACT point of view, they are a function of various inflexibility processes. Fusion with self-­judgmental thoughts and nonacceptance of aversive experiences feeds a sense of self that is limited to the aversive content of one’s past and present experience. Difficulty in con- tacting values and engaging in valued actions also undermines self-­worth, getting clients further into their heads and keeping them stuck in a painful cycle of ineffective action, self-­depreciation, and shameful hatred of personal history. By increasing their flexibility, clients can come to learn how to surf the waves of negative thoughts, aversive experiences, and self-­denigrating stories so they can move in valued life directions.

To a large extent, what happens in therapy happens in the context of the therapeutic relationship. And as is the case in the analogy of surfing above, ineffective behavior is best observed directly, rather than through the filter of clients’ reconstructed verbal accounts. Likewise, the skills that will help clients progress are best practiced in session, allowing clinicians to coach clients toward a more compassionate and self-­compassionate stance. This emphasis on the present (therapeutic) moment is ideally suited to using operant learning prin- ciples, which are focused on providing consequences in the moment. This chapter will describe how operant learning principles can be used in session to help clients become adept at surfing self-­critical thoughts and shameful self-­ directed emotions as they navigate toward a valued life.

Self-­Compassion as a Condition of Compassion From an ACT perspective, compassion and self-­compassion are highly related. Being truly compassionate implies being truly self-­compassionate and vice versa (Hayes, 2008c). Both compassion for others and self-­compassion imply embrac- ing difficult feelings, noticing judgmental thoughts without becoming entangled in them, connecting with a flexible sense of an observing self, and gently carry- ing one’s history forward into a life of engagement with deeply held values. Furthermore, practicing both compassion and self-­compassion is a central part of a therapist’s skill. And just as for clients, these qualities are best fostered by cultivating compassionate flexibility and extending kindness and self-­validation to whatever difficult experiences and self-­judgments may arise.

Using Positive Reinforcement to Train Compassion The functional contextual approach has its roots in learning theory principles and, more particularly, in the principles of operant learning. Countless experi- ments have shown positive reinforcement to be the most effective tool of behav- ior modification. Positive reinforcement denotes a relationship between two events in which the event that follows a behavior increases the future probability of the behav- ior. Animal models have shown that the effectiveness of the reinforcing event depends on its temporal proximity to the behavior. The closer the reinforcer is to the behavior, the more effective it is likely to be in making that behavior more probable in the future. It can be important to remember that positive and negative reinforcement denote an arithmetic operation in the sense that a con- sequence is added to or subtracted from the environment, rather than the rein- forcer having a positive or negative valence or feeling. For example, sometimes parents will criticize a child’s behavior at length only to find that the behavior criticized actually increases. In such cases, criticism serves as a positive rein- forcer, even though it may feel negative to both child and parent. Positive reinforcement is fairly straightforward when applied to nonverbal animals, and the marvelously elaborate behaviors that animals accomplish on film attest to its effectiveness (Pryor, 2009). In such contexts, reinforcers consist of physical or physiological events. However, when it comes to verbal humans, the effects of derived relational responding make reinforcement much more complex. Through derived relational responding, the functions of inner experi- ences (such as bodily sensations, emotions, or images) and symbolic stimuli (such as words or thoughts) are transformed in ways that are governed by complex relational networks, which themselves are the product of unique and complex individual histories.

Once derived relational responding comes into play, it becomes harder to identify the contexts in which a given event will be reinforcing. For example, with one client a compliment might serve to increase the behavior compli- mented, whereas for another client it will have the effect of punishing (i.e., decreasing) the behavior. In the latter case, it is probable that the client’s verbal history has served to transform the functions of compliments into a punishing consequence. This does not negate the power or effectiveness of positive rein- forcement, but it does make the clinician’s task more complex. It is therefore particularly important for clinicians to pay close attention to the potential rein- forcing or punishing functions their behavior may have on clients.

Functional Analytic Psychotherapy and Compassion Functional analytic psychotherapy can be of particular interest to clinicians seeking to foster and train compassion and self-­compassion in their clients. It can serve as both a model and a series of techniques that apply operant learning principles to therapy and, specifically, to the therapeutic relationship. FAP focuses attention on clinically relevant behavior (CRB), meaning in-­session client behaviors that are functionally similar to their behaviors outside of session. There are two main classes of clinically relevant behavior: • CRB1, denoting instances of client problematic behavior • CRB2, denoting improved behavior as compared with CRB1 FAP invites both therapist and client to notice CRB1 and the client to prac- tice CRB2 within a reinforcing environment: the therapeutic relationship. Clinically relevant behaviors are defined idiographically. For example, expressing criticism might be a CRB2 for a client who has difficulty being asser- tive, but a CRB1 for a client whose relationships are negatively impacted by a high propensity to criticize others. In FAP, the therapist cultivates awareness of client behavior, has the courage to invite the client to notice when clinically relevant behavior might be present, and lovingly reinforces CRB2 while paying close attention to the reinforcing (or punishing) functions of therapist behavior. The therapist offers the therapeutic relationship as a sacred space (Tsai & Kohlenberg, 2012), a safe context in which clients can try out new behavior without fear of overly punishing consequences or a break in the relationship. Such a loving and reinforcing context is ideally suited to helping clients work through self-­shame and self-­hatred while exploring the practice of compassion and self-­compassion.

FAP uses behavior modification tools to promote CRB2. One of the most important of these tools is shaping by successive approximations. In shaping, one first observes the behavioral repertoire such as it is and seeks to reinforce the slightest step in the direction of the desired behavior. When a further step is taken, that new step is reinforced in preference to the previous step, and so on, until the behavior is fully shaped. So in the example of expressing critical thoughts as CRB2, the therapist will initially reinforce any sign of a negative reaction to her behavior, then any form of critical speech, then only critical speech that is likely to be well received by others (for example, including empathic validation of the person criticized). Once the behavior is ready to be taken “on the road,” the therapist encourages and promotes generalizing the improved behavior into the client’s life beyond the therapeutic relationship.

The Five Rules of FAP Kohlenberg and Tsai (1991) have proposed five clinical rules to guide the practice of FAP. More recently they have described FAP as being based on awareness, courage, and love (Tsai et al., 2008); and, as you will see, these quali-ties are highly relevant to the five rules of FAP.

Rule 1: Notice CRB. FAP invites both therapist and client to identify CRB. Noticing CRB implies awareness of client behavior. This awareness implies pres- ence, mindfulness, and empathic connection. Rule 2: Evoke CRB. FAP requires that CRB be present so that it can be worked on. Evoking CRB requires courage on the part of both therapist and client. Both are invited to be honest and authentic, take risks, show vulnerability, ask bold questions, and gently confront avoidance. Rule 3: Respond contingently to CRB. The therapist seeks to reinforce CRB2 while responding appropriately to CRB1. This is inherently compassionate and a demonstration of love. By truly caring for and gently tending to clients, tire- lessly supporting them, authentically acknowledging them, and deeply appreci- ating and respecting them in both their difficulties and progress, therapists can most effectively reinforce improved behavior and help clients modify problem- atic behavior. Rule 4: Notice the reinforcing effects of your behavior. This invites more awareness as the therapist seeks to observe whether her interventions have been reinforcing or not. Here, a willingness to hold interpretations lightly and ask clients how her behavior has impacted them is helpful. Rule 5: Promote generalization of improved behavior. This last rule implies awareness, courage, and love as the therapist helps clients recognize similarities in the functions of CRB and the functions of behavior in outside life and encourages appropriate risk taking in the presence of similar antecedents outside of session.

Applying these rules encourages clients to become more mindful of their behavior in the moment and can help them identify as CRB1 those clinically difficult moments when noticing their unworkable behavior leads to further self-­criticism and shame. Promoting mindfulness of such behaviors and concep- tualizing them as teachable moments can be a powerful way to promote com- passion and self-­compassion.

Finally, these rules are not meant as rigid prescriptions but more as gentle invitations to try new behavior. If by doing so you contact your own reinforcers in the shape of deeper and more effective therapeutic relationships, you may find yourself using them regularly.

Clinical Example: Noticing the Self-­Critical Mind in Action and Defusing from It The self-­critical mind is often hyperactive and will use everything it can to fuel the fires of self-­hatred. In the example below, Sam had been invited to notice, over the week between sessions, actions he took to move toward who and what is important to him and actions he took to move away from what he didn’t want to think or feel.

Therapist: So, what did you notice? Client: I had never realized how many away moves I engage in. It’s pathetic. [CRB1] Therapist: I notice you’re putting yourself down. Do you also put yourself down when you’re with other people? (Applies FAP rule 1: noticing CRB and offering a parallel between client behavior in and out of session.) Client: es, I’m always putting myself down because of my lack of self-­esteem. Y (Confirms CRB1.) Therapist: And is being harsh on yourself a toward move or an away move? (Applies FAP rule 1: noticing CRB.) Client: I guess an away move. …See, I did it again! [CRB1] Therapist: Ouch! That’s harsh. How about noticing your toward and away moves—is that a toward move or an away move? (Applies rules 2 and 3: evoking CRB and responding contingently to CRB.) Client: A toward? [CRB2] Therapist: What’s showing up for me is how easy it is for you to get hooked by your critical mind, and then it’s as if you grabbed the bat yourself and started banging away on yourself. (Applies rule 1, missing an opportu- nity to apply rule 3: reinforcing CRB2.) Client: Yes. You see? I told you. [CRB1] Therapist: (Makes a gesture to go grab an imaginary baseball bat behind her chair.) Here it comes again! (Applies rule 3: responding contingently to CRB.) Client: (Laughs.) Okay, I see it now. [CRB2] Therapist: So how about noticing when your mind hands you the bat and just letting us know? (Applies rule 2: evoking CRB.) Client: I think I can do that. [CRB2] Therapist: So tell me about your toward moves over the week. (Applies rules 2 and 3: evoking CRB and reinforcing CRB2.) Client: I called my parents, took my son for a walk, and talked to my wife about going out to dinner together. [CRB2] But really, it wasn’t much… [CRB1] Oh, here comes the bat! [CRB2] (Laughs.) Therapist: So if you didn’t grab the bat, what would you say? (Applies rules 2 and 3: evoking CRB and reinforcing CRB2.) Client: That I’m glad I did these things, and I feel proud. [CRB2] Therapist: Great, Sam. How was this whole exchange for you? (Applies rule 4: noticing the reinforcing effects of therapist behavior.) Client: At first it was hard, but I think I got the hang of it and could catch myself before going for the bat. And it’s true that it makes a difference.

Therapist: I’m also happy you could notice your toward moves. (Applies rule 3: reinforcing CRB2.) Would you be willing to continue doing that over the week, even when your mind tries to gang up on you? (Applies rule 5: promoting generalization of CRB2 to life outside of session.) In this exchange, the therapist is focusing on present-­moment processes and inviting the client to do the same. The therapist offers a parallel between in-­ session behavior and potential problematic behavior outside of therapy. When the client offers an explanation (lack of self-­esteem), the therapist does not get into the content and instead remains focused on CRB, gradually shaping a CRB2 of noticing the CRB1 of being harsh on oneself, and reinforcing the CRB2 of naming toward moves without depreciating them in the next breath.

Shaping Compassion in Session The stance of the FAP therapist is one of deep compassion for her clients, their suffering, and their learning history. Seeing behavior as the result of a learning history, she does not hold her clients responsible for their suffering, their thoughts, or their emotions and stands ready to walk with them through their suffering and toward more workable behavior. Seeing behavior as the result of learning history, she appreciates that providing her clients with a safe learning environ- ment (the therapeutic relationship) can help them choose more effective behav- ior outside of session, setting a new course for their relationships and their lives.

FAP invites the therapist to reinforce clients naturally, noticing how her heart responds to their improved behavior and letting them know how she gen- uinely feels. As in ACT, the FAP therapist also opens her heart to her clients’ suffering with a deep wish to see that suffering diminish and a courageous will- ingness to stand by her clients and their suffering. The FAP therapist makes a commitment to responding with authenticity and kindness to her clients, including being willing to cry with them.

Clinical Example: Using FAP Principles to Promote Compassion Below, we illustrate how a therapist can use FAP principles to promote compas- sion in an example from a session with Joe, a teacher and community activist who is beset by deep self-­shame. Although he obtained a PhD and is a well-­ respected member of his community, Joe has gone through life with an unshak- able sense of being a fraud and undeserving of others’ regard. His community involvement is a function of his values, but he has always felt inferior to his peers: less intelligent, less handsome, less well-­read. To this day, he feels he received his PhD by some sort of fluke, being certain he was the dullard among his peers in graduate school. Now, at the age of sixty, he feels his cognitive abili-ties are declining and complains of attention deficit and an impaired memory. Client: I think people should work harder. [CRB1] Therapist: You sure have worked hard all your life, not just teaching, but also as a community activist. (Applies rule 2: evoking CRB.) Client: ( Looks uncomfortable.) I didn’t work that hard, really, and I only got involved in my community because of my religious beliefs. [Probable CRB1, harshly judging himself and others] Therapist: I’m noticing that your mind is being harsh on both you and other people. Does it happen just in here or does it show up elsewhere? (Applies rule 1: noticing CRB and offering a parallel between in- and out- of-session behavior.) Client: ell, you know, that’s the way I was educated. We had it hard. But W even so, I managed to remain the laziest of the bunch. [CRB1] But yeah, my wife always tells me I’m too harsh on my daughters. Mind you, I try to be extra nice to my granddaughters. They’re so sweet! [CRB2 to shape] Therapist: It’s lovely to hear that you’re sweet with your granddaughters. And it makes me sad to think you have to live under the yoke of such a criti- cal mind. I wonder if, deep down, the person you want to be gives voice to the most critical thoughts your mind comes up with. I mean, I know religion means a lot to you, and I wonder: If you could choose, would you choose to be known as harsh, or more as a compassionate person? (Applies rule 3: reinforcing CRB2 and seeking to shape further CRB2.) Client: Compassionate, I guess. [CRB2 to shape] Therapist: And if no one ever knew or if it wasn’t a question of reputation but of the impact you really had on others, would you choose to align with your harsh mind or with a more compassionate stance? (Applies rule 3: aiming to further shape CRB2.) Client: The same. I would be compassionate. [CRB2] Therapist: That is so touching to hear you say this when I know your mind is waiting to ambush you at any second. (Applies rule 3: naturally rein- forcing CRB2.) How about we use our time here to help you behave in this more compassionate way, as you’d like—could that make a difference? (Applies rules 2 and 3: evoking and reinforcing CRB2.) Client: Do you think I can do it? [Probable CRB2] Therapist: I’m sure you can, and I’m here to help. (Applies rule 3: reinforcing CRB2.)

In this dialogue, the therapist focuses on clinically relevant behavior as it shows up in the room rather than on what the client is saying about his life outside of therapy. By paying close attention to how the client progresses and by introducing values, the therapist is able to get him to move to a more compas- sionate stance and choose compassion as a valued direction.

Helping Clients Accept Compassion from Others The therapeutic relationship is peculiar in many ways. In contrast to “normal” relationships, it does not exist for its own sake. It is a professional rela-tionship. Yet unlike other professional relationships, and due to its nature— being a space into which clients bring their most difficult personal problems and vulnerabilities—­it cannot be limited to a surface relationship in which the cli- nician as a person remains hidden behind a veneer of professional distance. FAP invites clinicians to open their hearts to their clients and foster relationships that are every bit as deep as relationships in outside life, and often deeper. Yet the therapeutic relationship remains significantly different from other relationships in that at all times it is in the service of the client’s therapeu-tic goals and best interests. Within such a relationship, clinicians can use their own reactions to shape more compassionate behavior in clients.

Clients with deeply ingrained histories of self-­criticism and shame, perhaps as a result of childhood trauma, are commonly fused with the most painful forms of self-­hatred, shame, and guilt. Histories of physical or sexual abuse often lead to a sense of guilt on the part of the victim. In cases of physical or sexual abuse at the hands of a caregiver, it is not uncommon for victims to feel they deserved it and carry a crippling burden of guilt and shame. That shame and guilt can make it exceedingly difficult to truly accept genuine care and compas- sion from others. In such cases, establishing a profound therapeutic relationship can provide a context in which clients can gradually open up to compassion and care—first to receiving it from the therapist, and then to evoking that com- passion from themselves, toward themselves.

Clinical Example: Using the Therapeutic Relationship to Shape Acceptance and Compassion In the following extract the therapist invites his client to connect with a past situation in which shame arose. As a child, Clare was for years sexually and emotionally abused by her father. She has been carrying a crippling burden of guilt and shame related to the abuse. Although she has mentioned the abuse to others in her family and distanced herself from her parents long ago, it is still difficult for her to contact her tangled feelings around what she has been through. Clare and her therapist have been working on interpersonal issues for over six months, and she now feels ready to address the abuse.

Client: I feel so guilty because I feel like I used my body. I’ve hated it ever since. Therapist: It makes me sad to hear this. Would you be willing to close your eyes and bring to mind one of the situations from your childhood that you feel ashamed of? Client: I can try. Therapist: Where are you, and how old are you? Client: I’m twelve and in my parents’ living room. My father is there. Therapist: What can you see around you? Client: I can see the sofa. I can see the pictures on the walls and the sunlight through the bay window. I see my father sitting in his recliner. He’s reading a newspaper. He’s not paying attention to me. Therapist: Can you notice what you are feeling? (Pauses.) What you are think- ing? (Pauses.) What do you do? Client: I feel bored. I… (Pauses.) I am striking provocative poses. (Starts sobbing softly.) I feel so ashamed! This is really hard! Therapist: Could we just pause here for a minute? I want you to stay with that twelve-­year-­old Clare. Would you be willing to stay with her and how she feels? Client: (Speaks softly.) Okay… Therapist: Imagine that we could both go together and meet her. You can see what she sees, hear what she hears, and feel what she feels. (Pauses.) Could we just ask her, “What do you need right now?” Client: ( Speaks in a little-­girl voice.) I just want to play. I want to go outside and play. I want to see people and have fun! (Sobs.) Therapist: Yes, you just want to go outside and play. You want to see people. Those are perfectly normal needs for a twelve-­year-­old girl. You need attention. And that’s a perfectly normal need for a twelve-­year-­old girl. (Pauses.) And the only way you know how to get attention is by doing what you’re doing. Client: (Sobs.) Yes. Therapist: Clare, do you think we should condemn that young girl for that? Client: No, of course not. …She doesn’t know any better. Therapist: What could we do to help her? Client: Could I just hug her and tell her I love her? Therapist: Let’s do that. Give her a hug and tell her that you love her. (Has tears in his eyes, obviously moved by the client’s pain.) She just needs to be seen and loved, and to feel safe. Is there something more you can tell her? Client: Just that I love her and that it’s not her fault. (Sobs.) Therapist: No, it’s not her fault. It’s all she knows how to do. (Pauses.) Clare, take your time, and when you feel ready, you can come back to this room with me and open your eyes. Client: (Opens her eyes.) Therapist: I feel so moved that you had the courage to go there with me. How are you feeling now? Client: I trust you. I think you’re a good person. It’s the first time that I’ve realized I don’t have to hate myself for what happened and what I did. I didn’t know any better. I’ve known these things intellectually, but this was the first time I could actually feel it. Therapist: How could you have known any better? How could anyone who’d been through what you went through know any better? Client: Yes. Therapist: Do you think that now, when guilt shows up, you can go back and give that little girl the support and love she needs? Client: I can try. At least now I know I don’t have to hate myself and my body. In this exchange, the therapist invited Clare to go back not to a moment of abuse, but rather to an episode that evoked the most shame for her: her pro- vocative bids for attention from her father and abuser, the only way she could get some of the attention she craved. In contact with that memory, the therapist invited Clare to take the little girl’s perspective and notice that, at the time, she did not have other options. From that experiential realization, and with gentle coaching from her therapist, Clare got to feel that she was not to blame for what happened, nor for the behaviors that have brought her the most shame over the years and fed her deep hatred of her body and sexuality. Such a realization could not have arisen through intellectual discussion or argument. The experiential element was essential to the work, and the therapist used the strength and sacred space of the relationship and the sense of trust within it to ease Clare into this very difficult experience.

Using the Therapeutic Relationship to Train Compassionate Perspective Taking Combining compassion-­focused ACT and FAP can lead to very powerful inter- ventions in which clients can directly experience, through perspective taking, compassion and ultimately self-­compassion. As they become better aware of what they do when they become more compassionate and self-­compassionate in session, they are more likely to do it outside of the therapeutic relationship. From an ACT position, perspective taking involves inviting clients to shift as fully as possible from the perspective of their here-­now experience to a different spatial and temporal perspective, contacting as fully as possible their own expe- rience there-­then or someone else’s experience. Taking someone else’s perspec- tive is part of the definition of empathy. Taking one’s own perspective at a different time and place can thus help foster empathy and compassion for oneself in those other situations. Combining these different aspects of perspective taking can provide the clinician with a powerful means of training compassion and self-­compassion.

Clinical Example: Using the Therapist’s Experience to Evoke Perspective Taking In this example, we return to Joe, the teacher and community activist who is worried about cognitive decline and attention deficits. Leading up to this dia- logue, it has been two weeks since Joe’s previous session, and Joe’s therapist was fifteen minutes late to this session. He’d made a mistake when writing down Joe’s appointment time, a fairly common occurrence for him. In the dialogue that follows, they are discussing Joe’s interpersonal risk log, a FAP-­inspired exer-cise in which the client keeps a daily record of intentionally taking at least one interpersonal risk.

Therapist: How did it go with keeping an interpersonal risk log? Client: It worked really well for about a week, and I did feel that I was able to connect with others. But then I realized that all of this was super- ficial because I called a lady I know by the wrong name. I keep on making the same mistakes, like forgetting people’s names. In my position, that’s unacceptable. I’ll never be able to really connect with other people. Therapist: Oh yeah, the mistakes we make. …Five minutes ago I got here fifteen minutes late. That’s exactly the type of situation in which I feel like a jerk and where I get really self-­judgmental. But when I got here you were really nice about it and immediately made me feel at ease. Client: ( Laughs.) Actually, it did cross my mind that you’d done it on purpose just to show me that I don’t judge you harshly because of a small mistake! Therapist: No, it really was a mistake. I goofed up. It’s the kind of mistake that’s all too frequent for me, as you know. But it’s true that I immediately felt accepted by you—­so much so that my habit of coming down really hard on myself when that happens sort of dissolved. Client: Well, everyone can make mistakes, and you have other qualities… Therapist: Sure, but this is one mistake I make too often, so it’s particularly meaningful to me that, having been on the receiving end of it a few times, you could still accept me with such kindness. (Pauses.) Joe, I’d like to ask you to imagine that you’re looking through the eyes with which you looked at me when I goofed up. But now, I’d like you to imagine being beamed back to the situation in which you called that lady by the wrong name. As you do so, look at yourself as if you were witnessing the scene from a little distance. Take your time… (Pauses.) What do you see? Client: ( Pauses.) Well, I see a kind man. He wants to help and he gets the name wrong. …A man with his weaknesses. I see a man I rather like, a man for whom it’s not easy… (Pauses. His face softens and looks sadder.) Therapist: Yes, Joe. This man is the Joe I know: a man who has his weaknesses, but also a warmhearted man who lives by his values. A man I feel touched by… Client: Yes, it’s true. Therapist: I have to tell you that I’m getting teary right now. It’s the first time since we’ve started working together that I’ve seen you give yourself the compassion that you have for others, and that made you choose your line of work. It’s as if you finally allowed yourself to see yourself as a human being like any other… Client: Yes, it’s true. (Pauses, then laughs.) But you know my mind doesn’t agree. It’s still trying to say I don’t deserve to be forgiven for my mistakes. Therapist: Sure, that’s what minds do. Could you describe what you did just now when you looked at yourself from that more compassionate perspec- tive, and how it felt? Client: Well, I relaxed my shoulders, I relaxed my chest, and I think I opened my heart a tiny bit… (Pauses.) It’s not easy to say. I wonder if I’m not reconstructing it now… Therapist: Not easy to say, and yet you knew how to do it. See if you can do it once again. So you’re standing in front of that lady and you get her name wrong. Okay, relax your shoulders and chest… Client: (Pauses.) Okay, I see. (Pauses, then laughs.) Therapist: Thanks for trying this. I want to invite you to see if you can notice yourself doing some of that in the coming week and include it in your interpersonal risk log, only now as an interpersonal risk you are taking with yourself, so to speak. Client: Okay, I’ll do that, even if I’m not too sure how I’ll do it.

This dialogue marked a turning point in Joe’s therapy, being the first time that he behaved in a deeply compassionate way toward himself. He did not just say compassionate words about himself and his memory lapses; he did so from a place of feeling. When the therapist could see him visibly soften, he felt touched and expressed that.

In this exchange, the therapist invited Joe to shift perspective by looking at himself in the situation that generated shame and self-­criticism from the per- spective he took when looking at the therapist’s mistake. Here again, the key to this intervention was inviting the shift in perspective from an experiential rather than intellectual place. The therapist then reinforced Joe’s new behavior by openly sharing how Joe’s self-­compassionate behavior impacted him (CRB2) and by inviting Joe to notice what he had done to direct compassion toward himself, thereby promoting generalization to situations outside the therapeutic relationship (FAP rule 5).

As discussed, within the ACT model, flexible perspective taking is a key component of psychological flexibility. In our experience, perspective-­taking exercises often elicit self-­compassion in clients. For example, inviting a client to experientially return to particularly hurtful childhood events to meet the child she was then and give or say something to that hurt or frightened child typically evokes more compassionate behavior toward that child and her suffering, as illustrated in the dialogue with Clare.

Clinical Example: Using Self-­as-­Context to Train a More Self-­Compassionate Stance Other approaches to perspective taking can also be useful in training clients to approach their present life difficulties from a more empathic and self-­ compassionate stance, as illustrated in this dialogue with Mike, who is in therapy for severe OCD accompanied by intense shame and self-­disparagement. Mike has made good progress with the ACT model and, in particular, has become quite adept at sorting his experience with the matrix. Because sorting into the different quadrants of the matrix implies being able to look at one’s experience, rather than being fused with it, an ability to do this indicates a capacity to take the observer perspective.

Therapist: I’m quite impressed by the progress you’ve made in terms of noticing your toward and away moves and the difference between your five-­ senses experience and inner and mental experience. Client: Yes, but I still get stuck when it comes to checking the stove before going to bed at night. Therapist: Let’s look at that now. Imagine that you, as you are sitting across from me right now, could somehow be teleported to meet you, as you will be in your kitchen tonight. Is there something you could tell yourself that may help you with the obsessions and compulsions? Take your time, and once you’ve found something to say, just say it as you would if you were in your kitchen, meeting the you who’s having obsessions and the urge to check. Client: Okay: “Don’t be stupid! You know it’s no use.” Therapist: How do you, in the kitchen, receive what you just said? Client: Not well. Therapist: Does it work? Client: No. Therapist: What tone of voice did you speak in? Client: Harsh, I guess. Therapist: Is that how you need to be spoken to when you’re stuck in the kitchen? Client: I need to be spoken to more gently. Therapist: Could you, as you are here with me right now, speak more gently to the you that’s stuck with your obsessions in the kitchen? What could you say? Client: ( Pauses.) I could say, “I know it’s hard to have these thoughts and feel so much anxiety.” Therapist: How do you, in the kitchen, receive this? Client: Better. I feel heard. It’s like something is softening up a bit. Therapist: What else could you, here with me, tell you in the kitchen? Client: I could encourage myself to choose to do something important to me rather than my series of checks. Therapist: How do you, in the kitchen, receive that? Client: I can hear it. It feels like I could do it. Therapist: What else could you do? Client: I could go pet my cat and spend time with my partner. Therapist: Would that be important to you? Client: Yes, because checking the stove is about making sure my partner and my cat don’t die in a house fire caused by me. So it’s really about taking care of them. Therapist: That sounds great. Would you now come back to this moment? It was touching to see this dialogue between you, here and now, and you, there and then in the kitchen. I was particularly touched by how you became kinder to yourself as the conversation went on and you turned toward what’s important to you. What showed up for me is that it seems the more difficult the situation, the more you need to be spoken to gently and have your difficult emotions validated. Would that make sense to you? Client: Yes, I guess that’s true. I have had a tendency to treat myself harshly. Therapist: So how about we continue practicing treating yourself more gently, the way we’ve been doing here? Client: That would be nice. Therapist: I wonder how you would rate the probability that you will be able to speak to yourself in the way you’ve just done when you’re there in your kitchen. Client: Maybe 70 percent. Therapist: I’m looking forward to hearing what you notice.

Having established the therapeutic relationship as an experiential model of a more compassionate relationship in prior sessions, in this session the therapist invites Mike to generalize this ability through some perspective-­taking work. Guiding Mike carefully through several shifts between here-­now and there-­then perspectives, the therapist helps him notice the functions of different ways of speaking to himself, particularly a harsh and judging stance versus a gentler stance. By the end of the exchange, Mike has been able to practice a kinder stance (CRB2) and notice its reinforcing functions. The therapist then con- cludes the exchange by asking Mike to assess the probability of engaging in a similar perspective-­taking exercise when next besieged by obsessions. No matter what estimate the client provides, the therapist reinforces it, given that simply paying attention to whether or not one engages in the targeted behavior increases the probability of doing it.

Compassion in the Therapeutic Dyad In summary, this chapter addressed how clinicians can maximize the benefits of the therapeutic relationship and use operant learning principles to aid clients in cultivating compassion and transforming their responses to self-­critical thoughts and shameful self-­directed emotions. We explored self-­compassion as a condi- tion for compassion and highlighted relevant behavioral principles. Among these, we examined positive reinforcement to cultivate compassion and self-­ compassion, applying FAP principles to cultivating compassion, using defusion with shame-­based self-­criticism, and specifically shaping compassion through in-­session interactions. We also reviewed the therapeutic process of helping clients accept compassion from others and eventually turn that compassion toward themselves.

Using the principles of FAP, the therapeutic relationship can provide a context that is ideally suited to noticing self-­criticism and shame in the moment and gently shaping kinder behavior toward self and others. From an ACT per- spective, compassion and self-­compassion are highly related and both are invalu- able, and in this chapter we demonstrated different ways in which the therapeutic relationship can be used to foster more compassionate behaviors toward self and others. The components and processes that are emphasized in FAP expand the clinician’s awareness and shape compassion and self-­compassion in the moment, while also encouraging clients to incorporate these qualities and behaviors into daily life. This is done through training in flexible perspective taking, including extending compassion to oneself and others when faced with shame-­eliciting situations or stimuli.