前言

Foreword The last ten years have seen a proliferation of interest in the scientific study of compassion. Given that Buddhism argued that the cultivation of compassion is central to the well-­being of self and others over 2,500 years ago, some would say “about time”! Yet when William Tuke established one of the first therapeutic communities at the York Retreat in 1796, he purposely tried to create a compas- sionate, supportive environment. The medical historian Roy Porter (2002) says “Tuke’s grandson Samuel noted that medical therapies had initially been tried there with little success; the Retreat had then abandoned ‘medical’ for ‘moral’ means, kindness, mildness, reason, and humanity, all within a family atmosphere—­with excellent results” (p. 104). However, until recently, compassion has not fared well as a scientific focus in psychotherapy. Although Carl Rogers identified core ingredients of the ther- apeutic relationship based on empathy and positive regard, the idea of the “com- passionate therapeutic relationship” was always rather vague, while the deliberate cultivation of compassion for self and others in our clients as a therapeutic aim is entirely new (Gilbert, 2009a, 2010). The early psychodynamic formulations of Freudians focused on the darker side of humanity—­sexuality and violence—­ and compassion was but a sublimation of these (Kriegman 1990, 2000). Behaviorists were interested in exposure to what we fear, and cognitive thera- pies were keen to help us our address our irrational thinking. Today, however, psychotherapists are beginning to look anew at the concept of compassion and its therapeutic potential. Part of this is because compassion has gained scientific acceptability. This was especially inspired by neuroscientists working with the Dalai Lama and studying what happens in the brain when people practice compassion (Lutz, Brefczynski-­Lewis, Johnstone, & Davidson, 2008). A second major impetus for the integration of compassion in therapy has come from the increasing recognition of the evolved nature and importance of attachment, which is rooted in competencies for parents to be sensitive to the distress of their infants and have the ability to respond to that stress, and for infants to be responsive to that care (Mikulincer & Shaver, 2007b). A third influence is the growing evidence that prosocial behavior, affec- tion, affiliation, and a sense of belonging and connectedness with others all have major impacts on mental well-­being (Cacioppo & Patrick, 2008) and on many physiological processes (Cozolino, 2007), including genetic expression (Slavich & Cole, 2013). In fact, there is good evidence now to suggest that humans function at their best when they feel valued, loved, and cared for, and when they in turn can be valuing and caring of others (Gilbert & Choden, 2013). So affiliative relationships are the center of well-­being, and it’s rather surprising that psychotherapists have been so slow in looking at the processes by which affiliative emotion is created, is shared, and heals. Against this growing research interest in affiliative, prosocial, and compas- sionate behavior, many therapies now are beginning to think about the nature and therapeutic potential of compassion. It is therefore timely that acceptance and commitment therapy (ACT), as one of the major new schools of psycho- therapy, is also beginning to consider the nature and value of compassion within its own context. ACT has always seen the therapeutic relationship as central to the therapeutic journey (Pierson & Hayes, 2007), but it is comparatively recently that compassion itself has become a focus of interest. So, what better guides to have for the ACT therapist to begin the journey into compassion than Drs. Dennis Tirch, Laura Silberstein, and Benjamin Schoendorff? Dr. Tirch not only is an experienced and world-­recognized ACT therapist, he has trained in compassion-­focused therapy (CFT; Gilbert 2009a, 2010) and been involved with Buddhist practice for many, many years. He has established The Compassionate Mind Foundation USA (http://www.compassionfocusedtherapy .com) and The Center for Mindfulness and CFT (http://www.mindfulcompas sion.com), both of which seek to further training, research, and development of CFT in North America. Dr. Schoendorff is an internationally known expert in and trainer of ACT and functional analytic psychotherapy (FAP) who empha- sizes training self-compassion in the psychotherapeutic relationship. Dr. Silberstein is an expert in the role of emotions in psychological flexibility and has been researching, practicing, and writing about the integration of CFT, Buddhist psychology, and ACT throughout her career. These authors bring unique schol- arship and wisdom to offer important insights into the different models of ACT, FAP, CFT, and more, with rich and innovative ideas on how these approaches can be integrated in bringing compassion into therapeutic focus. Compassion is easily misunderstood and confused with love and kindness. In fact, the hardest but most powerful forms of compassion are for things we neither love nor like, and this includes such things in ourselves. In the Mahayana Buddhist tradition, for which the Dalai Lama is one of the most powerful advo- cates, the core of compassion is motivation—­the motivation to be of benefit to others—­called bodhicitta. This motivation is to cultivate one’s ability to be sen- sitive and attentionally and emotionally attuned to the suffering in self and others, able to see into its causes and to acquire the wisdom and commitment to try to alleviate and prevent it. Captured here is obviously the motivation to turn toward suffering, into its wind, rather than away from it; to cultivate a willingness to engage with suffering and its causes. Here we see an immediate resonance with ACT, which since its inception has focused so elegantly on the issue of emotional avoidance and on creating a willingness to experience things as they are. More importantly, however, in both CFT and ACT, compassion is made a therapeutic focus not just for the relief of suffering but for the promotion of well-­being. This is partly why CFT pays a lot of attention to the underlying dynamics of attachment and affiliative behavior. Compassion as a therapeutic focus must be about promoting well-­being, not just reducing suffering. While CFT has sought to illuminate some of the key constituents of compassion—­such as care-­focused motivation, attentional sensitivity, sympa- thy, distress tolerance, empathy, and nonjudgment—­and to help people culti- vate these attributes, ACT has focused more on principles of liberating people from the tangles the mind can weave. These tangles arise because in addition to basic motives and emotions that we share with other animals, about 2 million years ago humans evolved capacities for imagination, rumination, a sense of self, and self-­monitoring. The way these newly evolved cognitive competencies integrate and fuse with older emotion motivational systems is a central concern for ACT. Essential to helping people disengage from aversive self-­monitoring and self-­labeling that have become fused with painful emotions is the cultiva- tion of what ACT calls psychological flexibility. Like compassion, this concept is not a straightforward one; it is really an outcome of a number of sub-­processes such as defusion, values, self-­as-­context, acceptance, committed action, and mindfulness. So Tirch, Schoendorff, and Silberstein set themselves the task of consider- ing how the different processes of compassion and psychological flexibility relate to each other and how each can be considered from the other’s perspective. The aim is not to collapse one model into another but to illuminate how ACT can address the phenomenology of compassion in its own terms. The result is an innovative and thought-­provoking narrative on new ways of cultivating com- passion, or at least creating the conditions for it to arise. So if ACT practitioners want to think about how they can bring compassion center ground in ACT terms, here is a way of doing so. CFT suggests that the healing qualities of compassion are rooted in particu- lar states of mind that recruit core physiological systems that evolved in part alongside attachment, altruism, and caring behavior (Gilbert, 2009a)—­oxytocin and the myelinated vagus nerve of the parasympathetic nervous system being two such systems. So CFT involves breath training, mindfulness, imagery, and body-­focusing work. CFT also uses method acting techniques to practice acting as if…, and imagining oneself to be a compassionate person (Gilbert, 2010), which help clients to build a self-­identity around the core attributes of compassion. This sense of self then becomes the focus—­the secure base and safe haven, to use attachment terms—­from which we can engage with suffering. ACT derives its theoretical nutrients from behavioral research, and it does not call on attachment theory or focus on any specific underlying physiological mechanisms that may create a calmer, wiser, more affiliative mind. Although ACT also sees compassion as rooted in ancient evolved systems of mind, it places its evolutionary emphasis on cooperation, rather than caring. For ACT, the advantages of cooperation created evolutionary pressures that enhanced human beings’ abilities to cooperate. Obvious ones were verbal communication and languages open to the use of symbols as representations of the world. So, words and symbols became signifiers that allowed people to share knowledge, concepts, and learning. But none of that could arise without people having a fundamental interest in each other and a desire to share, as well as to take some joy in the sharing. In ACT it was the evolution of human language and the symbolic and verbal representations it enabled that opened the door to fusion; that is to say, symbolic and verbal representations could become fused with a person’s sense of self. By contrast, a monkey that experienced threat from a dominant and responded submissively would not have the linguistic or symbolic capacity to begin to think of itself as inferior and subordinate or consider the consequences of that experience for its life and relationships with other monkeys—­indeed, it wouldn’t have a sense of self in this sense. So as you will see, this book has a lot of focus on the concept of verbal labeling, since that is an ability unique to humans. This is not unimportant in CFT, but less important, because CFT is more focused on direct experience and would be interested in the “emotional scenes in the mind” and the emotional memories associated with feelings of inferior- ity, rather than their verbal labeling. For instance, in the case of shame: If a parent is angry with a child, the child lays down memories of self (conditioned emotional learning) as stimulating anger in others. This is coded as an “emo- tional scene,” and such emotional scenes become the basis for subsequent self-­ definition. So an individual who has experienced anger from a parent (and may also have verbally labeled them as inadequate or bad) may talk about feeling inadequate or vulnerable to criticism. But actually the key is they are indicating that “In my emotional memory, I have experienced myself as inad- equate and as the target of others’ anger” (Gilbert, 2009c). In CFT, it is trying to illuminate these powerful emotional experiences, which can be seen in clas- sical conditioning learning terms, that is central, rather than exploring verbal labels to experience. So a CFT practitioner would inquire when that individual first thought of herself like that and what early scenes come to mind when she talks about herself in that way. Importantly, however, ACT is the most prominent therapy exploring the way our newly evolved cognitive competencies for symbolization, mentalizing, developing a self-­identity, and having the self-­as-­context play significant roles in determining our vulnerability to mental health difficulties. The way ACT cho- reographs these important evolutionary adaptations in the human line in a story of compassion is innovative, and again, Tirch, Schoendorff, and Silberstein provide excellent guidance. These authors offer many clinical examples which helpfully guide the ACT therapist and also offer important points of contrast between ACT and CFT. For example, in CFT, shame and self-­criticism are seen to be at the root of many psychological difficulties, but they in turn are rooted in real and feared experi- ences of social loss and rejection. Behind self-­criticism are the fears of the abused, marginalized, and forgotten, and fueling them are painful emotional memories. Indeed, CFT was partly born out of efforts to work with these ways of thinking and feeling about oneself. CFT notes that Freud had two basic theo- ries of self-­criticism. One was that self-­criticism arose from the internalization of the critical voice of the parent, sometimes referred to as superego prohibi- tion. The other was that it was anger turned inward, whereby people became critical of themselves rather than directing anger towards others whom they needed in some way. The treatment of these may be quite different, with the latter requiring some engagement with repressed and avoided rage (Busch, 2009); but for each case, the fear of giving up self-­criticism is central (Tierney & Fox, 2010). Indeed, many therapies now have their ways of working with self-­criticism because it’s potentially so disruptive to well-­being (Kannan & Levitt, 2013). In CFT we develop compassion to develop the courage to engage with the difficult stuff, which includes some of the darker aspects of our minds. Indeed, CFT suggests that the emotions that don’t turn up in the therapy can be ones the client is frightened of, and the ones that require the most work. For example, a depressed person might be quite confident in talking about his sadness and sense of loss but not about the rage he feels for the parent who failed to protect him or love him as he needed or wanted. Similarly, the angry person may be quite happy to rage about the world but entirely out of touch with the sense of loss and loneliness that hides real grief and pain. ACT thera- pists will be very familiar with experiential avoidance and the idea that one emotion can be a safety strategy to hide another emotion. The ACT therapist treating the angry person might ask “I see you are angry right now, but if I was to peel back the anger, what might I see behind it?” (Robyn Walser, personal communication, 2012). However, when exploring self-­criticism, ACT also places a central focus on the verbal construction of experience. Time and again in the clinical anecdotes we see this focusing on verbal representations. As the authors of this book write, “Understanding the verbal processes that lie at the root of self-­hatred and rein- force it can help clinicians devise targeted interventions that can gradually undermine self-­critical behavior and foster a more compassionate approach to how hard it is to live in this world” (p. 91). This makes it clear how ACT sees “verbal experience” and labeling as being at the root of self-­hatred. In ACT, we verbally create representations of ourselves out of the experiences that we have had; ACT focuses on the words people use to describe their experience.

Meanwhile, CFT would focus on in-­the-­body experience, the actual memories that created this experience, and fear of changing an identity of being a shame- ful, self-­critical person. In some of the later clinical chapters, the authors draw heavily from the CFT approach, offering ACT practitioners many new ways of creating compassion and utilizing its therapeutic potential. Central there is the fact that the “compassionate self” CFT encourages individuals to build helps them access the inner courage and wisdom necessary to begin to work with dif- ficult aspects of the mind, be they anger, anxiety, or trauma. This book shows how ACT practitioners can bring their own unique version of compassion into the therapeutic process, even to the degree that it can become a core value. At some point, of course, we will need to do further research to see how different models of compassion and their therapeutic strate- gies compare. But for the moment, endeavors to understand and cultivate com- passion are vitally important. This is not just because we desperately need better ways to understand and help those seeking our support but because compassion is crucial to the creation of a better world. The more deeply we understand compassion and how to cultivate it in our schools, businesses, and politics, the greater the chance is that those yet to be born will arrive in a fairer, more just, and caring world. Tirch, Schoendorff, and Silberstein offer us a fascinating and remarkable book to help us on that journey. They’ve written the book in a spirit of real encouragement and enthusiasm for the potential of improving our thera- pies. As such, it makes a significant contribution to the ongoing journey to understand and find ways to better help patients. —­Paul Gilbert, PhD, FBPsS, OBE