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8 个案概念化、评估与治疗计划

案例构建、评估与治疗计划

历史上，佛教哲学将慈悲描述为四无量心之一，这些代表了有助于解脱痛苦的健康心态：慈爱（metta）、悲悯（karuna）、喜乐（mudita）和平等心（upekkha）。前科学传统可能认为这样的体验超出了定量分析的范畴。然而，西方心理学对无法测量的事物感到不太自在，并且非常强调基于评估和证据的人类功能维度的概念化。正如“无量”一词所暗示的那样，使用现代心理计量工具来评估慈悲确实有些困难。尽管存在多种不同的基于证据的慈悲评估方法（本章中会描述几种），但每一种都只能揭示在情境性慈悲聚焦疗法中理解的慈悲心智的一部分。尽管如此，基于证据的原则和过程进行彻底的案例概念化是可能的——而且对于帮助来访培养慈悲能力也是至关重要的。

本章提供了深入指导，关于如何以慈悲为中心进行案例概念化、评估和治疗规划。我们回顾的技术和概念可以被任何模式的实践者使用，而不仅限于ACT、CFT或FAP。当我们在深入了解来访的个人目标和历史时引入慈悲，可以增强治疗关系并揭示问题的重要部分。面对艰难情绪时，慈悲创造了一个平静、安抚和扎根的情境，以及我们提倡的治疗规划方法。此外，这里概述的案例概念化方法和评估工具在培养更大的心理灵活性方面提供了明确的好处。

为了最好地说明本章中的概念和技术，我们将回到Josh的案例研究，探讨他的学习历史、安全行为以及经验回避的努力是如何与其在关键依恋关系中的创伤和威胁经历相关的。我们还将介绍一个半结构化的临床访谈，旨在评估来访在多大程度上具备慈悲的特质和技能，再次使用Josh的案例来举例说明这一访谈的应用。虽然这不是一个经过实证验证的评估工具，但它可以为来访提供一个路线图，让来访和治疗师共同制定治疗目标，并识别阻碍自我慈悲的因素。

自我慈悲心智访谈

参与和缓解这两种慈悲心理学的过程是慈悲心智训练、CFT和慈悲聚焦ACT的关键目标。因此，识别我们的来访在多大程度上能够获得这些方面的慈悲是很重要的。随着我们通过治疗过程开始塑造这些特质和技能，了解我们的起点是一个好主意。此外，理解那些可能阻碍或抑制来访访问其自我慈悲能力及接受、勇气和致力于有价值目标成长的回避、控制或不必要的防御模式也很重要。

目前，几位研究人员正在开发多种形式的自我报告来衡量慈悲的不同维度。在此工作进行的同时，我们已经与CFT的研究人员合作开发了一个半结构化访谈，旨在帮助来访洞察他们在慈悲方面的优势和潜在成长领域。这个访谈旨在帮助制定干预目标，并为治疗计划提供信息，应在治疗早期的一个会话中使用。最佳时机可能是当来访已经与治疗师建立了验证性和投入的关系，设定了一些初步的治疗目标，并通过诸如激发创造性绝望、参与第三章的现实检查和探索无责智慧等方法介绍了一些慈悲聚焦ACT的假设之后。所有这些都将作为理解的基础，使来访能够更有效地参与访谈中提出的问题。理想情况下，来访还应了解两种慈悲心理学，或者已经学到了一些关于如何训练慈悲以及它如何帮助容忍困难经历以实现更有意义和目的的生活的基本知识。由于慈悲的各个方面与六边形过程之间的自然关系，如第二章所述，该访谈也允许评估心理灵活性过程。

尽管访谈指南提供了治疗师可能对来访说什么的建议，但非常重要的是，访谈应在考虑来访的性格和挣扎的情况下，作为一种正念和慈悲的对话进行。此外，第4至6章中讨论和展示的验证和连接的语气应该影响你的治疗立场，当你根据来访所在的位置与他们见面，并在此基础上建立对话风格、默契和同理心桥梁时。

临床案例：在会谈中使用自我慈悲心智访谈

本章稍后会提供一个空白模板，用于进行自我慈悲心智访谈。然而，为了帮助您更好地理解和感受这个过程，我们首先通过Josh的案例来呈现它。

治疗师：现在我们已经理解了“慈悲”的含义，并且看到了你的自我批评对你有多大的影响，我想看看我们是否可以更仔细地探讨如何帮助你建立一些新的应对方式。

来访：新的应对方式——处理这种情况？那很好，因为我真的厌倦了这种感觉。

治疗师：嗯，我们会做一些类似的事情。坦白说，我们的重点不是要找出如何最好地消除你的感受，而是要看看你在哪些方面更有能力去承受困难并继续前进。我们会看看你如何能够在早晨起床，好好照顾自己，并以善意和力量开始新的一天。你觉得这样可以吗？

来访：这听起来比躺在床上宿醉未醒，背景播放着有线新闻来掩盖我的思绪好多了。

治疗师：我能想象是这样的。

来访：那我们什么时候开始呢？

治疗师：听上去你已经准备好了，我们现在就开始吧。我会问你关于你认为自己在特定类型的慈悲行动中能够参与并且愿意参与的程度。我们的慈悲之心可以引导我们在生活中采取具体的步骤，我想了解你认为自己在这些方面的参与能力如何。

来访：哪些方面？

治疗师：你还记得我们之前讨论过的那些可以通过培养正念慈悲来发展的不同能力吗？

来访：保持当下，以及更能承担事物？

治疗师：完全正确。

来访：好的，我知道你的意思了。请继续。

随后，治疗师引导Josh完成了自我慈悲心智访谈，并记录了Josh的回答，如下例所示。为了让你熟悉表格格式，在许多项目中，治疗师会让来访根据0到6的评分标准来评价某一经历或能力，其中0表示完全没有或完全缺乏，6表示非常高。（请注意，在Josh的情况下，治疗师实际上在对话的早期就已经开始了正式访谈的第一步。）

自我慈悲心智访谈工作表

现在我要问你一些关于你在特定类型慈悲行动中的能力和意愿的问题。我们的慈悲之心可以引导我们在生活中采取具体的步骤，我想了解你认为自己在这些方面的参与能力如何。

慈悲参与心理学的属性

  1. 敏感性

    • 你对自己当下发生的痛苦体验有多敏感？你能注意到自己的痛苦是如何产生的吗？请用0到6的评分标准来评价这一点，其中0表示你完全不敏感，6表示你非常敏感。
      • 0 完全没有
      • 1
      • 2
      • 3
      • 4
      • 5
      • 6 非常高
      • X
    • 哪些经历和情绪可能会阻碍你对自己的痛苦产生慈悲敏感性？
      • 当我清醒或不处于麻木状态时，我能注意到自己有多么痛苦。我的焦虑让我想要逃避或自毁。此外，我讨厌自己！
    • 我们能否一起想出一种方法来解决这个障碍或阻碍？
      • 根据我们之前的讨论，我认为我需要能够直接面对这些感受，不再隐藏它们。

  2. 照顾福祉的动机

    • 使用同样的0到6的评分标准，你有多大的动力去照顾自己并确保自己的福祉？你在多大程度上被激励去缓解或预防你所见证的自身痛苦？
      • 0 完全没有
      • 1
      • 2
      • 3
      • 4
      • 5
      • 6 非常高
      • X
    • 哪些经历和情绪可能会阻碍你照顾自己福祉的动力？
      • 当我纠结于所有失败的方式或是害怕与女性交谈时，我觉得自己根本不在乎了。当我拖延太多时，我也开始放弃。
    • 我们能否一起想出一种方法来解决这个障碍或阻碍？
      • 我可以计划每天做一件正念的事情，比如煮咖啡，作为一种自我关怀的行为。这听起来可能有点奇怪，但我可以做一件事。另外，我可以联系我在奥斯汀12步戒瘾小组的老赞助人。

  3. 同情心

    • 使用同样的0到6的评分标准，你在困难经历中能向自己展示多少同情心？当你注意到自己的痛苦时，你会在多大程度上自发地感到同情？
      • 0 完全没有
      • 1
      • 2
      • 3
      • 4
      • 5
      • 6 非常高
      • X
    • 哪些经历和情绪可能会阻碍你对自己的同情心？
      • 我知道这可能是错的，但我觉得自己对自己的痛苦相当麻木。有时直到太晚了我才意识到。
    • 我们能否一起想出一种方法来解决这个障碍或阻碍？
      • 当我想到母亲因成瘾而醒来时，我会想哭。如果我能以这种方式对待自己，那会更好。

  4. 同理心

    • 使用同样的0到6的评分标准，你在多大程度上能够反思自己的痛苦并理解自己的经历？你在多大程度上能够以对他人的痛苦感同身受的方式来看待自己的经历？
      • 0 完全没有
      • 1
      • 2
      • 3
      • 4
      • 5
      • 6 非常高
      • X
    • 哪些经历和情绪可能会阻碍你对自己的同理心？
      • 我觉得我在理智上是明白的。我能看清楚大局，知道自己在搞砸事情。我知道这些模式正在摧毁我，但我似乎无法关心，因为我内心充满了对自己的恨意。
    • 我们能否一起想出一种方法来解决这个障碍或阻碍？
      • 上周我开始意识到所有的自我厌恶言论只是我头脑中的故事，这对我有所帮助。我可能无法停止这样思考——抱歉！但我可以意识到这是一个老故事。

  5. 无评判

    • 使用同样的0到6的评分标准，你认为自己能在多大程度上对自身的痛苦采取非评判的态度？你在多大程度上能够摆脱评判性和谴责性的思想和态度的影响？
      • 0 完全没有
      • 1
      • 2
      • 3
      • 4
      • 5
      • 6 非常高
      • X
    • 哪些经历和情绪可能会阻碍你对自己的非评判态度？
      • 我觉得你一定是在开玩笑吧！真的，我认为如果我不再逃避和吸毒，也许我可以给自己一个机会。如果我能连续几天保持清醒，也许会有转机。
    • 我们能否一起想出一种方法来解决这个障碍或阻碍？
      • 我可以再去参加一次会议。也许如果我去了一次会议，我可以给自己一个小休息的机会。

  6. 痛苦容忍度

    • 使用同样的0到6的评分标准，你觉得你在经历困难情绪时能在多大程度上容忍痛苦？你能在多大程度上采取接受和开放的态度面对痛苦？
      • 0 完全没有
      • 1
      • 2
      • 3
      • 4
      • 5
      • 6 非常高
      • X
    • 哪些经历和情绪可能会阻碍你容忍痛苦？
      • 这个问题很有趣，因为我可以承受很多痛苦和困扰，除了对自己感到厌恶。当我觉得自己看起来很好或表现得非常好时，我会感觉很棒。大多数类型的痛苦我都能处理，但我讨厌自己如此愤怒和恐惧。
    • 我们能否一起想出一种方法来解决这个障碍或阻碍？
      • 听起来我需要停止把自己看得那么严重。也许我可以放松一两个小时？

缓解心理学属性，或慈悲心智技能

现在我要问你一些关于你在各种慈悲心智技能中的能力的问题。对于所有这些问题，请使用我们一直在使用的0到6的评分标准。

  1. 自我慈悲思维或推理的能力

    • 你如何评价自己进行自我慈悲思考或推理的能力？
      • 0 完全没有
      • 1
      • 2
      • 3
      • 4
      • 5
      • 6 非常高
      • X

  2. 将自我慈悲注意力带入当下体验的能力

    • 你如何评价自己将自我慈悲的注意力带入当前体验的能力？
      • 0 完全没有
      • 1
      • 2
      • 3
      • 4
      • 5
      • 6 非常高
      • X

  3. 使用唤起温暖、智慧、力量和对福祉承诺的意象的能力

    • 你如何评价自己使用能够唤起温暖、智慧、力量和对福祉承诺的意象的能力？
      • 0 完全没有
      • 1
      • 2
      • 3
      • 4
      • 5
      • 6 非常高
      • X

  4. 保持对安抚性感官体验开放的能力

    • 你如何评价自己保持对那些对你有安抚作用的感官体验开放的能力？
      • 0 完全没有
      • 1
      • 2
      • 3
      • 4
      • 5
      • 6 非常高
      • X

  5. 接触自我慈悲感受（如满足感、连接感和安全感）的能力

    • 你如何评价自己接触自我慈悲感受（如满足感、连接感和安全感）的能力？
      • 0 完全没有
      • 1
      • 2
      • 3
      • 4
      • 5
      • 6 非常高
      • X

  6. 以自我慈悲的方式行为，旨在照顾和保护你的福祉的能力

    • 你如何评价自己以自我慈悲的方式行为，旨在照顾和保护你的福祉的能力？
      • 0 完全没有
      • 1
      • 2
      • 3
      • 4
      • 5
      • 6 非常高
      • X

临床案例：总结Josh的自我慈悲心智访谈揭示的内容

鉴于Josh普遍带有羞耻感的自我对话的语气和风格，他自述几乎没有自我慈悲的能力并不令人意外。然而，他提供的一些细节指出了治疗师可能希望在治疗中强调的领域。这些回答可以被视为假设并轻柔地对待，但它们确实提供了关于Josh如何体验自己的更精确的信息：

  • Josh说，当他没有醉酒或半解离状态时，他能够敏感地接触当下的痛苦。他认为自己通过逃避对经历的敏感性来应对焦虑。
  • 他对照顾自己作为有价值的目标比我们想象的更有动力，但他被与羞耻的自我故事融合在一起而无法行动。
  • Josh对自己的痛苦感到麻木，并且完全缺乏对自己的同情心。然而，他能够在认知上对自己产生同理心，并能理解自己的经历。当他将自己的痛苦与母亲成瘾对他造成的伤害联系起来时，他的感受更加深刻。
  • Josh对自己非常苛刻，并希望自己能够放松一些，不要把自己看得那么严重。
  • 他认为自己很坚强，能够承受很多痛苦和困扰。然而，社交威胁、羞耻和恐惧对他来说很难面对。
  • 他报告说，他使用慈悲心智技能的能力非常有限。然而，他可以通过感官体验进行自我安抚。
  • Josh已经意识到寻求清醒可能会对他有益，并且这可能是对自己的一种善意行为。

所有这些信息可能在几次常规会谈中生成，但通过结构化访谈，在单次会谈的一半时间内就收集到了。在这个过程中，明确识别了几个发展来访自我慈悲能力的途径。

自我慈悲心智访谈工作表

此工作表供治疗师与来访一起使用。结构化访谈及其评分标准为评估慈悲的属性和技能提供了一个格式。我们为你提供了围绕两种慈悲心理学的每个属性和技能与来访互动的初步问题；然而，请让你自己的慈悲智慧引导你完成评估。在进行访谈时，简要反思每个问题，然后使用0到6的评分标准对来访的慈悲技能或属性进行评分，其中0表示该技能或属性完全不存在，6表示它存在程度非常高。本次访谈中收集的所有信息都可能指导你的案例构建和治疗计划，帮助确定慈悲聚焦干预的方向和进程。请随意复制此工作表以供你在实践中使用。如需下载版本，请访问http://www.newharbinger.com/30550（有关如何访问的更多信息，请参阅书的最后一页）。

开始时，向来访介绍这个过程：“现在我要问你一些关于你在特定类型慈悲行动中的能力和意愿的问题。我们的慈悲之心可以引导我们在生活中采取具体的步骤，我想了解你认为自己在这些方面的参与能力如何。”

参与心理学的属性

  1. 敏感性

    • 你对自己在当下发生的痛苦体验有多敏感？你能注意到自己的痛苦是如何产生的吗？请用0到6的评分标准来评价这一点，其中0表示你完全不敏感，6表示你非常敏感。
      • 0 完全没有
      • 1
      • 2
      • 3
      • 4
      • 5
      • 6 非常高
    • 哪些经历和情绪可能会阻碍你对自己的痛苦产生慈悲敏感性？
    • 我们能否一起想出一种方法来解决这个障碍或阻碍？

  2. 照顾福祉的动机

    • 使用同样的0到6的评分标准，你有多大的动力去照顾自己并确保自己的福祉？你在多大程度上被激励去缓解或预防你所见证的自身痛苦？
      • 0 完全没有
      • 1
      • 2
      • 3
      • 4
      • 5
      • 6 非常高
    • 哪些经历和情绪可能会阻碍你照顾自己福祉的动力？
    • 我们能否一起想出一种方法来解决这个障碍或阻碍？

  3. 同情心

    • 使用同样的0到6的评分标准，在困难经历中你能向自己展示多少同情心？当你注意到自己的痛苦时，你会在多大程度上自发地感到同情？
      • 0 完全没有
      • 1
      • 2
      • 3
      • 4
      • 5
      • 6 非常高
    • 哪些经历和情绪可能会阻碍你对自己的同情心？
    • 我们能否一起想出一种方法来解决这个障碍或阻碍？

  4. 同理心

    • 使用同样的0到6的评分标准，你在多大程度上能够反思自己的痛苦并理解自己的经历？你在多大程度上能够以对他人的痛苦感同身受的方式来看待自己的经历？
      • 0 完全没有
      • 1
      • 2
      • 3
      • 4
      • 5
      • 6 非常高
    • 哪些经历和情绪可能会阻碍你对自己的同理心？
    • 我们能否一起想出一种方法来解决这个障碍或阻碍？

  5. 无评判

    • 使用同样的0到6的评分标准，你认为自己能在多大程度上对自身的痛苦采取非评判的态度？你在多大程度上能够摆脱评判性和谴责性的思想和态度的影响？
      • 0 完全没有
      • 1
      • 2
      • 3
      • 4
      • 5
      • 6 非常高
    • 哪些经历和情绪可能会阻碍你对自己的非评判态度？
    • 我们能否一起想出一种方法来解决这个障碍或阻碍？

  6. 痛苦容忍度

    • 使用同样的0到6的评分标准，你觉得你在经历困难情绪时能在多大程度上容忍痛苦？你能在多大程度上采取接受和开放的态度面对痛苦？
      • 0 完全没有
      • 1
      • 2
      • 3
      • 4
      • 5
      • 6 非常高
    • 哪些经历和情绪可能会阻碍你容忍痛苦？
    • 我们能否一起想出一种方法来解决这个障碍或阻碍？

缓解心理学属性，或慈悲心智技能

现在我要问你一些关于你在各种慈悲心智技能中的能力的问题。对于所有这些问题，请使用我们一直在使用的0到6的评分标准。

  1. 自我慈悲思维或推理的能力

    • 你如何评价自己进行自我慈悲思考或推理的能力？
      • 0 完全没有
      • 1
      • 2
      • 3
      • 4
      • 5
      • 6 非常高

  2. 将自我慈悲注意力带入当下体验的能力

    • 你如何评价自己将自我慈悲的注意力带入当前体验的能力？
      • 0 完全没有
      • 1
      • 2
      • 3
      • 4
      • 5
      • 6 非常高

  3. 使用唤起温暖、智慧、力量和对福祉承诺的意象的能力

    • 你如何评价自己使用能够唤起温暖、智慧、力量和对福祉承诺的意象的能力？
      • 0 完全没有
      • 1
      • 2
      • 3
      • 4
      • 5
      • 6 非常高

  4. 保持对安抚性感官体验开放的能力

    • 你如何评价自己保持对那些对你有安抚作用的感官体验开放的能力？
      • 0 完全没有
      • 1
      • 2
      • 3
      • 4
      • 5
      • 6 非常高

  5. 接触自我慈悲感受（如满足感、连接感和安全感）的能力

    • 你如何评价自己接触自我慈悲感受（如满足感、连接感和安全感）的能力？
      • 0 完全没有
      • 1
      • 2
      • 3
      • 4
      • 5
      • 6 非常高

  6. 以自我慈悲的方式行为，旨在照顾和保护你的福祉的能力

    • 你如何评价自己以自我慈悲的方式行为，旨在照顾和保护你的福祉的能力？
      • 0 完全没有
      • 1
      • 2
      • 3
      • 4
      • 5
      • 6 非常高

慈悲聚焦的案例构建

慈悲聚焦的案例构建旨在提供对来访生活特定性质、历史和背景的理解。通过理解这种高度个性化的学习历史以及强化模式、回避模式和情绪调节之间的功能关系，我们可以更有效地解决导致来访寻求心理治疗的痛苦和挣扎。因此，在案例构建中区分来访的思维、情感和行为的预期与非预期功能非常重要。在慈悲聚焦的方法中，案例构建的目标是提供个性化的案例概念化、确立治疗目标和焦点、提供验证，并激发来访自由选择的价值观（Gilbert, 2007; Tirch, 2012）。这种类型的慈悲聚焦构建必须包括四个基本要素：

  • 来访的生物和环境背景：这既包括过去的也包括现在的背景，需要在塑造来访行为模式和应对策略的前因、行为和后果的背景下加以理解。
  • 来访最害怕且最不愿意经历的事物：例如围绕被遗弃、拒绝、羞耻、虐待或伤害等主题的恐惧。
  • 来访内部和外部关注的“保护性”安全策略和行为。
  • 这些安全策略（公共和私人）对来访的预期和非预期后果：例如基于羞耻的自我批评、关于应对的信念或对来访自身痛苦性质的看法，包括抑郁和焦虑。

为了指导慈悲聚焦构建的过程，我们创建了一个案例构建工作表（受Gilbert, 2009b的原则启发），稍后会提供。当然，这样的构建是一个持续进行的过程，分为几个阶段，从最初的评估和构建开始，其中治疗师对来访进行访谈并收集有关当前困难、症状和问题的信息。治疗师还提供了关于来访挣扎和当前应对方式的验证和心理教育。这是通过合作视角获取和承认普遍的慈悲需求来完成的。治疗师还帮助来访认识到，鉴于来访的背景和迄今为止的经历，她对待问题的方式是可以理解的，尽管可能不是功能性的。慈悲基础构建的初始阶段另一个重点是建立融洽的关系和有效的治疗关系。在使用同理心、慈悲倾听和反思的同时，治疗师寻找任何可能阻碍建立这种关系的潜在困难，包括任何阻碍慈悲的因素。

接下来，治疗师和来访调查来访的文化背景和学习历史，一般而言以及与慈悲及相关过程相关的经历。这使来访能够分享她的生活故事，并让治疗师了解来访对自己的情感记忆和其他人的印象。治疗师可能会询问来访早期感受到被照顾、忽视或未满足需求的经历。此外，治疗师还会寻找与早期发展、依恋以及感到安全或受到威胁的重要经历，并始终评估是否有重大创伤或虐待的历史。这些早期经历往往与某些情感记忆相关，这些记忆可以成为来访自我体验的核心，并且可以通过当前的情境和经历被激活。治疗师不仅要听来访的内容，还要注意语气和其他非语言交流，以识别来访对于重要情感记忆及其对自我和他人的印象的感受。例如，当来访难过哭泣时多次被单独送回房间的经历可能导致来访将痛苦体验与孤独感联系起来。

反复的不安全感或未被关怀的感觉可能导致个体容易感到受到威胁，或者损害个体采取视角、体验慈悲或回忆早期或创伤相关事件的能力（Gilbert, 2009b; Mikulincer & Shaver, 2007a）。因此，重要的是要对来访敏感，并认识到他们在回忆历史时可能遇到的任何困难，包括在重述他们的故事时可能激活的威胁反应系统。每个来访在构建过程中都会有不同的节奏和阶段顺序。因此，鼓励治疗师根据每位来访的能力和意愿来适应。无论如何，全面的慈悲聚焦评估早期经历和学习，使治疗师能够利用慈悲同理心和验证，针对来访的历史和当前挣扎，并为来访提供机会（可能是第一次）在一个专注、无评判、同情、安全和温暖的人面前讲述自己的故事（Gilbert, 2009b）。

治疗师帮助来访识别特别有问题的行为或策略

接下来，治疗师帮助来访识别为应对恐惧和感知到的威胁而采取的特别有问题的行为或策略。这些个人意义上的威胁通常与来访最害怕且最不愿意经历的公共和私人事件有关。因此，来访试图通过避免或控制这些事情来感到安全，并最终保护自己。这些都是自然的防御反应或策略，它们在不同的人之间以及内部和外部威胁之间可能会有所不同（Gilbert, 2007）。这些“保护性”或应对策略的例子包括回避、沉思、物质滥用和寻求安慰。治疗师和来访可以一起回顾这些安全行为的成本和收益。此外，治疗师提供关于行为强化性质和原则的信息，以及这些策略的各种功能及其使用的原因。然而，治疗师也说明了这些看似保护性的安全行为有时会创造更多的困难，而不是解决问题。例如，这些反应的非预期后果可能包括阻碍新学习、消除测试威胁信念可行性的机会，以及减少来访的行为范围（Tirch, 2012）。因此，治疗师帮助来访认识到这些行为，并对自己因这些非预期困难或后果产生同情心。在会谈中可以使用隐喻、清单和体验练习来说明这一点。

基于上述所有内容，治疗师拥有了完成结构化慈悲聚焦构建所需的信息和见解，该构建涵盖以上列出的四个领域（历史影响、重要威胁和恐惧、安全策略、非预期后果）。这种构建强调去羞耻化，治疗师提供一个开放和安全的情境，不使用评判性的语言或术语如“扭曲”或“适应不良”（Gilbert, 2007, 2009b）。治疗师引导来访通过这个构建过程，让他们理解自己的挣扎和困难不是他们的错，也不是他们选择的结果。进行这种细致的评估和构建可以让来访采用新的视角，找到新的方式承担责任，并获得自由选择如何应对感知到的和实际的威胁。

如你所见，这种构建涉及一个流动的、协作的功能分析和反思倾听过程（Gilbert, 2009a）。治疗师支持来访发展自己的构建，这种方法贯穿整个治疗过程。必要时，治疗师和来访可能会确定新的治疗目标、目标和干预措施，或修订旧的目标。治疗师在与来访进行治疗的过程中始终牢记这一构建，持续跟踪进展和发展，使用功能和解决方案分析，并评估技能的不足、整合和泛化。除了根据进展定期审查和重新检查早期构建外，治疗师还不断留意新的或之前被忽视的慈悲障碍或其他干扰治疗的事件或行为，以保持构建尽可能全面和最新。

临床案例：发展慈悲聚焦的案例构建

正如本章前面的自我慈悲心智访谈工作表一样，我们再次以Josh为例，提供了一个在临床实践中使用的慈悲聚焦案例构建工作表示例，以帮助说明其使用方法。

慈悲聚焦案例构建工作表

  1. 当前症状和问题

    • 狂饮和长期的羞耻感、焦虑、抑郁及行为回避。“我讨厌自己，只有在聚会、看起来很好、成为关注焦点时才开心。这是否让我成为一个坏人？”

  2. 问题的当前背景

    • 来访正在大学完成戏剧学位，并开始演员生涯。他依靠家庭财富生活，忽视了自己的需求和责任，变得越来越回避。物质滥用、“崩溃”和“逃避世界”的循环导致心理灵活性降低、生活受限，除了醉酒期间的短暂时间外，自我慈悲和积极情绪水平较低。

  3. 背景和历史影响

    • 你认为对来访当前挣扎有重要影响的背景经历是什么？
      • 来访在童年时期长期遭受父亲的言语和身体虐待，在寄宿学校里受到严重欺凌和情感虐待。他在社交上被亲人忽视，亲人表现出缺乏关心，有时甚至敌意。
    • 其他人是如何表达关爱的？
      • 来访的依恋关系中充满了敌意、虐待和忽视。基于威胁的情绪和情感记忆已经与亲和情感和人际关系相关联。

当来访感到痛苦时，照顾者如何提供安慰或安抚？

  • 来访描述了缺乏安慰和连接的情况。

照顾者和其他重要人物是如何回应来访的成就的？

  • Josh报告说，他的成就被忽视，直到他开始因外表和表演能力而受到同龄人的赞扬。他也因为是“聚会的灵魂”而受到赞扬。

重要的生物或发展事件

  • 学术困难、ADHD和抑郁症的诊断，以及随后的“过度用药”。在身体成熟之前经历孤立和社会斗争。

重要的情感记忆

  • 拒绝、羞耻、悲伤、害怕孤独。

对来访的问题

  • 当你想到这些事件和记忆时，你的身体感觉如何？出现了哪些情绪？
    • “我不喜欢想这些事情。我对自己感到厌恶。”
  • 你的注意力被吸引到哪里？
    • “我想去睡觉。我想离开这里。”
  • 在成长过程中，你对情绪的经历是什么样的？
    • “被大喊大叫，被打得遍体鳞伤，被拒绝，被遗弃。我可能已经死了也没人管。”
  • 在成长过程中，你对亲近的人或照顾者的情绪体验是什么样的？
    • “愤怒、疯狂。”
  • 你对自己的感受是什么？
    • “我觉得自己低人一等。我得到了世界上所有的机会和金钱，但我搞砸了一切。”
  • 你对他人的感受是什么？
    • “其他人比我更惨。我被欺负，有个酗酒的父亲——那又怎样。我没有抱怨的理由。别人也让我害怕。”

4. 主要威胁及由此产生的恐惧

  • 对来访的问题：

    • 你认为这些经历对你产生了哪些重大的恐惧和担忧？
      • “除非人们真的印象深刻或我喝得很醉，否则我无法忍受被人看到。”
    • 你对他人可能做什么或者环境中可能发生的事情有哪些重大恐惧？
      • “拒绝！还有更多的惩罚。”
    • 你对自己可能做的事情有哪些重大恐惧或担忧？
      • “让人们看到我是多么软弱和混乱。”
    • 这些恐惧中是否有特定的主题或联系，比如拒绝、抛弃、羞耻或身体伤害？
      • “以上全部！”

  • 治疗师总结来访的外部威胁：

    • 社会排斥、药物和酒精导致的死亡、失败。

  • 治疗师总结来访的内部威胁：

    • 生活在持续的羞耻和孤立状态中。被愤怒和恐惧压倒。

5. 安全策略

  • 对来访的问题：

    • 面对这些威胁和恐惧时，你会采取什么应对措施？
      • “躺在床上，或者变得非常兴奋和醉酒。用魅力征服所有人。”
    • 回顾过去，你觉得你的头脑是如何试图保护你免受这些威胁和恐惧的？
      • “成为摇滚明星。”
    • 你的头脑是如何试图保护你免受来自他人的外部威胁（如攻击）的？
      • “躲开所有人。显得非常酷和到位。”
    • 你的头脑是如何试图保护你免受内部威胁（如强烈的情绪或身体感觉）的？
      • “麻木、逃避、吸毒。”

  • 治疗师总结外部安全行为：

    • 吸毒、饮酒、“装模作样”，白天隔离。

  • 治疗师总结内部安全行为：

    • “自我攻击以激励自己。”

6. 非预期后果

  • 对来访的问题：
    • 这些策略带来了哪些非预期的成本或不利影响？
      • “制造尴尬场面，浪费我的钱，失去关系，伤害好人，看起来像个混蛋，失去表演角色，糟糕的学习表现，可怕的恐慌发作，和严重的抑郁——这还不包括不断的自我憎恨。医生，这样够了吗？”
    • 当这些恐惧、行为或后果出现时，你怎么看待自己？
      • “就像我说的，我充满了自我憎恨。”

治疗师总结外部后果

  • 多个领域的功能受损，缺乏明确的价值方向，难以承诺责任和“重要的事情”，奖励减少，与越来越多的同龄人疏远。

治疗师总结内部后果

  • 抑郁、焦虑、普遍的羞耻感和恐惧、“强烈的”醉酒渴望、高水平的压力报告、反复经历虐待的情绪重现、缺乏快乐，以及与敌对自我批评的融合。

如你所见，这个案例中存在回避、控制和自毁行为的重复主题，这些是对广泛创伤历史的反应。Josh在关键依恋关系中的虐待和忽视经历、他的安全策略，以及他在压力情况下未能学会情感安抚，都导致了一种僵化且不灵活的应对模式，几乎没有正念、接受、慈悲或承诺行动。这个案例构建揭示了一个痛苦的历史和一个经历了许多羞耻的年轻人。从CFT（慈悲聚焦治疗）的角度来看，治疗师可以认识到Josh的痛苦很少是他自己的选择或过错，并基于对使他陷入困境的模式的精确而细致的理解来敏感地对待他的痛苦。通过建立在这个慈悲聚焦的案例概念化基础上，治疗师可以帮助Josh体验到关爱自己并走向自由、选择甚至可能是快乐的价值。Josh前面还有很长的路要走——无论是治疗、康复还是生活。在CFT中，希望是慈悲能够作为接受的基础，帮助他找到立足之地，也许这是他生命中的第一次。

为了便于您对自己来访的案例构建，我们提供以下空白工作表。请随意复制并在您的实践中使用。要获取可下载版本，请访问http://www.newharbinger.com/30550（有关如何访问的说明，请参阅本书最后一页）。

慈悲聚焦案例构建工作表

  1. 当前症状和问题

  2. 问题的当前背景

  3. 背景和历史影响

    • 你认为来访今天面临的挣扎有哪些重要的背景经历？
    • 其他人是如何表达关爱的？
    • 当来访感到痛苦时，照顾者是如何提供安慰或安抚的？
    • 照顾者和其他重要人物是如何回应来访的成就的？
    • 重要的生物或发展事件：
    • 重要的情感记忆：
    • 对来访的问题
      • 当你想到这些事件和记忆时，你的身体感觉如何？出现了哪些情绪？
      • 你的注意力被吸引到哪里？
      • 在成长过程中，你对情绪的经历是什么样的？
      • 在成长过程中，你对亲近的人或照顾者的情绪体验是什么样的？
      • 你对自己的感受是什么？
      • 你对他人的感受是什么？

  4. 主要威胁及由此产生的恐惧

    • 对来访的问题
      • 你认为这些经历对你产生了哪些重大的恐惧和担忧？
      • 你对他人可能做什么或者环境中可能发生的事情有哪些重大恐惧？
      • 你对自己可能做的事情有哪些重大恐惧或担忧？
      • 这些恐惧中是否有特定的主题或联系，比如拒绝、抛弃、羞耻或身体伤害？
    • 治疗师总结来访的外部威胁
    • 治疗师总结来访的内部威胁

  5. 安全策略

    • 对来访的问题
      • 面对这些威胁和恐惧时，你会采取什么应对措施？
      • 回顾过去，你觉得你的头脑是如何试图保护你免受这些威胁和恐惧的？
      • 你的头脑是如何试图保护你免受来自他人的外部威胁（如攻击）的？
      • 你的头脑是如何试图保护你免受内部威胁（如强烈的情绪或身体感觉）的？
    • 治疗师总结外部安全行为
    • 治疗师总结内部安全行为

  6. 非预期后果

    • 对来访的问题
      • 这些策略带来了哪些非预期的成本或不利影响？
      • 当这些恐惧、行为或后果出现时，你怎么看待自己？
    • 治疗师总结外部后果
    • 治疗师总结内部后果

慈悲聚焦评估工具

像许多人类体验一样，慈悲是一个非常难以科学测量的过程。根据其定义和训练的多模态方法，慈悲需要更符合其动态性质的评估工具（MacBeth & Gumley, 2012）。迄今为止，实证科学和研究主要依赖于慈悲和自我慈悲的自我报告测量。对于进一步开发和研究用于评估和测量慈悲的工具仍然存在显著需求。西方的慈悲科学还很年轻，自我报告测量也有局限性。然而，在您开始将慈悲聚焦技术引入您的工作中时，有一些测量工具我们想向您介绍。

自我报告的慈悲测量工具

自我慈悲量表（SCS）是一种用于衡量个体对自我慈悲反应信念和态度的自我报告工具（Neff, 2003a）。这个包含二十六个项目的自我报告问卷旨在评估整体自我慈悲，以及Neff（2003a）所概述的每个自我慈悲组成部分的得分：

  • 自我仁慈（SCS-SK）
  • 共同人性（SCS-CH）
  • 正念（SCS-M）

在开发此量表的过程中，因子分析建议使用六个子量表来表示每个方面的积极和消极方面（Neff, 2003b）。因此，SCS有六个子量表，反映了其各组成部分的对立面：自我仁慈（SK）与自我评判（SJ），共同人性（CM）与孤立（I），以及正念（M）与过度认同（OI）（Neff, 2003a, 2003b）。

参与者使用从1（几乎从不）到5（几乎总是）的五点李克特量表回答问题，这些问题旨在反映他们在困难时期对自己反应的看法。每个组成部分的负面方面被反向计分。以下是一些示例项目：

  • 自我仁慈（“我试图理解和耐心对待我不喜欢的性格方面”）与自我评判（反向计分；“我对自己的缺点和不足持否定和批判的态度”）
  • 共同人性（“我试图将我的失败视为人类状况的一部分”）与孤立（反向计分；“当我想到我的不足时，这往往会让我感到更加分离和脱离世界其他部分”）
  • 正念（“当痛苦的事情发生时，我试图以平衡的观点看待情况”）与过度认同（反向计分；“当我情绪低落时，我倾向于纠结并专注于所有错误的事物”）

已有报道指出，SCS具有良好的跨文化信度和效度（Neff, 2003b; Neff, Pisitsungkagarn, & Hsieh, 2008）。这项研究支持了SCS的适当因子结构，其中单一的高阶自我慈悲因子解释了子量表之间的强相关性（Neff, 2003a）。子量表的内部一致性信度报告为0.78（SK）、0.77（SJ）、0.80（CH）、0.79（I）、0.75（M）和0.81（OI）。该量表显示了聚合效度（即与治疗师评分相关）、区分效度（即与社会期望无关）和重测信度（α = 0.93; Neff, 2003a; Neff, Kirkpatrick, et al., 2007）。

SCS的心理测量特性已在大学生和研究生样本中进行了检验（Neff, 2003a），以及冥想练习者、未指定社区成人样本和复发性抑郁症缓解期成人样本中进行过测试，这些成人被招募参与基于正念的认知疗法（Kuyken et al., 2010; Van Dam et al., 2011）。总体SCS得分与自我批评、抑郁、焦虑和沉思呈负相关，与社会连接感和情商呈正相关（Neff, 2003a）。MacBeth和Gumley（2012）在他们关于自我慈悲与精神病理学关联的元分析中，仅使用总分来分析使用SCS的研究。他们发现较高的自我慈悲与较低的精神病理学和情感困扰之间存在显著关联，并注意到显著的效果大小。然而，本书作者也指出了这种自我报告量表的局限性，并认为这些分析的结果不能区分结果是由于高水平的自我慈悲还是低水平的自我评判和自我孤立导致的。

慈悲恐惧量表

Gilbert、McEwan、Matos和Rivis（2011）开发了一系列测量慈悲恐惧的量表，考察了三个不同的过程。第一个过程考察对他人表达或感受慈悲的恐惧，即慈悲流出。第二个过程考察接受来自他人的慈悲的恐惧，即慈悲流入。第三个过程评估对自己慈悲的恐惧，即自我慈悲体验（Gilbert等人，2011）。在这三个量表上，受访者使用四点李克特量表来评价他们对每个陈述的同意程度。在一个学生样本中，对表达对他人的慈悲的恐惧的Cronbach's α系数为0.72，对接受他人慈悲的恐惧的α系数为0.80，对自己慈悲的恐惧的α系数为0.83（Gilbert等人，2011）。在治疗师样本中，这些量表的Cronbach's α系数分别为：对他人的慈悲恐惧0.76，从他人那里获得慈悲的恐惧0.85，以及对自己的慈悲恐惧0.86（Gilbert等人，2011）。临床上，这三个量表非常有用，可以区分来访在不同方向上的慈悲能力，并允许探索来访对参与慈悲体验或行为的恐惧和主动抵抗。它们还提供了关于一般亲和情绪可能存在的恐惧的信息（Gilbert等人，2011）。这对接近性情感在有效应对恐惧和威胁经历中的重要作用具有重要意义，因此对于慈悲聚焦干预措施和治疗关系来说至关重要。该量表可以在http://www.compassionatemind.co.uk/downloads/scales/Fear_of_Compassion_Scale.pdf找到。

慈悲之爱量表

Sprecher和Fehr（2005）开发了慈悲之爱量表（CLS），用于衡量个体向各种目标展示慈悲或利他之爱的倾向。CLS有三个原始版本，分别针对家庭成员或朋友、一般人（“陌生人-人类”）或特定的亲近者，后一个版本的每个项目都包括特定目标的名字（Sprecher & Fehr, 2005）。作者将慈悲之爱定义为“对他人（无论是亲近的人还是陌生的所有人）的态度；包含关怀、关心、温柔的感觉、认知和行为，以及支持、帮助和理解他人的导向”（Sprecher & Fehr, 2005, p. 630）。每个版本都有二十一个陈述或项目，采用七点李克特量表评分，范围从“根本不适用于我”到“非常适用于我”。所有三个版本都有类似措辞的项目（例如，以“我花很多时间关心...的福祉”开始），根据每个量表适当修改（例如，以“那些与我亲近的人”、“人类”或特定目标的名字结束）。三个CLS版本具有单因子结构和良好的内部一致性，报告的Cronbach's α系数为0.95（Sprecher & Fehr, 2005）。

圣克拉拉简短慈悲量表

圣克拉拉简短慈悲量表（SCBCS）是基于CLS为大规模流行病学研究开发的（Hwang, Plante, & Lackey, 2008）。该量表的五个项目是通过因子分析从较长的工具中选择出来的。受访者被要求使用五点李克特量表对每个项目进行自评，范围从1（不怎么描述我）到5（非常描述我）。该量表的得分是对所有五个问题的平均评分。原始版本与简短版本之间的相关性为0.96（Hwang等人，2008）。一项比较SCS与CLS的研究（Gilbert等人，2011）发现，在学生样本中，自我慈悲与对他人的慈悲之爱之间存在显著相关性（r = 0.31, p < 0.01）。然而，在治疗师样本中，自我慈悲与对他人的慈悲之爱之间没有显著相关性（r = 0.21, p = n.s.）。

自我-他人四无量心量表

自我-他人四无量心量表（SOFI）是一个自我施测的量表，它评估佛教教义核心中的四种品质，称为四无量心（Kraus & Sears, 2009）：慈、悲、喜、舍。它使用五点李克特量表，由作者选择形容词来体现或代表佛教心理学中的四无量心及其对立过程的理论品质。经过因子分析后的最终版本量表产生了八对形容词（总共十六个项目），并提出了四个子量表。对立过程的形容词是友善与仇恨、喜悦与愤怒、接纳与残忍、慈悲与刻薄。子量表分别是正面自我、负面自我、正面他人、负面他人。参与者被指示在每个项目上标记适当的答案，以表明他们在过去一周内对自己和他人思考、感觉或行为的程度。量表作者计算了四个拟议子量表和整个量表的Cronbach's α系数。当测量所有项目时，内部一致性为0.60。对于正面自我，内部一致性为0.86；对于负面自我，为0.85；对于正面他人，为0.80；对于负面他人，为0.82（Kraus & Sears, 2009）。

慈悲体验访谈

研究人员正在探索测量和评估慈悲的不同方法。这些新的慈悲测量工具旨在考察作为迄今为止讨论的慈悲理论与科学基础的意图性和行为性成分及过程的具体变体（Gilbert, 2010; Goetz, Keltner, & Simon-Thomas, 2010; Neff, 2003a, 2003b）。其中一个尝试的例子是开发了一种基于访谈的慈悲评分量表（Gumley, 2013）。这种评估方法的开发旨在补充并增强关于慈悲的研究和数据，特别是在临床人群中（Gumley, 2013; MacBeth & Gumley, 2012）。

2013年，在由慈悲心基金会组织的第二届慈悲聚焦疗法国际会议上，Gumley描述了这种基于叙述的方法来评估慈悲，特别是慈悲体验访谈。该访谈被提议作为一种方式，让个体参与从自我到他人、从他人到自我以及自我对自我的慈悲评价。这一评估的灵感来源于临床和理论观察中关于自我和他人的慈悲体验在语义记忆和情景记忆之间明显矛盾的现象。这种评估慈悲的方法源于对个体叙述的编码，并包括四个反映四个领域中的智慧和慈悲的子量表（Gumley, 2013）：

  • 对慈悲的理解
  • 自我慈悲
  • 来自他人的慈悲
  • 对他人的慈悲

这个访谈通过卡片分类任务使用语义描绘，以及三个情境的情景描绘：受访者向他人表达慈悲的时候、他人向受访者表达慈悲的时候，以及受访者对自己表达慈悲的时候。Gumley (2013) 认为，这种测量方法对CFT的效果敏感，与心智化过程相关，并能促进慈悲体验。

培养慈悲行为

虽然我们对慈悲的需求不是自由选择的，但基于慈悲的行为和价值观却是可以自主选择的。换句话说，我们如何体现慈悲行为以及对这种行为的承诺取决于我们自己。在本节中，我们将讨论几种可以帮助来访培养更广泛的慈悲行为的方法，特别侧重于缓解痛苦并促进成长和福祉。这涉及到探索体现智慧体验的行为，即做有效的事情，通过面对恐惧的经历获得力量和勇气，并接触对痛苦的认识。这些方法依赖于以符合个人价值观和意愿的方式有意使用行为实验、行为激活和暴露（Tirch, 2012）。为了开始这项工作，治疗师和来访协作达成一致，确定这些新行为是什么样的，它们看起来如何，以及它们会让来访感觉如何。在整个过程中，慈悲聚焦的行为激活和暴露还通过使用温暖、勇气、力量和善良来强调慈悲和价值观，从而促进参与更加令人害怕或具有挑战性的活动（Gilbert, 2010）。

真正有助于减轻来访痛苦的是提供给他们学习新方法的机会，以应对他们的痛苦。为此，治疗师提醒来访过去由于改变他们对痛苦的关系和反应而发生的事情。例如，不听从焦虑自我的命令而是去约会，尽管有预期的担忧或压力。慈悲行为就是选择出去，即使这样做很困难。因此，慈悲行为不仅关乎做什么，还包括怎么做。

为什么要求来访参与这些具有挑战性的行动？因为这有助于他们摆脱习惯性的融合和回避模式，这些模式导致生活越来越受限。因此，我们经常开发灵活且具有挑战性但不过度压倒的干预措施和一系列行为实践，其中，来访逐步开始参与连续（且成功）接近他们所期望的慈悲行为。例如，对于患有广场恐惧症的来访来说，建议他们仅仅待在家里，那里感觉不那么可怕，并不是真正的慈悲。这是显而易见的。但未经警告就将他们直接带到滚石乐队音乐会中间也不会是真正的慈悲。因此，我们可能会开始鼓励他们走到门口并看看街道；然后下次，鼓励他们沿着人行道走几步或走到邮箱旁，依此类推。这种渐进式的暴露是一种自我慈悲的行为，因为它考虑到了速度和意图，也可以作为一种慈悲的暴露形式，因为来访和治疗师都积极调动了来访先前训练过的正念慈悲和在面对恐惧刺激时的灵活反应能力。

我们越能够帮助来访为自己创造一个理解、支持和温暖的内心声音——一种认可并认识到痛苦有多么不愉快的视角——他们就越有可能找到一个安全的基础，从中探索并面对挑战。慈悲心训练可以帮助他们保持与慈悲智慧的联系：这部分自我已经学会了痛苦是暂时的，并且可以为痛苦留出空间而不是与其融合或逃避。这种慈悲的自我视角使来访更容易回忆起新的、预期的反应，并指导自己采取这些反应。所有的行为改变都很重要，因为它们都有助于来访建立勇气和信心。

明确有价值的目标并选择关注福祉

当来访开始面对他们的痛苦时，他们将有意识地走向那些历史上一直回避的困难事物。这种体验很可能会让人感到不适。因此，作为治疗师，我们会听到来访问：“为什么要这样做？”对此，我们必须保持灵活性，并记住对于特定来访来说，哪种暴露练习或慈悲行为是重要的并没有绝对的规则。在第六章中，我们提到创造性绝望和无责智慧可以为开始有意义且充满活力的生活过程创造一个背景，即使在存在困难情绪的情况下也是如此。然而，在基于慈悲的ACT（接受与承诺疗法）中，澄清和个人意义的价值观的撰写也起着至关重要的作用。因此，某些问题可能与基于慈悲的暴露工作相关，而其他问题则可能不相关，这取决于价值观和实用性。例如，一位来访可能害怕长颈鹿，但并不认为有必要克服它，因为它不会干扰正念、慈悲和基于价值观的生活。因此，重要的是要与来访合作，探索和明确他们的基于价值观的目标和目的。这将为决定是否以及如何处理特定的困难或治疗目标提供信息，并揭示出哪些部分的痛苦最值得关注。

例如，一个来访可能希望解决他的慢性但轻微的抑郁症，因为他想搬到一个新的城市并开始一份新工作；而另一位来访可能希望停止强迫性地向她的朋友和亲戚寻求保证，以确保她能够面对通勤到工作的焦虑。显然，具体明确来访想要实现什么以及为什么想要实现它是很重要的。换句话说，为什么某个目标对一个人来说很重要，是什么让它值得去克服习惯性的回避模式和过度的控制尝试？当治疗过程中出现障碍或阻力时，这一点尤其有用，它允许治疗师帮助来访记住他们的目标是什么，以及这项工作为什么是值得的。否则，当痛苦出现时，来访可能会失去动力和视角，使他们很容易回到回避模式和不愿意的感觉中。

正如您无疑非常清楚的那样，有价值的目标或有价值的方向是内在奖励的行为，这些行为随着时间的推移和情境的变化而持续反映来访真正希望在这个世界上如何行为的意图。这意味着选择了他们最希望自己成为的那个版本。因此，治疗师和来访的一个关键目标是发现具体来说是什么点燃了来访的热情。这将揭示来访的价值观，并反映出某些行为的强化程度。因此，为了帮助来访参与真正的慈悲行为并好好照顾自己，探索他们的价值观并帮助他们找到有效的方法朝着有价值的目标前进是很重要的。

通过引导式发现，治疗师可以帮助来访发现对他们来说最有意义和价值的目标和方向。以下所有问题都有助于探索来访的价值观和慈悲行为的目标：

  • 鉴于面对我们的痛苦是困难的，生活中有哪些东西值得为之受苦？
  • 你必须放弃关心什么才能不想避免这种经历？
  • 为了服务于哪个有价值的目标，你愿意面对这些困难的情绪？
  • 哪些行为对你来说是内在奖励的？
  • 如果你要对自己慈悲并在追求有价值的目标上勇敢，你会朝哪个方向前进？
  • 你在这生中想要追求什么？对你来说最重要的是什么？为了实现这些价值观，你愿意面对什么？

此外，治疗师还可以通过使用下面的工作表（改编自Tirch, 2012，并受到Hayes等人1999年启发）来帮助来访撰写自己的有价值方向，并开始追求有价值的目标。请随意复制此工作表用于您的实践中。要下载该工作表，请访问http://www.newharbinger.com/30550（有关如何访问的说明见本书最后一页）。该工作表可以在会话中使用，也可以作为家庭作业由来访在会话之间完成。

成为我有价值目标和方向的作者

本工作表旨在为您提供空间，记录您希望在生活的不同领域（如职业、家庭和亲密关系）追求的价值行为模式。在完成每个部分之前，请花几分钟时间反思，在您的生活中，哪些目标对您来说是有意义、有回报且充满活力和目的感的。如果您不是在会话中填写此工作表，请找一个让您感到安全的地方，并且不会被打扰。给自己足够的时间来完成它。另外安排一两天后的时间，回顾工作表并反思您的答案。

  1. 职业或工作生活

    • 这个领域对我有多重要？(0-10)：   
    • 在这个领域中，我的基于慈悲和价值观的意图是什么？
    • 实现这一意图时可能会遇到哪些障碍？
    • 我如何用力量、慈悲和智慧克服这些障碍？

  2. 家庭

    • 这个领域对我有多重要？(0-10)：   
    • 在这个领域中，我的基于慈悲和价值观的意图是什么？
    • 实现这一意图时可能会遇到哪些障碍？
    • 我如何用力量、慈悲和智慧克服这些障碍？

  3. 亲密关系

    • 这个领域对我有多重要？(0-10)：   
    • 在这个领域中，我的基于慈悲和价值观的意图是什么？
    • 实现这一意图时可能会遇到哪些障碍？
    • 我如何用力量、慈悲和智慧克服这些障碍？

  4. 社交生活

    • 这个领域对我有多重要？(0-10)：   
    • 在这个领域中，我的基于慈悲和价值观的意图是什么？
    • 实现这一意图时可能会遇到哪些障碍？
    • 我如何用力量、慈悲和智慧克服这些障碍？

  5. 教育

    • 这个领域对我有多重要？(0-10)：   
    • 在这个领域中，我的基于慈悲和价值观的意图是什么？
    • 实现这一意图时可能会遇到哪些障碍？
    • 我如何用力量、慈悲和智慧克服这些障碍？

  6. 身体健康

    • 这个领域对我有多重要？(0-10)：   
    • 在这个领域中，我的基于慈悲和价值观的意图是什么？
    • 实现这一意图时可能会遇到哪些障碍？
    • 我如何用力量、慈悲和智慧克服这些障碍？

  7. 精神生活

    • 这个领域对我有多重要？(0-10)：   
    • 在这个领域中，我的基于慈悲和价值观的意图是什么？
    • 实现这一意图时可能会遇到哪些障碍？
    • 我如何用力量、慈悲和智慧克服这些障碍？

  8. 社区参与

    • 这个领域对我有多重要？(0-10)：   
    • 在这个领域中，我的基于慈悲和价值观的意图是什么？
    • 实现这一意图时可能会遇到哪些障碍？
    • 我如何用力量、慈悲和智慧克服这些障碍？

  9. 爱好和休闲

    • 这个领域对我有多重要？(0-10)：   
    • 在这个领域中，我的基于慈悲和价值观的意图是什么？
    • 实现这一意图时可能会遇到哪些障碍？
    • 我如何用力量、慈悲和智慧克服这些障碍？

鼓励慈悲行为

在来访完成工作表后，您可能希望花一些时间帮助他们反思所学到的内容以及这些内容如何与他们的慈悲行为和正念发展相关。可以解释说，当人们的行为与其价值观一致时，他们就更接近于过上一种充满慈悲的生活。同时，他们也真正地走上了更好地面对挑战、克服不必要的痛苦以实现美好生活之路。

治疗师和来访应仔细审视来访如何培养符合其自由选择的价值观和慈悲自我的慈悲行为，共同讨论这一过程，并承认这需要勇气、纪律和牺牲，同时也提供了体验喜悦和温暖的机会。治疗师应鼓励来访在追求有价值的目标时，对当下出现的任何情况保持开放态度，包括羞耻、愤怒、悲伤、对未知的恐惧以及其他具有挑战性的情绪。慈悲和自我慈悲的行为涉及坚持到底，并朝着最重要的目标前进，即使存在痛苦，最终也会扩展来访的行为范围和选择。治疗师还可以强调来访可能已经在进行的一些慈悲行为，例如：

  • 通过接受按摩或与所爱的人共度时光来照顾自己。
  • 通过定期看医生或锻炼来关注自己的健康。
  • 从压力情境中暂时抽身，放松并享受带来快乐的其他活动。

此外，治疗师可以指出，通过自我慈悲的行为面对痛苦也可能采取不太明显但非常重要的形式。以下是一些例子：

  • 坚持朝向有价值的生活方向前进，如备考或追求职业，即使这样做会感到不适并涉及时间和精力的牺牲。
  • 面对令人害怕的事物，以便能够采取更多基于价值观的行动，尽管这样做会经历痛苦。
  • 避免参与那些可能会带来短期愉悦但实际上有害的活动，比如在派对上大量饮酒以“缓解压力”或“平复神经”，而他们知道这种行为长期来看会有负面影响。

显然，在进行价值观澄清和个人书写之后，来访可能会面临一些艰难的决定。例如，选择不吃短期内口感好但违背身体健康价值观的不健康食物。始终要记住，每个人都是独特的，拥有独特的历史、价值观以及身体和情感上的优势。然而，作为人类，我们都有能力通过慈悲心智的多种技能和特质来培养我们的慈悲心。为此，帮助来访参与慈悲行动的一个重要部分是查看他们理想中应该面对哪些恐惧或困难，以及如何面对它们。

发展参与慈悲行动的动力

ACT（接纳承诺疗法）涉及正念和接纳过程与直接行为改变过程之间的平衡，旨在服务于有意义、有目的且充满活力的生活。作为ACT治疗师的一部分工作是跟踪来访的当下体验，并根据来访的需求和当下的机会强调正念和意愿，或特定的改变步骤。价值观书写和行动承诺的过程涉及激发向更高福祉迈进的动力，这是慈悲动机的基石。治疗师和来访可以一起通过一个具体的行为改变计划，使来访逐渐朝着有价值的目标前进，并克服回避模式，如社交孤立或成瘾行为。在这个过程中，来访承诺并自愿进入她可能宁愿避免的经历和情境，这样做时带着清晰的目的。为此，治疗师应帮助来访增强她的慈悲动力。

来访可能遇到问题的原因有很多。有时，痛苦的经历似乎明显与持续的心理问题或DSM中的“障碍”或症状群有关。其他痛苦的来源可能是外部的，如生活中的压力事件或环境灾难。从慈悲聚焦治疗师的角度来看，重要的是提醒来访，他们所经历的痛苦并不是他们的错，他们并没有选择拥有如此活跃的威胁检测系统。回顾他们与痛苦斗争的许多原因也可能是有帮助的。通过传达和重申这一智慧——即痛苦是作为人类的基本部分——治疗师可以帮助来访对自己有更多的慈悲，对当前的痛苦体验有更多的接受。我们的痛苦以及我们识别它的能力是我们本质人性的一部分，对这一点敏感可能会增加来访参与慈悲行动的动力，并朝着他们希望的生活迈进。

通过多种方法激发慈悲动机

在本书中，我们详细介绍了许多通过正念、意象、慈悲思考、六边形过程工作、治疗关系以及其他多种方法来激发慈悲动机的方式。以一种非常简单直接的方式，治疗师也可以利用引导发现的过程来帮助澄清慈悲行为的重点，并增加来访面对挑战情境的动力。例如，考虑一个患有焦虑症的来访。治疗师可能会首先提到来访可能因为焦虑而放弃，并避免恐惧的情境。然后，治疗师可以询问具体的回避行为带来的代价，并让来访反思甚至写下答案。在这种情况下，治疗师可能会问以下问题：

  • 你在与不想要的情绪斗争中，个人关系方面付出了多大的代价？你是否避免了某些关系，或者这些关系因为你试图避免或控制情绪而变得紧张？
  • 你是否因为担心自己会有的感觉而避免了一些情境，从而错过了有意义的机会？你是否因回避而做出了对你的职业生活或财务状况产生负面影响的决定？
  • 你的经历斗争是否限制了你追求喜欢事物的自由？你是否因为回避行为放弃了休闲活动、旅行或爱好？你的挣扎所涉及的负面情绪消耗了多少时间和精力？
  • 你在生活中整体上为应对不想要的经历和情绪付出了多少代价？

在探讨这些问题之后，重要的是通过提醒来访他们现在正在采取步骤改变这种动态并重新获得他们的生活，来提供鼓励和希望。帮助他们记住自己的目标：重新夺回生活，以善良、勇气和权威的态度体验生活。

保持目标的重要性

特别是在进行慈悲实践时，保持这些目标尤为重要，此时治疗师要求来访接受这样一个事实：一开始他们可能会感到更多的痛苦。通过这种方式，治疗师可以帮助来访培养短期内承受一些痛苦的意愿，以便长期更好地克服这些困难。威胁检测系统可能会突然激活，由于伴随的身体感觉、情绪和想法，导致的反应不容易被控制或抑制。因此，治疗师应强调，关键是以勇气和日益增长的承受痛苦的能力来进行这项工作，这将有助于在未来遇到类似情况时建立技能。在CFT（慈悲聚焦疗法）中，这种逐步的慈悲暴露有时被称为“具有挑战性但不过度”。

在上述引导发现的工作过程中或之后，治疗师可以与来访合作记录并检查参与逐步慈悲暴露的成本和收益，或许可以使用下面提供的正式工作表。要下载该工作表，请访问http://www.newharbinger.com/30550（有关如何访问的说明见本书最后一页）。

面对我的恐惧情绪和经历的成本与收益

使用此工作表列出您可能面临的特定成本和收益。

成本 收益
面对恐惧的具体成本 面对恐惧的具体收益

在审查完来访的成本和收益后，您可以继续提出一些类似的问题：

  • 在回顾和列出面对挑战情境的成本和收益后，您发现了什么？
  • 您是否创建了一个清晰的心理愿景，描述了如何通过应对困难来改善您的生活？
  • 您如何描述通过更正念和慈悲的方式应对痛苦情境，您的生活会如何得到改善？

用慈悲的眼光看待彼此

当我们把慈悲的关注点带入案例概念化时，我们可能会发现来访生活中那些原本隐藏的苦难方面。当我们从慈悲聚焦且与ACT一致的角度进行系统的评估和案例概念化时，我们对来访所经历的痛苦的敏感度可能会增加，同时我们深切地减轻和预防他们痛苦的动力也会增强。当我们与他们的斗争联系起来，并意识到他们的许多痛苦实际上并不是他们的错时，我们希望看到他们繁荣并过上更大、更有意义的生活的愿望可能会加深。这个循环中，一个人的痛苦唤醒了另一个人的慈悲心，而这种慈悲心又引发了共同的、深刻的愿望，即为所有众生减轻痛苦，这可能是人类独有的特质。它很可能代表了我们在自己和彼此身上能看到的最好的一面。

本章知识点阐述

知识点阐述

  1. 慈悲的历史与现代心理学：

    • 虽然慈悲在佛教哲学中被视为一种超越量化的精神状态，但现代心理学试图通过实证研究来理解和评估慈悲。这种结合传统智慧与现代科学的方法有助于更全面地理解慈悲的作用及其在心理治疗中的应用。

  2. 慈悲与心理灵活性：

    • 慈悲不仅是情感上的支持，也是心理灵活性的重要组成部分。通过培养慈悲，个体能够更好地处理生活中的挑战，保持开放的心态，并更加灵活地应对各种情况。

  3. 案例概念化的重要性：

    • 在慈悲聚焦的心理治疗中，细致的案例概念化是基础。这有助于治疗师和来访共同识别问题的核心，并制定有效的治疗策略。通过这种方式，可以更系统地促进慈悲品质的发展。

  4. 半结构化访谈的应用：

    • 使用半结构化访谈可以帮助治疗师深入了解来访在慈悲方面的现状和潜力。这种访谈不仅有助于评估来访的慈悲特质，还可以发现阻碍自我慈悲的因素，从而为治疗提供方向。

  5. 治疗关系中的慈悲：

    • 治疗过程中，治疗师展现出的慈悲态度对于建立信任和支持性的治疗关系至关重要。这种关系本身就是一个强大的治疗因素，有助于来访感受到被接纳和理解。

  6. 慈悲与心理治疗的整合：

    • 将慈悲融入心理治疗中，不仅有助于提高治疗效果，还能增强来访的整体福祉。通过慈悲练习，个体能够学会如何更好地对待自己和他人，从而促进心理健康和个人成长。

通过上述知识点可以看出，慈悲在心理治疗中的应用不仅有助于解决具体的心理问题，还能促进个体的心理灵活性和整体福祉。这种方法强调了慈悲作为一种核心心理品质的重要性，并提供了实用的工具和策略，帮助治疗师和来访共同实现治疗目标。

知识点阐述

  1. 自我慈悲的重要性：

    • 自我慈悲是心理治疗中的一个重要概念，它帮助个体以一种更加接纳和支持的方式对待自己的痛苦和挑战。通过自我慈悲，个体能够减少自我批评，增强内在的力量和韧性。

  2. 具体化的慈悲行动：

    • 慈悲不仅仅是情感上的支持，还涉及具体的行动。通过评估个体在特定类型慈悲行动中的能力和意愿，治疗师可以帮助来访识别他们的优势和需要改进的地方。

  3. 正念与慈悲的关系：

    • 正念练习有助于个体更加清晰地认识到自己的情绪和体验，而慈悲则在此基础上提供了情感的支持和理解。两者结合，可以帮助个体更好地面对生活中的挑战。

  4. 结构化访谈的价值：

    • 结构化访谈如自我慈悲心智访谈，为治疗师提供了一个系统的方法来评估来访的慈悲能力。这种访谈不仅有助于治疗师了解来访的情况，还能为来访提供一个反思自身慈悲特质的机会。

  5. 治疗关系中的信任与合作：

    • 通过与来访建立信任和合作关系，治疗师可以更有效地引导来访探索和提升其慈悲能力。这种关系本身就是一个重要的治疗因素，有助于来访感受到被支持和理解。

  6. 从自我批评到自我慈悲的转变：

    • 通过识别和改变自我批评的习惯，个体可以逐渐学会以更加慈悲的态度对待自己。这种转变不仅有助于改善心理健康，还能促进个人的整体福祉和发展。

通过上述知识点可以看出，自我慈悲心智访谈不仅是一种评估工具，也是一种促进个体成长和变化的有效方法。通过这种访谈，治疗师和来访可以共同探索和提升个体的慈悲能力，从而实现更好的心理健康和个人发展。

知识点阐述

  1. 自我慈悲的重要性：

    • 自我慈悲是一种重要的心理技能，它帮助个体以更加接纳和支持的方式对待自己的痛苦和挑战。通过自我慈悲，个体可以减少自我批评，增强内在的力量和韧性。

  2. 具体化的慈悲行动：

    • 慈悲不仅仅是情感上的支持，还涉及具体的行动。通过评估个体在特定类型慈悲行动中的能力和意愿，治疗师可以帮助来访识别他们的优势和需要改进的地方，并制定具体的行动计划。

  3. 敏感性与自我觉察：

    • 敏感性是指个体对自己痛苦体验的觉察能力。这种觉察能够帮助个体更好地识别和处理自己的情绪，从而促进心理健康。

  4. 动机与自我关怀：

    • 动机是个体采取行动的重要驱动力。通过提高个体照顾自己福祉的动机，可以促进其进行积极的自我关怀行为，从而改善整体的心理健康状况。

  5. 同情心与自我接纳：

    • 同情心是指个体对自己痛苦的同情和理解。培养对自己痛苦的同情心有助于个体更好地接纳自己，减少自我批评，增强内心的平和感。

  6. 同理心与自我理解：

    • 同理心是指个体能够站在他人的角度理解自己的经历。通过发展同理心，个体可以更好地理解自己的情绪和经历，从而促进自我成长和治愈。

  7. 无评判与自我宽容：

    • 无评判是指个体能够以非批判性的态度对待自己的痛苦。这种态度有助于个体减少自我责备，增加自我宽容，从而促进心理健康。

  8. 痛苦容忍度与情绪调节：

    • 痛苦容忍度是指个体在面对困难情绪时能够容忍痛苦的程度。提高痛苦容忍度有助于个体更好地应对生活中的挑战，增强情绪调节能力。

通过上述知识点可以看出，自我慈悲心智访谈不仅是一个评估工具，也是一种促进个体成长和变化的有效方法。通过这种访谈，治疗师和来访可以共同探索和提升个体的慈悲能力，从而实现更好的心理健康和个人发展。这种方法强调了慈悲作为一种核心心理品质的重要性，并提供了实用的策略，帮助个体在生活中实践慈悲。

知识点阐述

  1. 自我慈悲思维与推理：

    • 自我慈悲思维是指个体在面对困难时，能够以一种理解和接纳的态度对待自己。这种思维方式有助于减少自我批评，促进内心的平和与宽容。通过练习自我慈悲思维，个体可以学会用更加积极和支持性的语言来对自己说话。

  2. 自我慈悲注意力：

    • 将自我慈悲的注意力带入当下体验意味着在当下的每一刻都能对自己充满同情和理解。这种注意力可以帮助个体更好地觉察自己的情绪状态，并采取相应的关怀行动。通过正念练习，个体可以培养这种自我慈悲的注意力。

  3. 使用意象：

    • 使用能够唤起温暖、智慧、力量和对福祉承诺的意象是一种有效的自我慈悲技巧。这些意象可以帮助个体感受到内在的支持和力量，从而增强应对困难的能力。通过想象一个支持性的形象或场景，个体可以更好地与自我慈悲联系起来。

  4. 保持对安抚性感官体验开放：

    • 保持对安抚性感官体验的开放意味着个体能够识别并接受那些能带来安慰和平静的感觉。这包括触觉、视觉、听觉等感官体验。通过这种方式，个体可以在日常生活中找到更多的平静时刻，从而缓解压力和焦虑。

  5. 接触自我慈悲感受：

    • 接触自我慈悲感受，如满足感、连接感和安全感，是自我慈悲的核心部分。这些感受有助于个体建立内在的安全基地，从而更好地应对生活中的挑战。通过练习，个体可以逐渐增加这些正面感受的频率和强度。

  6. 以自我慈悲的方式行为：

    • 以自我慈悲的方式行为意味着在日常生活中采取具体行动来照顾和保护自己的福祉。这可能包括自我关怀的行为，如休息、锻炼、寻求支持等。通过这种方式，个体不仅能够提升自己的心理健康，还能增强整体的生活质量。

通过上述知识点可以看出，慈悲心智技能不仅是个体心理健康的重要组成部分，也是促进个人成长和幸福的关键因素。通过评估和练习这些技能，个体可以逐步提高自我慈悲的能力，从而实现更健康、更平衡的生活方式。

知识点阐述

  1. 自我对话与自我慈悲：

    • Josh的自我对话充满了羞耻感，这直接影响了他的自我慈悲能力。这种负面的自我对话不仅阻碍了自我接纳，还导致了自我批评和逃避行为。通过改变自我对话的方式，个体可以逐步培养出更加积极和支持性的内在声音。

  2. 逃避与自我觉察：

    • Josh倾向于通过逃避来应对焦虑，这表明他在面对困难情绪时缺乏自我觉察。通过正念练习，个体可以学会在当下保持觉察，从而更好地理解和处理自己的情绪体验。

  3. 动机与自我关怀：

    • 尽管Josh有照顾自己的动机，但羞耻感的故事阻碍了他付诸行动。治疗师可以帮助来访识别和挑战这些负面故事，从而释放其内在的自我关怀动机。

  4. 情感麻木与同理心：

    • Josh对自己的痛苦感到麻木，但能够从认知上理解自己的经历。通过将个人经历与他人类似的经历联系起来，个体可以更容易地感受到同理心，从而增强自我同情。

  5. 自我评判与自我宽容：

    • Josh对自己非常苛刻，希望放松一些。通过练习自我宽容，个体可以减少自我评判，学会以更加温和的态度对待自己，从而促进心理健康。

  6. 痛苦容忍度与社会威胁：

    • Josh认为自己能够承受很多痛苦，但在面对社交威胁、羞耻和恐惧时却难以应对。通过提高对这些情绪的容忍度，个体可以更好地处理生活中的挑战。

  7. 感官体验与自我安抚：

    • Josh能够通过感官体验进行自我安抚。利用感官体验，如听音乐、触摸柔软的物品等，可以帮助个体在日常生活中找到更多的平静时刻，从而缓解压力和焦虑。

  8. 清醒与自我关怀：

    • Josh意识到寻求清醒可能是一种自我关怀的行为。通过戒除有害习惯，个体可以更好地照顾自己的身心健康，从而提升整体的生活质量。

通过上述知识点可以看出，自我慈悲心智访谈不仅是一个评估工具，也是一种促进个体成长和变化的有效方法。通过这种访谈，治疗师和来访可以共同探索和提升个体的慈悲能力，从而实现更好的心理健康和个人发展。这种方法强调了慈悲作为一种核心心理品质的重要性，并提供了实用的策略，帮助个体在生活中实践慈悲。

知识点阐述

  1. 敏感性：

    • 敏感性是指个体对自己当下的痛苦体验的觉察能力。这种觉察能够帮助个体更好地识别和处理自己的情绪，从而促进心理健康。如果个体缺乏敏感性，可能需要通过正念练习来提高觉察力。

  2. 照顾福祉的动机：

    • 动机是个体采取行动的重要驱动力。提高个体照顾自己福祉的动机，可以促进其进行积极的自我关怀行为，从而改善整体的心理健康状况。如果动机受到阻碍，可以通过设定具体目标和逐步实现这些目标来增强动机。

  3. 同情心：

    • 同情心是指个体对自己痛苦的同情和理解。培养对自己痛苦的同情心有助于个体更好地接纳自己，减少自我批评，增强内心的平和感。如果同情心受到阻碍，可以通过反思和情感表达练习来增强同情心。

  4. 同理心：

    • 同理心是指个体能够站在他人的角度理解自己的经历。通过发展同理心，个体可以更好地理解自己的情绪和经历，从而促进自我成长和治愈。如果同理心受到阻碍，可以通过角色扮演和情感共鸣练习来增强同理心。

  5. 无评判：

    • 无评判是指个体能够以非批判性的态度对待自己的痛苦。这种态度有助于个体减少自我责备，增加自我宽容，从而促进心理健康。如果无评判受到阻碍，可以通过认知重构和自我对话练习来培养无评判的态度。

  6. 痛苦容忍度：

    • 痛苦容忍度是指个体在面对困难情绪时能够容忍痛苦的程度。提高痛苦容忍度有助于个体更好地应对生活中的挑战，增强情绪调节能力。如果痛苦容忍度受到阻碍，可以通过暴露疗法和放松技巧来提高容忍度。

  7. 自我慈悲思维：

    • 自我慈悲思维是指个体在面对困难时，能够以理解和接纳的态度对待自己。这种思维方式有助于减少自我批评，促进内心的平和与宽容。如果自我慈悲思维受到阻碍，可以通过正念冥想和自我对话练习来培养。

  8. 自我慈悲注意力：

    • 将自我慈悲的注意力带入当下体验意味着在当下的每一刻都能对自己充满同情和理解。这种注意力可以帮助个体更好地觉察自己的情绪状态，并采取相应的关怀行动。通过正念练习，个体可以培养这种自我慈悲的注意力。

  9. 使用意象：

    • 使用能够唤起温暖、智慧、力量和对福祉承诺的意象是一种有效的自我慈悲技巧。这些意象可以帮助个体感受到内在的支持和力量，从而增强应对困难的能力。通过想象一个支持性的形象或场景，个体可以更好地与自我慈悲联系起来。

  10. 保持对安抚性感官体验开放：

    • 保持对安抚性感官体验的开放意味着个体能够识别并接受那些能带来安慰和平静的感觉。这包括触觉、视觉、听觉等感官体验。通过这种方式，个体可以在日常生活中找到更多的平静时刻，从而缓解压力和焦虑。

  11. 接触自我慈悲感受：

    • 接触自我慈悲感受，如满足感、连接感和安全感，是自我慈悲的核心部分。这些感受有助于个体建立内在的安全基地，从而更好地应对生活中的挑战。通过练习，个体可以逐渐增加这些正面感受的频率和强度。

  12. 以自我慈悲的方式行为：

    • 以自我慈悲的方式行为意味着在日常生活中采取具体行动来照顾和保护自己的福祉。这可能包括自我关怀的行为，如休息、锻炼、寻求支持等。通过这种方式，个体不仅能够提升自己的心理健康，还能增强整体的生活质量。

通过上述知识点可以看出，参与心理学的属性和慈悲心智技能不仅是个体心理健康的重要组成部分，也是促进个人成长和幸福的关键因素。通过评估和练习这些技能，个体可以逐步提高自我慈悲的能力，从而实现更健康、更平衡的生活方式。

知识点阐述

  1. 来访背景的理解：

    • 了解来访的生物和环境背景有助于治疗师更好地理解来访的行为模式和应对策略。通过深入探讨这些因素，治疗师可以更准确地定位问题所在，并制定相应的治疗计划。

  2. 恐惧和回避的主题：

    • 来访最害怕且最不愿意经历的事情往往是他们内心深处的恐惧源。识别这些恐惧可以帮助治疗师更好地理解来访的内在冲突，并针对性地设计干预措施。

  3. 保护性策略及其后果：

    • 来访采用的安全策略虽然在短期内可能起到一定的保护作用，但长期来看可能会产生负面后果。治疗师需要帮助来访识别这些策略，并探索更为健康的应对方式。

  4. 慈悲聚焦的治疗关系：

    • 建立一个基于慈悲的治疗关系是治疗成功的关键。治疗师通过同理心、倾听和反思，为来访创造一个安全和支持的环境，促进治疗进展。

  5. 早期经历的影响：

    • 早期的经历特别是与依恋和安全感相关的经历，对个人的情感记忆和自我认知有着深远的影响。治疗师应特别注意这些经历，因为它们可能会影响来访当前的情绪状态和行为模式。

  6. 情感记忆的激活：

    • 当前情境有时会触发来访早期的情感记忆，这可能导致强烈的情绪反应。治疗师需要敏锐地捕捉这些情感线索，并帮助来访处理这些情绪，从而促进内心的治愈。

通过上述知识点可以看出，慈悲聚焦的案例构建不仅是一种评估工具，也是治疗过程中的重要组成部分。它帮助治疗师全面理解来访的情况，同时为来访提供一个安全和支持的空间，让他们能够自由地表达自己，从而促进心理健康和个人成长。

知识点阐述

  1. 识别问题行为：

    • 识别来访为了应对恐惧和威胁而采取的问题行为是治疗的重要一步。这些行为虽然在短期内提供了暂时的安全感，但长期来看可能导致更多的问题。治疗师需要帮助来访理解这些行为的双刃剑性质，并探索更健康的应对机制。

  2. 成本与收益分析：

    • 通过分析这些安全行为的成本和收益，来访可以更好地理解这些行为的实际效果。这有助于他们看到改变的必要性，并为后续的治疗提供方向。

  3. 行为强化原理：

    • 了解行为强化原理可以帮助来访理解为什么他们会继续采用某些行为。治疗师可以通过解释这些原理来增强来访的认知，从而促进行为改变。

  4. 非预期后果：

    • 问题行为常常带来非预期的负面后果，如阻碍新学习、限制行为范围等。治疗师应帮助来访认识到这些后果，并鼓励他们尝试新的应对策略。

  5. 去羞耻化：

    • 去羞耻化是慈悲聚焦治疗的核心。治疗师通过提供一个无评判的环境，帮助来访理解他们的挣扎并非源于自身的错误或选择，从而减轻内疚感和自责。

  6. 功能分析和反思倾听：

    • 功能分析和反思倾听是慈悲聚焦治疗中的关键技巧。通过这些方法，治疗师可以深入了解来访的行为模式，并帮助他们从新的角度看待问题。

  7. 持续评估和调整：

    • 治疗是一个动态的过程，需要持续评估和调整。治疗师应根据来访的进展定期审查和更新构建，确保治疗计划的有效性和适应性。

通过上述知识点可以看出，慈悲聚焦的案例构建不仅是一种评估工具，也是治疗过程中的重要组成部分。它帮助治疗师全面理解来访的情况，同时为来访提供一个安全和支持的空间，让他们能够自由地表达自己，从而促进心理健康和个人成长。

知识点阐述

  1. 缺乏安慰与连接：

    • 来访在成长过程中缺乏来自照顾者的安慰和支持，这可能导致他们在面对困境时难以寻求帮助，并且可能缺乏建立健康人际关系的能力。

  2. 成就的认可：

    • 来访的成就被忽视，直到他在某些方面（如外表和表演）受到同龄人的认可。这种有条件的赞赏可能使来访形成一种错误的价值观，即只有在特定条件下才能获得认可。

  3. 生物和发展事件的影响：

    • ADHD和抑郁症的诊断以及过度用药，加上早期的社会孤立，都可能对来访的情感和心理发展产生深远影响。这些问题需要综合治疗来解决。

  4. 情感记忆与当前感受：

    • 来访的负面情感记忆（如拒绝、羞耻、悲伤）直接影响了他对自己的看法和感受。这些记忆可能在无意识中触发类似的情感反应，影响其日常行为和决策。

  5. 主要威胁及恐惧：

    • 来访面临的威胁包括社会排斥、物质滥用的风险以及个人失败的恐惧。这些恐惧可能源于过去的经历，特别是那些与拒绝和羞耻相关的经历。

  6. 安全策略及其后果：

    • 来访采用的安全策略（如吸毒、饮酒、社交伪装）虽然在短期内提供了暂时的解脱，但长期来看却造成了更多的问题，如经济损失、人际关系破裂和个人健康的恶化。

  7. 自我认知与自我评价：

    • 来访对自己的负面看法（如自我憎恨）反映了深层次的自尊问题。治疗师需要帮助来访重新构建积极的自我形象，增强自我价值感。

通过上述知识点可以看出，慈悲聚焦的案例构建不仅帮助治疗师深入了解来访的背景和经历，还为制定有效的治疗计划提供了基础。它强调了理解来访的情感历史、识别关键威胁和恐惧、评估安全策略的有效性以及处理非预期后果的重要性。治疗师通过这种方式可以帮助来访逐步克服内心的障碍，建立更加健康的心理模式和行为习惯。

知识点阐述

  1. 外部后果：

    • 来访在多个领域中的功能受损，包括社会关系、职业和个人目标等方面。这反映了来访的行为模式对其生活质量的影响。

  2. 内部后果：

    • 来访经历了一系列负面情绪，如抑郁、焦虑、羞耻感等，这些情绪严重影响了他们的心理健康和幸福感。这些情绪往往是由于过去的创伤经历和不良的应对机制所致。

  3. 回避、控制和自毁行为：

    • 来访采用的回避、控制和自毁行为是为了应对长期的创伤历史。这些行为虽然在短期内提供了暂时的缓解，但长期来看却加剧了问题。

  4. 依恋关系的重要性：

    • 关键依恋关系中的虐待和忽视对来访的情感发展和应对机制有着深远的影响。理解和处理这些早期经历是治疗的重要部分。

  5. 安全策略及其后果：

    • 来访的安全策略（如吸毒、饮酒、社交伪装）虽然在短期内提供了暂时的解脱，但长期来看却造成了更多的问题。治疗师需要帮助来访识别这些策略的非预期后果，并探索更健康的应对方式。

  6. 慈悲聚焦的概念化：

    • 通过慈悲聚焦的案例构建，治疗师可以帮助来访理解自己的痛苦并非他们的选择或过错，并为他们提供一个安全和支持的环境，以促进自我接纳和改变。

  7. 评估工具的发展：

    • 慈悲的评估工具仍在发展中，目前主要依赖于自我报告测量。尽管如此，一些初步的评估工具已经可用于临床实践，帮助治疗师更好地了解来访的情感状态和慈悲水平。

通过上述知识点可以看出，慈悲聚焦的案例构建不仅帮助治疗师深入了解来访的背景和经历，还为制定有效的治疗计划提供了基础。它强调了理解来访的情感历史、识别关键威胁和恐惧、评估安全策略的有效性以及处理非预期后果的重要性。治疗师通过这种方式可以帮助来访逐步克服内心的障碍，建立更加健康的心理模式和行为习惯。

知识点阐述

  1. 自我慈悲量表 (SCS) 的组成：

    • SCS由26个项目组成，分为六个子量表，分别代表自我慈悲的三个主要成分及其对应的反面：自我仁慈 vs. 自我评判、共同人性 vs. 孤立、正念 vs. 过度认同。这些维度共同构成了一个全面的自我慈悲评估框架。

  2. 量表的可靠性和有效性：

    • SCS表现出良好的内部一致性和跨文化可靠性。它在不同人群中的应用均显示出稳定的结构和一致性，包括学生、冥想者以及临床患者等。

  3. 量表的应用：

    • SCS不仅用于学术研究，还广泛应用于临床实践，帮助治疗师了解来访的自我慈悲水平，从而制定更有效的干预措施。

  4. 自我慈悲与心理健康的关系：

    • 研究表明，较高的自我慈悲与较低的抑郁、焦虑和自我批评水平相关联，同时与更高的社会连接感和情商相关。这提示自我慈悲可能是促进心理健康的积极因素。

  5. 量表的局限性：

    • 尽管SCS具有良好的心理测量特性，但作为一种自我报告工具，它可能受到社会期望效应的影响。此外，SCS的总分可能无法区分出是由于高水平的自我慈悲还是低水平的自我评判和自我孤立导致的结果差异。因此，在解释SCS得分时需要谨慎，并结合其他评估方法综合考虑。

    知识点阐述

  6. 慈悲恐惧量表：

    • 慈悲恐惧量表旨在识别个体在给予、接受和对自己慈悲方面的恐惧。这种恐惧可能会阻碍人们体验和表达慈悲，从而影响他们的心理健康和社会关系。
    • 该量表在学生和治疗师样本中均表现出良好的信度，表明其在不同人群中的可靠性。

  7. 慈悲之爱量表：

    • CLS量表用于评估个体向家庭成员、朋友、陌生人或特定亲近者展示慈悲之爱的倾向。该量表有助于理解个体在不同情境下的慈悲态度。
    • 量表的高内部一致性（Cronbach's α = 0.95）表明其在评估慈悲之爱方面的可靠性和有效性。

  8. 圣克拉拉简短慈悲量表：

    • SCBCS是CLS的一个简化版，适合于大规模研究。它保留了原始量表的核心特征，同时减少了项目数量，便于快速评估。
    • 该量表与原版量表高度相关（r = 0.96），表明它可以作为有效的替代工具。

  9. 自我-他人四无量心量表：

    • SOFI量表结合了佛教心理学中的四无量心理念，评估个体对自己和他人的慈悲、喜乐、平等和接纳等品质。
    • 该量表的多个子量表设计能够更细致地反映个体在不同情境下的心理状态，有助于深入了解个体的情感特质。

通过上述知识点可以看出，这些量表不仅为研究人员提供了评估个体慈悲态度的有效工具，而且也为临床实践提供了宝贵的资源。理解和应用这些量表可以帮助治疗师更好地识别来访的慈悲障碍，并制定相应的干预策略。此外，这些量表的应用还有助于增进我们对慈悲这一重要心理特质的理解。

知识点阐述

  1. 慈悲体验访谈：

    • 这种基于访谈的评估方法旨在深入探讨个体对慈悲的理解及其在不同情境下的表现，包括自我慈悲、来自他人的慈悲以及对他人的慈悲。
    • 通过结合语义描绘和情景描绘，这种方法能够捕捉到个体在慈悲体验中的复杂感受和行为，有助于更全面地理解慈悲的心理过程。

  2. 培养慈悲行为：

    • 基于慈悲的行为不仅仅是行为本身，更重要的是行为背后的态度和意图。通过行为实验、行为激活和暴露等方法，治疗师可以帮助来访逐步建立更具慈悲心的行为模式。
    • 在实践中，逐步暴露和行为激活的过程需要细致规划，确保既具有挑战性又不会过度压倒来访，从而帮助他们在面对恐惧和痛苦时建立起勇气和自信。

  3. 慈悲心训练的重要性：

    • 慈悲心训练不仅帮助来访建立一个支持性的内在声音，还帮助他们学会如何与痛苦共存而不是逃避。这种内在的支持系统是来访在面对挑战时的重要资源。
    • 通过慈悲心训练，来访可以更好地理解和接纳自己的痛苦，从而为个人成长和心理健康奠定基础。

通过上述知识点可以看出，慈悲体验访谈和慈悲行为的培养都是慈悲聚焦疗法中的重要组成部分。这些方法不仅提供了评估和理解慈悲心理的有效工具，也为治疗师提供了实用的策略，帮助来访在实际生活中应用慈悲的原则，从而促进其整体福祉。

知识点阐述

  1. 明确有价值的目标：

    • 在基于慈悲的ACT中，明确个人的价值观和目标至关重要。这有助于确定哪些困难或治疗目标值得投入精力去克服。
    • 通过识别来访真正重视的事物，治疗师可以帮助来访建立更清晰的生活方向，并增强他们面对挑战的动力。

  2. 内在奖励的行为：

    • 有价值的目标和方向是指那些无论在何种情况下都能带来内在满足感的行为。它们反映了来访希望如何生活的真实意图。
    • 了解来访内在奖励的行为有助于治疗师设计更有效的干预措施，鼓励来访采取符合其价值观的行为。

  3. 引导式发现：

    • 通过一系列有针对性的问题，治疗师可以帮助来访深入探索他们的价值观和目标。这种方法有助于来访更清楚地认识到他们真正追求的东西。
    • 引导式发现不仅帮助来访明确目标，还促进了他们对自身动机和行为的理解，从而增强自我效能感。

  4. 工作表的应用：

    • 使用工作表可以帮助来访系统地思考和记录他们的价值观和目标。这不仅有助于治疗师更好地理解来访的需求，也为来访提供了一个具体的工具，帮助他们在日常生活中实践这些价值观。
    • 工作表的使用可以在治疗过程中进行，也可以作为家庭作业让来访在会话之间反思和规划，进一步加强治疗效果。

通过上述知识点可以看出，明确有价值的目标和选择关注福祉是基于慈悲的ACT中的核心组成部分。这些方法不仅帮助来访识别和追求对他们来说真正重要的事物，还为治疗师提供了实用的工具，促进来访在面对挑战时保持动力和韧性。

知识点阐述

  1. 自我反思与目标设定：

    • 通过填写这个工作表，来访可以深入反思他们在生活各个领域中的价值观和目标。这种反思有助于来访明确自己的优先事项，并制定出具体可行的目标。
    • 自我反思不仅帮助来访识别他们真正关心的事物，还促进了他们的自我认识和成长。

  2. 基于价值观的行为：

    • 工作表强调了基于慈悲和价值观的行为的重要性。这有助于来访在面对挑战时保持动力和方向，确保他们的行为与其内在价值观相一致。
    • 通过明确基于价值观的意图，来访可以更好地理解自己为什么要做某些事情，从而增强行动的意义和满足感。

  3. 障碍识别与应对策略：

    • 识别实现目标过程中可能遇到的障碍是成功的关键步骤之一。工作表鼓励来访思考潜在的障碍，并提出具体的应对策略。
    • 通过预先规划如何克服障碍，来访可以在实际遇到困难时更加从容不迫，提高解决问题的能力。

  4. 综合运用力量、慈悲和智慧：

    • 工作表强调了在克服障碍时综合运用力量、慈悲和智慧的重要性。这不仅包括外在的力量，也包括内在的情感支持和智慧决策。
    • 通过培养这些品质，来访可以更有效地应对生活中的挑战，同时保持内心的平衡和和谐。

通过上述知识点可以看出，这个工作表不仅是一个工具，帮助来访明确和追求他们的有价值目标，还是一个促进个人成长和自我提升的过程。通过系统地思考和规划，来访可以更有意识地朝着有意义的生活迈进，同时增强他们面对挑战的能力。

知识点阐述

  1. 慈悲行为的重要性：

    • 慈悲行为不仅有助于个人的心理健康，还能够帮助他们更好地面对生活中的挑战。通过将行为与个人价值观相匹配，来访可以感受到更多的内在满足感和幸福感。
    • 慈悲行为不仅仅是对外界的善举，也包括对自己的关怀和爱护，这对于建立积极的自我形象和提高生活质量至关重要。

  2. 价值观与行为的一致性：

    • 当个体的行为与其核心价值观一致时，他们会感到更加充实和满意。这不仅有助于个人成长，还能增强他们在面对困难时的韧性。
    • 价值观的澄清和书写过程可以帮助来访明确自己的优先事项，并制定出具体的行动计划，从而推动他们朝着更有意义的生活前进。

  3. 面对痛苦的勇气：

    • 面对痛苦和挑战需要勇气和决心。通过培养慈悲心，来访可以学会如何在痛苦中找到力量，并通过积极的行动来应对困境。
    • 自我慈悲的行为不仅包括照顾自己的身心健康，还包括勇于面对恐惧和不安，以实现更高的生活目标。

  4. 慈悲动机的发展：

    • 慈悲动机是推动个人改变和成长的重要动力。通过增强慈悲动机，来访可以更容易地接受当下的痛苦，并采取积极的行动来改善自己的生活。
    • 治疗师可以通过提供支持和指导，帮助来访发现和强化他们的慈悲动机，从而促进他们的心理健康和个人成长。

通过上述知识点可以看出，鼓励慈悲行为不仅有助于个人的心理健康，还能帮助他们更好地面对生活的挑战。通过价值观澄清和个人书写，来访可以明确自己的目标，并通过慈悲行为逐步实现这些目标。同时，治疗师的支持和指导对于帮助来访增强慈悲动机和克服障碍至关重要。

知识点阐述

  1. 慈悲动机的激发：

    • 通过正念、意象、慈悲思考等多种方法，治疗师可以帮助来访激发内在的慈悲动机。这种方法不仅有助于提高来访面对挑战时的韧性，还能增强他们的自我接纳和理解。
    • 通过引导发现的过程，治疗师可以促使来访反思其行为模式及其对生活的实际影响，从而增强他们改变现状的动力。

  2. 面对恐惧的成本与收益：

    • 来访在面对恐惧时，需要权衡其成本与收益。明确这些成本和收益有助于来访更加理性地看待自己的行为，并为未来的行动做出更明智的选择。
    • 通过记录和讨论这些成本和收益，来访可以更好地理解逃避行为对其生活质量的影响，并找到前进的方向。

  3. 慈悲视角下的相互理解：

    • 通过慈悲的视角来看待来访，治疗师能够更加深入地理解来访的处境，从而提供更加有效的支持。
    • 慈悲视角不仅帮助治疗师更好地理解来访，也促进了治疗师与来访之间的情感连接，增强了治疗效果。

  4. 逐步暴露与适应能力：

    • 逐步暴露是一种重要的治疗策略，它帮助来访逐渐适应并克服恐惧。通过逐步暴露，来访可以逐步建立对痛苦的容忍能力，从而更好地应对未来的挑战。
    • 逐步暴露的过程需要勇气和耐心，治疗师应鼓励来访在这个过程中保持开放和坚持，以达到长期的积极变化。

通过上述知识点可以看出，激发慈悲动机、明确面对恐惧的成本与收益、以及采用慈悲视角来看待彼此，都是帮助来访实现心理成长和提高生活质量的重要手段。这些方法不仅有助于来访更好地应对当前的挑战，也为他们未来的发展奠定了坚实的基础。

8 Case Formulation, Assessment, and Treatment Planning Historically, Buddhist philosophy has described compassion as being one of the four immeasurables, which represent wholesome states of mind that are key components to liberation from suffering: loving-­kindness (metta), compassion (karuna), empathetic joy (mudita), and equanimity (upekkha). Prescientific tra- ditions might have found it sufficient to view such experiences as being outside the realm of quantitative analysis. However, Western psychology is less comfort- able with things that can’t be measured and places a great deal of emphasis upon assessment and evidence-­ based conceptualizations of dimensions of human functioning. As might be inferred from the term “immeasurable,” though, compassion has proven somewhat difficult to assess using modern psy- chometric tools. Although a range of different evidence-­based assessments of compassion exists (with several being described in this chapter), each reveals only part of the picture of the compassionate mind as it is understood in con- textual compassion-­focused therapy. Nonetheless, a thorough case conceptual- ization, grounded in evidence-­based principles and processes, is possible—­and also crucial for helping clients cultivate a capacity for compassion. This chapter provides in-­depth guidance on case conceptualization, assess- ment, and treatment planning with a compassionate focus. The techniques and concepts we review can be used by practitioners in any modality, not solely ACT, CFT, or FAP. Bringing compassion into the equation as we come to know our clients’ aims and personal histories in detail can enhance the therapeutic relationship and uncover important pieces of the puzzle. Compassion creates a context for calming, soothing, and grounding in the face of difficult emotions, and for the treatment planning approach we advocate. Furthermore, the case conceptualization approach and assessment tools outlined here offer clear ben- efits in cultivating greater psychological flexibility. In order to best illustrate the concepts and techniques in this chapter, we will return to Josh’s case example, examining how his learning history, safety behaviors, and efforts at experiential avoidance were related to his experiences of trauma and threatening experiences in key attachment relationships. We will also present a semistructured clinical interview designed to assess the degree to which the attributes and skills of compassion are available to clients, again using Josh’s case to exemplify use of this interview. While this is not an empirically validated assessment tool, it can provide a road map for client and therapist to collaboratively formulate targets for treatment and identify blocks to self-­compassion. The Self-Compassionate Mind Interview The processes involved in the two psychologies of compassion (engagement and alleviation) are key targets of compassionate mind training, CFT, and compassion-­focused ACT. As such, it is important to identify how available these aspects of compassion are to our clients. As we start shaping these attri- butes and skills through the therapy process, it is a good idea to know where we are beginning. Furthermore, it is important to understand the patterns of avoid- ance, control, or needless defense that might be blocking or inhibiting clients’ ability to access their capacity for self-­compassion and growth in acceptance, courage, and commitment to valued aims. Several researchers are currently developing measures of various dimensions of compassion in a self-­report format. While this work is underway, we have collaborated with CFT researchers to develop a semistructured interview aimed at helping clients gain insight into their strengths and areas of potential growth in regard to compassion. This interview is designed to help formulate aims for interventions and inform treatment planning and is meant to be used in the course of one of the earlier sessions in therapy. The best time is probably as soon as the client has developed a validating and engaged relationship with the therapist, framed some preliminary aims for therapy, and been introduced to some of the assumptions of a compassion-­focused ACT via methods such as evoking creative hopelessness, engaging in the Reality Check from chapter 3, and exploring the wisdom of no blame. All of this will serve as a foundation of understanding from which the client can more effectively engage with the kinds of questions posed in the interview. Ideally, the client will also have an under- standing of the two psychologies of compassion or will have learned some basics about how compassion can be trained and how it can aid in tolerating difficult experiences in the service of living a life of greater meaning and purpose. The interview also allows for assessing psychological flexibility processes due to the natural relationship between aspects of compassion and hexaflex processes, as described in chapter 2. While the guidelines within the interview offer suggestions about what therapists might say to their clients, it is highly important that the interview proceed as a mindful and compassionate conversation within the context of the client’s nature and struggles. Furthermore, the tone of validation and connect- edness discussed and illustrated throughout chapters 4 through 6 should inform your therapeutic stance as you meet clients where they are and build on the conversational style, rapport, and empathic bridging they have displayed thus far in therapy. Clinical Example: Using the Self-­Compassionate Mind Interview in Session Later in this chapter, we present a blank template for conducting the Self-­ Compassionate Mind Interview. However, to help you visualize and genuinely feel the process, we first present it in the context of Josh’s case example. Therapist: Now that we’ve gotten our minds around what is meant by “compas- sion” and have seen how strong of a hold your self-­criticism has on you, I’d like to see if we can take a closer look at how we might help you build up some new ways of responding. Client: ew ways of dealing—­of coping with this? That’s good, because I’m N sick of feeling like this. Therapist: Well, we’re going to do something like that. Honestly, we’re not so much going to be finding out how to best get rid of what you’ve been feeling. We’re going to see where your strengths lie in being better able to hold the tough stuff and keep going. We’ll look at how you can get out of bed in the morning, take good care of yourself, and get moving with some kindness and strength. Is that good with you? Client: It sounds a lot better than lying in bed with a hangover and cable news in the background to drown out my brain. Therapist: I imagine so. Client: So when do we start? Therapist: You sound ready, so let’s begin now. I’m going to ask you about how able and willing you believe you are to engage in specific types of compassionate action. Our compassionate minds can guide us to take specific steps in our lives, and I’d like to know how able you believe you are to engage these aspects of your compassionate mind. Client: Aspects of what? Therapist: Do you remember how we took a look at the different capabilities we can work with to grow in mindful compassion? Client: To be present, and to be more able to take things on? Therapist: Exactly. Spot on. Client: Okay, I know what you mean. Fire away. The therapist then proceeded to walk Josh through the Self-­Compassionate Mind Interview, recording Josh’s responses as indicated in the example below. To orient you to the form, for many items the therapist asks the client to rate a given experience or capacity on a scale of 0 to 6, with 0 being absent or com- pletely lacking and 6 being very high. (And as you’ll note, in Josh’s case, the therapist actually began the first step of this formal interview a few exchanges earlier in the dialogue.) Self-­Compassionate Mind Interview Worksheet Now I’m going to ask you about how able and willing you believe you are to engage in specific types of compassionate action. Our compassionate minds can guide us to take specific steps in our lives, and I’d like to know how able you believe you are to engage these aspects of your compassionate mind. Attributes of the Psychology of Engagement

  1. Sensitivity How sensitive do you feel you are to your experience of distress as it occurs, in the present moment? Can you notice your experience of suffering as it arises in you? Please rate this on a scale of 0 to 6, where 0 means you aren’t at all sensitive to your experience and 6 means you’re highly sensitive to it. 0 Absent 1 2 3 4 5 6 Very high X What experiences and emotions might block or hinder your compassionate sen- sitivity to your own distress? I can notice how much distress I’m in when I’m sober or not zoned out. My anxiety makes me want to check out or get messed up. Also, I hate myself! Can we think of one way in which we can address that block or obstacle together? Based on what we’ve been talking about, I think I need to be able to just deal with these feelings without hiding anymore.
  2. Motivation to care for well-­being Using the same scale of 0 to 6, how motivated are you to take care of yourself and ensure your own well-­being? To what degree are you motivated to alleviate or prevent the suffering you witness within yourself? 0 Absent 1 2 3 4 5 6 Very high X What experiences and emotions might block or hinder your motivation to care for your well-­being? When I’m hung up on all the ways that I’ve failed or how I’m too scared to talk to women, I feel like I just don’t give a damn anymore. When I procras- tinate too much, I also start to give up. Can we think of one way in which we can address that block or obstacle together? I can plan to take one mindful action each day, like making coffee, as a way of doing something in my own interest. That sounds weird, but I can do one thing. This is another thing, but I could call my old sponsor from my 12-­step work in Austin.
  3. Sympathy Using the same scale of 0 to 6, how much can you extend sympathy toward yourself during difficult experiences? When you notice your own distress, to what degree do you feel spontaneously sympathetically moved? 0 Absent 1 2 3 4 5 6 Very high X What experiences and emotions might block or hinder your sympathy toward yourself? I know this is probably wrong, but I feel pretty numb about my own pain. Sometimes I don’t even see it until it’s too late. Can we think of one way in which we can address that block or obstacle together? When I think of my mother being caught up in her addiction and waking up from a blackout, it makes me want to cry. If I could feel that way about me, it would be better.
  4. Empathy Using the same scale of 0 to 6, to what degree do you feel able to reflect upon your own suffering and understand your experience? How much would you say you’re able to look upon your own experience with the empathy you might feel toward another person in distress? 0 Absent 1 2 3 4 5 6 Very high X What experiences and emotions might block or hinder your empathy for yourself? I think I get it intellectually. I can see the big picture and how I’m screwing up. I know the patterns are killing me, but I just don’t seem to be able to care because I’m so full of hate for myself. Can we think of one way in which we can address that block or obstacle together? Just noticing that all of the self-­hate talk was stories in my head started to help last week. I might not be able to stop thinking like that—­sorry! But I can notice that it’s an old story.
  5. Nonjudgment Using the same scale of 0 to 6, how much do you believe you’re able to adopt a nonjudgmental stance toward your own suffering? To what extent do you feel you can unlock yourself from the influence of judgmental and condemning thoughts and attitudes? 0 Absent 1 2 3 4 5 6 Very high X What experiences and emotions might block or hinder you in being nonjudg- mental with yourself? I think you must be joking here! Really, I think that if I stopped running and getting high, maybe I could give myself a break. If I put together a few days of sobriety, maybe something could happen. Can we think of one way in which we can address that block or obstacle together? I could get to a meeting again. Maybe if I go to one meeting I could give myself a small break.
  6. Distress tolerance Using the same scale of 0 to 6, to what extent do you think you can tolerate distress when you experience difficult emotions? How able are you to adopt an accepting and open attitude toward your distress? 0 Absent 1 2 3 4 5 6 Very high X What experiences and emotions might block or hinder you in tolerating your distress? This question is funny because I can take a lot of pain and distress except for feeling disgust for who I am. When I feel like I look good or just crush a performance, I feel on top. Most kinds of pain I can handle, but I hate how angry and scared I’ve been. Can we think of one way in which we can address that block or obstacle together? It’s starting to sound like I need to stop taking myself so seriously. Maybe I could lighten up for, like, an hour or two? Attributes of the Psychology of Alleviation, or Compassionate Mind Skills Now I’m going to ask you how capable you believe you are of engaging in various compassionate mind skills. For all of these questions, use the same scale of 0 to 6 that we’ve been using.
  7. How would you rate your ability to engage in self-­compassionate think- ing or reasoning? 0 Absent 1 X 194 2 3 4 5 6 Very high
  8. How would you rate your ability to bring self-­compassionate attention to your present-­moment experience? 0 Absent 1 2 3 4 5 6 Very high X
  9. How would you rate your ability to use imagery that evokes warmth, wisdom, strength, and commitment to your well-­being? 0 Absent 1 2 3 4 5 6 Very high X
  10. How would you rate your ability to remain open to sensory experiences that are soothing to you? 0 Absent 1 2 3 4 5 6 Very high X
  11. How would you rate your ability to access or contact self-­compassionate feelings, such as contentment, connectedness, and safeness? 0 Absent 1 2 3 4 5 6 Very high X
  12. How would you rate your ability to behave in a self-­compassionate way that’s intended to care for and protect your well-­being? 0 Absent 1 2 3 4 5 6 Very high X Clinical Example: Summarizing What Josh’s Self-­Compassionate Mind Interview Revealed Given the tone and style of Josh’s pervasively shaming self-­talk, it should come as no surprise that he said he had little capacity for self-­compassion. However, some of the details he offered point the way to areas his therapist might want to empha- size in treatment. These responses can be treated as hypotheses and held lightly, but they do offer more precise information about how Josh experiences himself: • Josh says he can contact the present moment with sensitivity to his suf- fering when he isn’t intoxicated or semidissociative. He believes that he responds to anxiety by checking out from sensitivity to his experience. • He has more motivation to care for himself as a valued aim than we might have thought, but he’s blocked from acting on that motivation by fusion with shaming self-­stories. • Josh feels numb to his pain and completely lacking in sympathy for himself. However, he is able to experience empathy for himself cogni- tively and can make sense of his experience. When he relates his suffer- ing to the way his mother’s addiction has harmed her, he’s more feeling. • Josh feels very judgmental toward himself and wishes he could give himself a break and not take himself so seriously. • He believes that he is tough and can handle a lot of pain and distress. However, social threats, shame, and fear are very hard for him to sit with. • He reports that he has a very limited ability to use compassionate mind skills. However, he reports that he can self-­soothe through sensory experiences. • Josh is already aware that he can benefit from seeking sobriety and that this might be an act of kindness toward himself. All of this information might have been generated in the course of a few regular sessions, but with the structured interview, it was gathered in just half of a single session. In the process, several avenues for developing the client’s capac- ity for self-­compassion were clearly identified. Self-­Compassionate Mind Interview Worksheet This worksheet is intended for use by therapists, to be completed with clients. The structured interview and its rating scale provide a format for assessing the attributes and skills of compassion. We have provided preliminary questions for you to engage with your client around each of the attributes and skills of the two psychologies of compassion; however, allow your own compassionate wisdom to guide you through the assessment. When conducting the interview, briefly reflect on each question together, then rate the client’s skills or attributes of compassion using a scale of 0 to 6, in which 0 means the skill or attribute is absent, and 6 means it is present to a very high degree. All of the information gathered in the course of this interview may guide your case formulation and treatment planning, helping determine the direction and course of a compassion-­ focused intervention. Feel free to copy this worksheet for use in your practice. For a downloadable version, please visit http://www.newharbinger.com/30550 (see the last page of the book for more information on how to access it). Begin by orienting the client to the process along these lines: Now I’m going to ask you about how able and willing you believe you are to engage in specific types of compassionate action. Our compassionate minds can guide us to take specific steps in our lives, and I’d like to know how able you believe you are to engage these aspects of your compassionate mind. Attributes of the Psychology of Engagement
  13. Sensitivity How sensitive do you feel you are to your experience of distress as it occurs, in the present moment? Can you notice your experience of suffering as it arises in you? Please rate this on a scale of 0 to 6, where 0 means you aren’t at all sensitive to your experience and 6 means you’re highly sensitive to it. 0 Absent 1 2 3 4 5 6 Very high What experiences and emotions might block or hinder your compassionate sen- sitivity to your own distress? Can we think of one way in which we can address that block or obstacle together?
  14. Motivation to care for well-­being Using the same scale of 0 to 6, how motivated are you to take care of yourself and ensure your own well-­being? To what degree are you motivated to alleviate or prevent the suffering you witness within yourself? 0 Absent 1 2 3 4 5 6 Very high What experiences and emotions might block or hinder your motivation to care for your well-­being? Can we think of one way in which we can address that block or obstacle together?
  15. Sympathy Using the same scale of 0 to 6, how much can you extend sympathy toward yourself during difficult experiences? When you notice your own distress, to what degree do you feel spontaneously sympathetically moved? 0 Absent 1 2 3 4 5 6 Very high What experiences and emotions might block or hinder your sympathy toward yourself? Can we think of one way in which we can address that block or obstacle together?
  16. Empathy Using the same scale of 0 to 6, to what degree do you feel able to reflect upon your own suffering and understand your experience? How much would you say you’re able to look upon your own experience with the empathy you might feel toward another person in distress? 0 Absent 1 2 3 4 5 6 Very high What experiences and emotions might block or hinder your empathy for yourself? Can we think of one way in which we can address that block or obstacle together?
  17. Nonjudgment Using the same scale of 0 to 6, how much do you believe you’re able to adopt a nonjudgmental stance toward your own suffering? To what extent do you feel you can unlock yourself from the influence of judgmental and condemning thoughts and attitudes? 0 Absent 1 2 3 4 5 6 Very high What experiences and emotions might block or hinder you in being nonjudg- mental with yourself? Can we think of one way in which we can address that block or obstacle together?
  18. Distress tolerance Using the same scale of 0 to 6, to what extent do you think you can tolerate distress when you experience difficult emotions? How able are you to adopt an accepting and open attitude toward yourself when you are in distress? 0 Absent 1 2 3 4 5 6 Very high What experiences and emotions might block or hinder you in tolerating your distress? Can we think of one way in which we can address that block or obstacle together? Attributes of the Psychology of Alleviation, or Compassionate Mind Skills Now I’m going to ask you how capable you believe you are of engaging in various compassionate mind skills. For all of these questions, use the same scale of 0 to 6 that we’ve been using.
  19. How would you rate your ability to engage in self-­compassionate think- ing or reasoning? 0 Absent 1 2 3 4 5 6 Very high
  20. How would you rate your ability to bring self-­compassionate attention to your present-­moment experience? 0 Absent 1 2 3 4 5 6 Very high
  21. How would you rate your ability to use imagery that evokes warmth, wisdom, strength, and commitment to your well-­being? 0 Absent 1 2 3 4 5 6 Very high
  22. How would you rate your ability to remain open to sensory experiences that are soothing to you? 0 Absent 1 2 3 4 5 6 Very high
  23. How would you rate your ability to access or contact self-­compassionate feelings, such as contentment, connectedness, and safeness? 0 Absent 1 2 3 4 5 6 Very high
  24. How would you rate your ability to behave in a self-­compassionate way that’s intended to care for and protect your well-­being? 0 Absent 202 1 2 3 4 5 6 Very high Compassion-­Focused Case Formulation Compassion-­focused case formulation is designed to provide an understanding of the specific nature, history, and context of clients’ lives. By understanding this highly individualized learning history and the functional relationships among patterns of reinforcement, avoidance, and emotion regulation, we can more effectively address the suffering and struggle that have led a client to seek psychotherapy. Therefore, in case formulation it is important to distinguish between the intended and inadvertent functions of the client’s thoughts, feel- ings, and behaviors. The aim in a compassion-­focused approach to formulation is to provide an individualized case conceptualization, establish treatment goals and targets, provide validation, and elicit the client’s freely chosen values (Gilbert, 2007; Tirch, 2012). This type of compassion-­focused formulation must include four essential elements: • The client’s biological and environmental contexts, both past and present, which must be understood in light of the antecedents, behav- iors, and consequences that have shaped the client’s patterns of action and coping • What the client fears most and is least willing to experience, such as fears around themes of abandonment, rejection, shame, abuse, or harm • The client’s internally and externally focused “protective” safety strate- gies and behaviors • The intended and unintended consequences of those safety strategies (both public and private) for the client, such as shame-­ based self-­ criticism, beliefs about coping, or views on the nature of the client’s own suffering, including depression and anxiety To guide the process of compassion-­focused formulation, we have created a case-­formulation worksheet (inspired by principles in Gilbert, 2009b), which we will provide shortly. Of course, such formulation is an ongoing endeavor that occurs in stages, beginning with the initial assessment and formulation, in which the therapist interviews the client and collects information regarding current difficulties, symptoms, and problems. The therapist also provides vali- dation and psychoeducation regarding the client’s struggles and current coping. This is done through collaborative perspective taking and by acknowledging the universal need for compassion. The therapist also helps the client recognize that, given the client’s context and experiences thus far, her approach to her problems is understandable, even though it probably isn’t functional. Another focus of this initial stage of compassion-­based formulation is the establishment of rapport and a working therapeutic relationship. While using empathy, com- passionate listening, and reflecting, the therapist looks for any potential difficul- ties in establishing such a relationship, including any obstacles to compassion. Next, therapist and client survey the client’s cultural context and learning history, in general as well as in relation to experiences of compassion and related processes. This allows the client to share her life narrative and gives the thera- pist insight into the client’s emotional memories of self and others. The thera- pist may inquire about the client’s early experiences of feeling cared for, neglected, or not having needs met. Furthermore, the therapist looks for significant expe- riences surrounding early development, attachment, and feeling safe or threat- ened and, as always, assesses for a history of significant trauma or abuse. These early experiences often relate to certain emotional memories that can be central to the client’s experience of the self and can be activated by current contexts and experiences. The therapist listens to the client’s content, as well as tone and other nonverbal communication, in order to identify the client’s felt sense sur- rounding important emotional memories and impressions of self and others. For example, repeated early experiences of being sent to her room alone when upset and crying might lead a client to associate the experience of distress with the feeling or felt sense of being all alone. Repeated early experiences of feeling unsafe or uncared for can lead to feeling easily threatened or impair an individual’s ability to take perspective, experience compassion, or remember early or trauma-­related events (Gilbert, 2009b; Mikulincer & Shaver, 2007a). Thus, it is important to be sensitive to clients and recognize any difficulty they may have in recalling their history, including the possible activation of threat-­response systems when retelling their narrative. Each client will have a different pace and sequence of stages during this formulation process. Therefore, the therapist is encouraged to meet each client wherever she may be in ability and willingness. In any case, a comprehen- sive compassion-­focused assessment of early experiences and learning allows the therapist to utilize compassionate empathy and validation for both the cli- ent’s historical and current struggles, and provides the client with the chance (perhaps for the first time) to tell her story in the presence of someone who is attentive, nonjudgmental, empathic, safe, and warm (Gilbert, 2009b). Next, the therapist helps the client identify particularly problematic behav- iors or strategies adopted in response to fears and perceived threats. These per- sonally significant threats often relate to public and private events the client fears most and is least willing to experience. Thus, the client tries to avoid or control these things in an effort to feel safe and ultimately protect herself. These are natural defense responses or strategies, and they often vary between people and between internal and external threats (Gilbert, 2007). Examples of these “protective” or coping strategies include avoidance, rumination, substance abuse, and reassurance seeking. Together, therapist and client might review the costs and benefits of these safety behaviors. In addition, the therapist provides information regarding the nature and principles of behavioral reinforcement, and about the various functions of these strategies and why employing them is understandable. However, the therapist also illustrates how certain forms of these seemingly protective safety behaviors can often create more difficulties, rather than solving problems. Examples of unintended consequences of these responses are impeding new learning, eliminating opportunities to test the workability of beliefs about the threat, and reducing the client’s range of behav- iors (Tirch, 2012). Thus, the therapist helps the client develop awareness of these behaviors and extend compassion to herself regarding unintended diffi- culties or consequences. Metaphors, inventories, and experiential exercises can be used in session to illustrate this point. Based on everything outlined above, the therapist has the information and insights necessary for completing a structured compassion-­focused formulation addressing the four domains as listed above (historical influences, significant threats and fears, safety strategies, and unintended consequences). This formu- lation emphasizes de-­shaming, with the therapist providing an open and safe context and not using judgmental language or terms like “distortion” or “mal- adaptive” (Gilbert, 2007, 2009b). Therapists guide clients through this formula- tion and to the understanding that their struggles and difficulties are not their fault and not of their choosing. Engaging in this careful assessment and formu- lation allows clients to adopt new perspectives and find new ways of taking responsibility and gaining the freedom to choose how they want to respond to both perceived and actual threats. As you can see, this formulation involves a fluid, collaborative process of functional analysis and reflective listening (Gilbert, 2009a). Therapists support clients in developing their own formulation, an approach that continues through- out therapy. As necessary, therapist and client may identify new therapeutic targets, goals, and interventions or revise old ones. The therapist keeps this for- mulation in mind while moving through therapy with the client, consistently tracking progress and developments, using functional and solution analysis, and assessing for deficits, integration, and generalization of skills. In addition to peri- odically reviewing and reexamining earlier formulations based on progress, the therapist persistently keeps an eye out for new or previously overlooked obstacles to compassion or other events or behaviors that interfere with treatment in order to keep the formulation as comprehensive and up-to-date as possible. Clinical Example: Developing a Compassion-­Focused Case Formulation As with the Self-­Compassionate Mind Interview Worksheet earlier in this chapter, we provide an example of the Compassion-­Focused Case Formulation Worksheet in clinical practice, once again with Josh, to help illustrate its use. Compassion-­Focused Case Formulation Worksheet
  25. Presenting symptoms and problems Binge drinking and chronic shame, anxiety, depression, and behavioral avoidance. “I hate myself and am only happy when I’m partying, looking good, and the center of attention. Doesn’t that make me a bad person?”
  26. Current context of problems Client is in college completing a degree in theater and beginning a career as an actor. He is living on family wealth, neglecting his own needs and responsibilities, and becoming increasingly avoidant. A cycle of substance abuse and “crashing” and “hiding from the world” has resulted in psycho- logical inflexibility, a constricted life, and low levels of self-­compassion and positive emotions except for brief periods during intoxication.
  27. Background and historical influences What do you see as important background experiences to the struggles the client is experiencing today? The client experienced prolonged periods of verbal and physical abuse in childhood at the hands of his father, and severe bullying and emotional abuse from students and teachers in boarding schools. He was socially neglected by loved ones, who exhibited lack of care and sometimes hostility. How did others show affection or caring? The client’s attachment relationships involved a great deal of hostility, abuse, and neglect. Threat-­based emotions and emotional memories have become associated with and related to affiliative emotions and interpersonal relationships. When the client was distressed, how did caregivers provide comfort or soothing? The client describes an absence of comforting and connection. How did caregivers and important others respond to the client’s achievements? Josh reports that his achievements were ignored until he began to be praised for his good looks and acting ability, but only by peers. He was also praised for being “the life of the party.” Significant biological or developmental events Academic difficulties, diagnoses of ADHD and depression, and subsequent “overmedication.” Isolation and social struggles until physical maturity. Significant emotional memories Rejection, shame, sadness, fear of being alone. Questions for the client When you think about these events and memories, how do you feel in your body? What emotions show up? “I don’t like to think about them. I feel disgusted with myself.” Where is your attention drawn? “I want to go to bed. I want to get out of here.” What were your experiences of your emotions growing up? “Being screamed at, being beaten until I was black-­and-­blue, being rejected, and being left alone. I might as well have been left for dead.” What were your experiences of the emotions of close others or caregivers as you were growing up? “Rage, anger, and craziness.” What is your felt sense of yourself? “I feel like I’m lower than low. I’ve been given all the opportunities and money in the world and I’ve messed up.” What is your felt sense of others? “Other people have it worse than me. I got picked on and had a drunk dad—­ so what. I don’t have anything to complain about. Other people scare me, too.”
  28. Key threats and resulting fears Questions for the client What significant fears and concerns do you think these experiences influenced for you? “I can’t stand being seen by people unless they’re really impressed or I’m really drunk.” What significant fears do you have about what others might do or what might happen in your environment? “Rejection! That and more punishment.” What significant fears or concerns do you have about what you might do? “Letting people see how weak and messed up I am.” Are there particular themes or connections in these fears, such as rejection, abandonment, shame, or physical harm? “All of the above!” Therapist summarization of client’s external threats Social rejection, death from drugs and alcohol, failure. Therapist summarization of client’s internal threats Living in perpetual state of shame and isolation. Feeling overwhelmed by rage and fear.
  29. Safety strategies Questions for the client What do you do to cope when faced with these threats and fears? “Stay in bed or get really high and drunk. Charm the pants off of everyone.” Looking back, how do you think your mind has tried to protect you from these threats and fears? “By being a fucking rock star.” How did your mind try to protect you from external threats, such as aggression from others? “Hiding from everyone. Seeming very cool and on point.” How did your mind try to protect you from internal threats, such as the experi- ence of intense emotions or physical sensations? “Being numb, checking out, and getting high.” Therapist summarization of external safety behaviors Taking drugs, drinking, “being fake,” and isolating during the day. Therapist summarization of internal safety behaviors “Attacking myself so I can kick my ass into shape.”
  30. Unintended consequences Questions for the client What unintended costs or disadvantages have these strategies had? “Making embarrassing scenes, wasting my money, losing relationships, hurting good people, seeming like a jerk, losing acting roles, bad academic performance, horrible panic attacks, and crushing depression—­that and constant self-­loathing. Is that enough for you, Doc?” What do you think about yourself when these fears, behaviors, or consequences come up? “Like I said, I’m full of self-­hate.” Therapist summarization of external consequences Compromised functioning across many domains, lack of clear valued directions, difficulty in commitment to responsibilities and “things that matter,” diminishing rewards, alienation from more and more peers. Therapist summarization of internal consequences Depression, anxiety, pervasive shame and dread, “fierce” cravings for intoxication, high levels of reported stress, recurrent emotional reexperiencing of abuse, absence of joy, and fusion with hostile self-­criticism. As you can see, repetitive themes of avoidance, control, and self-­destructive behaviors in response to a pervasive history of trauma are present in this case. Josh’s history of abuse and neglect in the context of key attachment relation- ships, his safety strategies, and the fact that he did not learn to experience emotional soothing in stressful situations have all contributed to a rigid and inflexible pattern of responding, with minimal mindfulness, acceptance, com- passion, or committed action. This case formulation reveals a painful history and a young man who has experienced a great deal of shame. From a CFT point of view, the therapist can recognize that little of Josh’s suffering was of his choice or his fault, and be sensitive to Josh’s suffering based on a precise and nuanced understanding of the patterns that are keeping him stuck. By building on this compassion-­focused case conceptualization, the therapist can help Josh experience the value inherent in caring for himself and moving toward a place of freedom, choice, and perhaps even joy. Josh has a long road ahead—­in therapy, in his recovery, and in his life. Within CFT, the hope is that compas- sion can serve as a foundation for acceptance and help him find his feet, perhaps for the first time in his life. To facilitate the approach to case formulation with your own clients, we offer the following blank worksheet. Feel free to copy it for use in your practice. For a downloadable version, please visit http://www.newharbinger.com/30550 (see the last page of the book for instructions on how to access it). Compassion-­Focused Case Formulation Worksheet
  31. Presenting symptoms and problems
  32. Current context of problems
  33. Background and historical influences What do you see as important background experiences to the struggles the client is experiencing today? How did others show affection or caring? When the client was distressed, how did caregivers provide comfort or soothing? How did caregivers and important others respond to the client’s achievements? Significant biological or developmental events: Significant emotional memories: Questions for the client When you think about these events and memories, how do you feel in your body? What emotions show up? Where is your attention drawn? What were your experiences of your emotions growing up? What were your experiences of the emotions of close others or caregivers as you were growing up? What is your felt sense of yourself? What is your felt sense of others?
  34. Key threats and resulting fears Questions for the client What significant fears and concerns do you think these experiences influenced for you? What significant fears do you have about what others might do or what might happen in your environment? What significant fears or concerns do you have about what you might do? Are there particular themes or connections in these fears, such as rejection, abandonment, shame, or physical harm? Therapist summarization of client’s external threats Therapist summarization of client’s internal threats
  35. Safety strategies Questions for the client What do you do to cope when faced with these threats and fears? Looking back, how do you think your mind has tried to protect you from these threats and fears? How did your mind try to protect you from external threats, such as aggression from others? How did your mind try to protect you from internal threats, such as the experi- ence of intense emotions or physical sensations? Therapist summarization of external safety behaviors Therapist summarization of internal safety behaviors
  36. Unintended consequences Questions for the client What unintended costs or disadvantages have these strategies had? What do you think about yourself when these fears, behaviors, or consequences come up? Therapist summarization of external consequences Therapist summarization of internal consequences Compassion-­Focused Assessment Instruments Like many human experiences, compassion is a process that is very tricky to measure scientifically. By its very definition and the multimodal approaches to its training, compassion requires assessment tools that are more closely aligned with its dynamic nature (MacBeth & Gumley, 2012). Thus far, empirical science and research have mostly relied on self-­report measures of compassion and self-­ compassion. A significant need remains for further development and investiga- tion of instruments for assessing and measuring compassion. The Western science of compassion is young, and self-­report measures are limited. However, there are a few measures that we would like to introduce to you as you begin to implement compassion-­focused techniques into your work. Self-­Report Measures of Compassion The Self-­Compassion Scale (SCS) is a self-­report measure of beliefs and attitudes toward compassionate self-­responding (Neff, 2003a). This twenty-­six-­ item self-­report questionnaire aims to assess overall self-­compassion as reflected in the total score and the score for each component of self-­compassion outlined by Neff (2003a): • Self-­kindness (SCS-­SK) • Common humanity (SCS-­CH) • Mindfulness (SCS-­M) In the development of this scale, factor analysis suggested six subscales to represent a positive and negative aspect of each facet (Neff, 2003b). Thus, the SCS has six subscales that reflect opposing pairs of its components: self-­kindness (SK) versus self-­judgment (SJ), common humanity (CM) versus isolation (I), and mindfulness (M) versus over-­identification (OI) (Neff, 2003a, 2003b). Using a five-­point Likert scale ranging from 1 (almost never) to 5 (almost always), participants respond to items that are intended to reflect how they per- ceive their responses toward themselves in challenging times. The negative aspects of each component are reverse-­coded. Here are some example items: • Self-­kindness (“I try to be understanding and patient toward aspects of my personality I don’t like”) versus self-­judgment (reverse-­coded; “I’m disapproving and judgmental about my own flaws and inadequacies”) • Common humanity (“I try to see my failings as part of the human con- dition”) versus isolation (reverse-­coded; “When I think about my inad- equacies, it tends to make me feel more separate and cut off from the rest of the world”) • Mindfulness (“When something painful happens, I try to take a bal- anced view of the situation”) versus over-­identification (reverse-­coded; “When I’m feeling down, I tend to obsess and fixate on everything that’s wrong”) The SCS has been reported to have good reliability and validity cross-­ culturally (Neff, 2003b; Neff, Pisitsungkagarn, & Hsieh, 2008). This research supports appropriate factor structure of the SCS, with a single higher-­order factor of self-­compassion explaining the strong intercorrelations among the sub- scales (Neff, 2003a). The internal consistency reliability of the subscales were reported as 0.78 (SK), 0.77 (SJ), 0.80 (CH), 0.79 (I), 0.75 (M), and 0.81 (OI). The scale demonstrates convergent validity (i.e., correlates with therapist ratings), discriminate validity (i.e., no correlation with social desirability), and test-­retest reliability (α = 0.93; Neff, 2003a; Neff, Kirkpatrick, et al., 2007). The psychometric properties of the SCS have been examined in college and graduate student samples (Neff, 2003a), as well as with adults who practice meditation, an unspecified community sample of adults, and adults in remission from recurrent depressive disorder who were recruited to participate in mindfulness-­based cognitive therapy (Kuyken et al., 2010; Van Dam et al., 2011). Overall SCS scores correlated negatively with self-­criticism, depression, anxiety, and rumination, and positively with social connectedness and emo- tional intelligence (Neff, 2003a). In their meta-­ analysis of the association between self-­compassion and psychopathology, MacBeth and Gumley (2012) examined studies that used the SCS, using only the total score in their analysis. They found significant associations between higher self-­compassion and lower psychopathology and emotional distress and noted significant effect sizes. However, the authors of this book do note the limitations of this self-­report scale and assert that the results of these analyses cannot distinguish whether results are due to high levels of self-­compassion or due to low levels of self-­ judgment and self-­isolation. Fears of Compassion Scales Gilbert, McEwan, Matos, and Rivis (2011) developed a series of scales mea- suring fears of compassion that examine three distinct processes. The first examines fears of feeling or expressing compassion for others, or compassion flowing out. The second looks at fears of receiving compassion from others, or compassion flowing in. The third assesses fears of compassion for oneself, or the experience of self-­compassion (Gilbert et al., 2011). On all three scales, respon- dents use a four-­point Likert scale to rate how much they agree with each state- ment. In a student sample, the Cronbach’s alphas were 0.72 for fears of expressing compassion for others, 0.80 for fears of receiving compassion from others, and 0.83 for fears of compassion for oneself (Gilbert et al., 2011). In a therapist sample, the Cronbach’s alphas for this scale were 0.76 for fear of compassion for others, 0.85 for fear of compassion from others, and 0.86 for fear of compassion for oneself (Gilbert et al., 2011). Clinically, these three scales are quite useful in distinguishing capacities for the different flows of compassion in clients and allow for exploration of client experiences of fear and active resistance to engag- ing in compassionate experiences or behaviors. They also provide information on possible fears related to affiliative emotions in general (Gilbert et al., 2011). This has important implications for compassion-­focused interventions and the therapeutic relationship due to the significant role affiliative emotions play in effectively addressing experiences of fear and threat. The measure may be found at http://www.compassionatemind.co.uk/downloads/scales/Fear_of_Compassion _Scale.pdf. Compassionate Love Scale The Compassionate Love Scale (CLS) was developed by Sprecher and Fehr (2005) to measure the dispositional tendency to engage in compassionate or altruistic love toward various targets. There are three original versions of the CLS, targeting compassionate love toward family or friends, toward people in general (“stranger-­humanity”), or toward a “specific close other,” with each item of the latter version including the specific target’s name (Sprecher & Fehr, 2005). The authors define compassionate love as an “attitude toward other(s), either close others or strangers of all of humanity; containing feelings, cogni- tions, and behaviors that are focused on caring, concern, tenderness, and an orientation toward supporting, helping, and understanding the other(s)” (Sprecher & Fehr, 2005, p. 630). Each version has twenty-­one statements or items rated with a seven-­point Likert scale that ranges from “not at all true of me” to “very true of me.” All three versions have similarly worded items (e.g., beginning with “I spend a lot of time concerned about the well-­being of”), mod- ified as appropriate for each scale (e.g., ending with “those people close to me,” “humankind,” or the specific target’s name). The three CLS versions have a unifactorial structure and good internal reliability, with a reported Cronbach’s alpha of 0.95 (Sprecher & Fehr, 2005). Santa Clara Brief Compassion Scale The Santa Clara Brief Compassion Scale (SCBCS) was developed from the CLS for large epidemiological studies (Hwang, Plante, & Lackey, 2008). The five items of this scale were selected based on a factor analysis of the longer instrument. Respondents are asked to rate themselves on each of the five items using a five-­point Likert scale ranging from 1 (does not describe me well) to 5 (describes me very well). Scores on this scale are an average rating across all five questions. The correlation between the original and the brief version is 0.96 (Hwang et al., 2008). A study comparing the SCS with the CLS (Gilbert et al.,
  1. found a significant correlation of r = 0.31 (p { 0.01) for the association between self-­compassion and compassionate love for others in a student sample. However, there was not a significant correlation between self-­compassion and compassionate love in a sample of therapists (r = 0.21, p = n.s.). Self-­Other Four Immeasurables Scale The Self-­Other Four Immeasurables Scale (SOFI) is a self-­administered scale that assesses four qualities at the core of Buddhist teachings known as the four immeasurables (Kraus & Sears, 2009): loving-­kindness, compassion, empa- thetic joy, and equanimity. It uses a five-­point Likert scale for items consisting of adjectives chosen by the authors to embody or represent the theoretical quali- ties of the four immeasurables from Buddhist psychology and their opposing processes. The final version of the scale after factor analyses yielded eight pairs of adjectives (totaling sixteen items) with four proposed subscales. The adjec- tives of opposing processes are friendly versus hateful, joyful versus angry, accepting versus cruel, and compassionate versus mean. The subscales are posi- tive self, negative self, positive other, and negative other. Participants are instructed to mark the appropriate answer on each item to indicate to what extent they have thought, felt, or acted this way toward themselves and others during the past week. The measure’s authors calculated Cronbach’s alphas for the four proposed subscales and the entire measure. Internal consistency when measured across all items was 0.60. For the positive self, internal consistency was 0.86; for the negative self, 0.85; for the positive other, 0.80; and for the negative other, 0.82 (Kraus & Sears, 2009). The Experiences of Compassion Interview Researchers are beginning to explore different approaches to the measure- ment and assessment of compassion. These new measures of compassion are intended to examine the specific variants of the intentional and behavioral components and processes of compassion that are the foundation of the theory and science of compassion as discussed thus far (Gilbert, 2010; Goetz, Keltner, & Simon-­Thomas, 2010; Neff, 2003a, 2003b). One example of such an attempt is the development of an interview-­based rating scale of compassion (Gumley, 2013). The development of this assessment is intended to complement and enhance the research and data on compassion, particularly in clinical popula- tions (Gumley, 2013; MacBeth & Gumley, 2012). In 2013, at the Second International Conference on Compassion-­Focused Therapy, organized by the Compassionate Mind Foundation, Gumley described this narrative-­based approach to the assessment of compassion, specifically the Experiences of Compassion Interview. This interview is proposed as a way to engage individuals in the evaluation of compassion from self to others, from others to self, and from self to self. The inspiration for this assessment came from clinical and theoretical observations of apparent contradictions between semantic and episodic memory in regard to compassionate experiences of self and others. This approach to assessing compassion is derived from the coding of individuals’ narratives, and the measure includes four subscales of compas- sion that reflect wisdom and compassion in four realms (Gumley, 2013): • Understanding of compassion • Compassion for self • Compassion from others • Compassion for others This interview uses semantic portrayal, via a card-sorting task, and episodic portrayal of three scenarios: a time when respondents expressed compassion to another, a time when another expressed compassion to the respondents, and a time when the respondents expressed compassion toward themselves. Gumley (2013) asserts that this measure is sensitive to the effects of CFT, is associated with the process of mentalization, and can facilitate the experience of compassion. Cultivating Compassionate Behavior While our human need for compassion is not freely chosen, compassion-­based behavior and values are. In other words, the ways in which we embody compas- sionate behavior and commitment to such behavior are up to us. In this section, we will discuss several approaches that can help clients cultivate a broader repertoire of compassionate behavior, with a specific orientation toward allevi- ating suffering and allowing for growth and well-­being. This involves exploring behaviors that embody the experience of wisdom by doing what works, gaining strength and courage through facing feared experiences, and coming into contact with an awareness of suffering. These approaches rely on the inten- tional use of behavioral experiments, behavioral activation, and exposure in a manner that is consistent with the individual’s values and willingness (Tirch, 2012). To begin this work, therapist and client collaboratively arrive at an agree- ment as to what these new behaviors are, what they look like, and how they would feel to the client. Throughout, compassion-­focused behavioral activation and exposure also emphasize compassion and values through the use of warmth, courage, strength, and kindness to facilitate engaging in more frightening or challenging activities (Gilbert, 2010). What is truly helpful in easing the suffering of clients is to provide them with opportunities to learn new ways to behave in relationship to their suffer- ing. To this end, therapists remind clients of things that have happened in the past as a result of changing their relationship and response to distress. An example might be not obeying the orders of the anxious self and instead going out on a date, despite anticipatory worry or stress. Compassionate behavior is about choosing to go out, even if doing so is difficult. Thus, compassionate behavior comprises not just what to do but how to do it. Why ask clients to engage in these challenging actions? Because it helps them get unstuck from habitual patterns of fusion and avoidance that lead to increasingly constricted lives. Therefore, we often develop interventions and series of behavioral practices that are flexible and challenging but not over- whelming, where, step-­by-­step, clients begin to engage in successive (and success- ful) approximations of their desired compassionate behavior. For example, with clients who are suffering from agoraphobia, it isn’t truly compassionate to advise them to just stay inside, where it feels less scary. That much is obvious. But tele- porting them into the middle of a Rolling Stones concert without warning wouldn’t be truly compassionate either. So we might begin encouraging them to go to the door and look down the road; then, next time, by encouraging them to take a few steps down the sidewalk or to the mailbox, and so on. This gradual exposure is a form of self-­compassionate action by virtue of its pace and inten- tion, and it can also serve as a form of compassionate exposure as both client and therapist actively recruit the client’s previously trained capacity for mindful com- passion and flexible responding in the presence of feared stimuli. The more we can help clients create an understanding, supportive, and warm inner voice for themselves—­a perspective that validates and recognizes how unpleasant suffering can be—­the better able they may be to find a secure base from which to explore and face challenges. Compassionate mind training can help keep them in touch with their compassionate wisdom: the part of the self that has learned suffering is impermanent and that can make room for dis- tress rather than fuse with it or avoid it. This kind of compassionate self-­ perspective allows clients to more easily recall new, intended responses and coach themselves through engaging in those responses. All behavioral changes are important, as they all help clients build courage and confidence. Clarifying Valued Aims and Choosing to Care for Well-­Being When clients begin to engage with their suffering, they will be deliberately moving toward difficult things that they have historically avoided. This experi- ence is likely to be uncomfortable. Therefore, as therapists we hear clients asking, “Why bother?” In response, we must remain flexible, bearing in mind that there are no absolute rules in terms of which exposure practices or compas- sionate actions matter to a given client. In chapter 6, we noted how creative hopelessness and the wisdom of no blame could create a context to begin the process of moving toward a life of meaning and vitality, even in the presence of difficult emotions. However, clarification and authorship of personally mean- ingful values also plays a crucial role in compassion-­focused ACT. Therefore, some issues may be relevant to compassion-­based exposure work, while others may not, depending on values and workability. For example, a client may have a fear of giraffes and not see any reason to overcome it because it does not inter- fere with mindfulness, compassion, and values-­based living. Therefore, it is important to work with clients to explore and clarify their values-­based aims and goals. This will inform decisions about whether and how to work with par- ticular difficulties or treatment goals and illuminate which parts of their distress are most relevant to focus on. For example, one client might wish to address his chronic but mild depres- sion because he wants to move to a new city and begin a new job, whereas another client may want to stop compulsively seeking reassurance from her friends and relatives that she is able to face the anxiety of commuting to her job. Clearly, it is important to clarify with our clients specifically what they would like to achieve and why they would like to achieve it. In other words, why does a given aim matter to a person, and what makes it worth it to overcome habitual patterns of avoidance and excessive attempts at control? This becomes espe- cially useful when obstacles or resistance appear in therapy, allowing therapists to help clients keep in mind what their aims are and why the work is worth- while. Otherwise, clients may lose both motivation and perspective when suf- fering arises, making it all too easy for them to slip back into patterns of avoidance and feelings of unwillingness. As you are undoubtedly well aware, valued aims or valued directions are behaviors that are intrinsically rewarding across time and across situations, reflecting clients’ true intentions for how they want to behave in the world. This means choosing the version of themselves that they most wish to be. Therefore, a key goal for therapist and client alike is to discover what, specifically, seems to light a fire in the client. This will reveal the client’s values and reflect the degree to which certain behaviors are reinforcing. So in order to help clients engage in truly compassionate behavior and take good care of themselves, it is important to explore their values and help them find effective ways to move in the direc- tion of their valued aims. Through guided discovery, therapists can aid clients in discovering what aims and directions are most meaningful and worthwhile to them. All of the following questions can be helpful in exploring clients’ values and goals for com- passionate behavior: • Given that facing our suffering is difficult, what in life is worth suffering for? • What would you have to give up caring about in order to not wish to avoid this experience? • In the service of what valued aim would you be willing to face these dif- ficult emotions? • What behaviors are intrinsically rewarding for you? • If you were to be compassionate toward yourself and courageous in your pursuit of your valued aims, where would you be headed? • What do you want to be about in this life? What matters most to you? What would you be willing to face in order to realize these values? Additionally therapists can assist clients in authoring their own valued directions and beginning to pursue valued aims by using the following work- sheet (adapted from Tirch, 2012, and inspired by Hayes et al., 1999). Feel free to make copies of this worksheet for use in your practice. For a downloadable version, please visit http://www.newharbinger.com/30550 (see the last page of the book for instructions on how to access it). The worksheet can be used in session or be completed by clients as homework between sessions. Becoming the Author of My Valued Aims and Directions This worksheet is intended to give you space to write down some observa- tions about the patterns of valued behavior you’d like to pursue in different areas of your life, such as career, family, and intimate relationships. Before com- pleting each section, please take a few moments to reflect upon what aims you might pursue in your life that would be meaningful, rewarding, and filled with a sense of vitality and purpose for you. If you aren’t filling out this worksheet in session, please find a place that feels safe to you and where you will be free from interruptions. Allow yourself sufficient time to complete it. Also schedule a time a day or two later to look over the worksheet and reflect upon your answers.
  1. Career or work life How important is this area of my life to me? (0–­10):     What would my compassionate and values-­based intention be in this area? What obstacles might I face in realizing this intention? How might I overcome these obstacles with strength, compassion, and wisdom?
  2. Family How important is this area of my life to me? (0–­10):     What would my compassionate and values-­based intention be in this area? What obstacles might I face in realizing this intention? How might I overcome these obstacles with strength, compassion, and wisdom?
  3. Intimate relationships How important is this area of my life to me? (0–­10):     What would my compassionate and values-­based intention be in this area? What obstacles might I face in realizing this intention? How might I overcome these obstacles with strength, compassion, and wisdom?
  4. Social life How important is this area of my life to me? (0–­10):     What would my compassionate and values-­based intention be in this area? What obstacles might I face in realizing this intention? How might I overcome these obstacles with strength, compassion, and wisdom?
  5. Education How important is this area of my life to me? (0–­10):     What would my compassionate and values-­based intention be in this area? What obstacles might I face in realizing this intention? How might I overcome these obstacles with strength, compassion, and wisdom?
  6. Physical well-­being How important is this area of my life to me? (0–­10):     What would my compassionate and values-­based intention be in this area? What obstacles might I face in realizing this intention? How might I overcome these obstacles with strength, compassion, and wisdom?
  7. Spirituality How important is this area of my life to me? (0–­10):     What would my compassionate and values-­based intention be in this area? What obstacles might I face in realizing this intention? How might I overcome these obstacles with strength, compassion, and wisdom?
  8. Community involvement How important is this area of my life to me? (0–­10):     What would my compassionate and values-­based intention be in this area? What obstacles might I face in realizing this intention? How might I overcome these obstacles with strength, compassion, and wisdom?
  9. Hobbies and recreation How important is this area of my life to me? (0–­10):     What would my compassionate and values-­based intention be in this area? What obstacles might I face in realizing this intention? How might I overcome these obstacles with strength, compassion, and wisdom? Encouraging Compassionate Behavior After clients have completed the worksheet, you may want to take some time to help them reflect upon what they learned and how this might relate to their development of compassionate behavior and mindfulness. It may be worth- while to explain that when people’s behavior becomes consistent with what they value, they are that much closer to living a life of compassion. They are also truly on the way to being better able to face challenges and overcome unnecessary suffering in the service of a life well lived. Together, therapist and client should take a close look at how the client might cultivate compassionate behavior that fits with his freely chosen values and compassionate self, jointly discussing the process, acknowledging that it requires courage, discipline, and sacrifice and that it affords opportunities for joy and warmth as well. Therapists should encourage clients to remain open to whatever shows up in the present moment when pursuing valued aims, includ- ing shame, anger, sadness, fear of the unknown, and other challenging emo- tions. Compassionate and self-­compassionate behavior involves perseverance and moving toward what matters most, even in the presence of distress, ulti- mately expanding clients’ behavioral repertoires and choices. Therapists can also highlight compassionate behaviors that clients might already be engaging in, such as the following: • Taking care of themselves, whether by having a relaxing massage or spending time with people they love • Taking care of their health by visiting the doctor or exercising regularly • Taking a break from a stressful situation to relax and enjoy other activi- ties that bring them pleasure In addition, therapists can point out that facing suffering through self-­ compassionate behavior may also take less obvious yet very important forms. Here are some examples: • Dedication to moving in valued life directions, like studying for exams or pursuing a career, even when doing so is uncomfortable and involves sacrifices of time or energy • Facing things that are frightening in order to engage in more values-­ based action, even though doing so involves experiencing distress • Refraining from taking part in “pleasurable” activities that might be harmful, such as drinking a lot of wine at a party to “take the edge off” or “calm the nerves,” when they know this behavior will have negative results in the long run Clearly, after engaging in values clarification and authorship, clients are likely to face some difficult decisions. An example would be choosing to refrain from eating unhealthy foods that taste good in the short term but move the client away from his values around physical well-­being. As always, it is impor- tant to keep in mind that each individual is different, with a unique learning history, set of values, and physical and emotional strengths. However, as human beings we all have the capacity to cultivate our compassion through the many skills and attributes of the compassionate mind. To that end, an important part of helping clients engage in compassionate action is looking at which fears or difficulties they would ideally face and how to face them. Developing the Motivation to Engage in Compassionate Action ACT involves a balance of mindfulness and acceptance processes and direct behavioral change processes, enacted in the service of living lives of meaning, purpose, and vitality. Part of working as an ACT therapist involves tracking the client’s present-­moment experience and emphasizing mindfulness and willing- ness, or specific steps toward change, based upon the client’s needs and the opportunities in the moment. The process of values authorship and commit- ment to action involves evoking the motivation to move toward greater well-­ being, and this is a touchstone of compassionate motivation. Together, therapist and client can move through a specific behavioral change program, with the client gradually moving toward valued aims and overcoming patterns of avoid- ance, such as social isolation or addictive behaviors. In the process, the client commits to and then willingly enters experiences and situations she might prefer to avoid, doing so with clarity and purpose. To prepare for this, the therapist should help the client enhance her compassionate motivation. There are many reasons clients may experience problems. Sometimes the experience of suffering seems clearly related to an ongoing psychological problem, or a DSM “disorder” or cluster of symptoms. Other sources of suffering might be external, such as stressful life events or environmental disasters. From the perspective of the compassion-­focused therapist, it is important to remind clients that the suffering they experience is not their fault and that they didn’t choose to have such an active threat-­detection system. It may also be helpful to revisit the many reasons for their struggle with suffering. By conveying and reit- erating this wisdom—­that suffering is a fundamental part of being human—­ therapists can help clients experience more compassion for themselves and greater acceptance of their current experience of suffering. Our suffering, and our ability to recognize it, is part of our essential humanity, and being sensitive to that may increase clients’ motivation to engage in compassionate action and move toward the life they wish to live. Throughout this book, we have elaborated many ways that compassionate motivation can be stimulated through mindfulness, imagery, compassionate thinking, hexaflex process work, the therapeutic relationship, and a range of other methods. In a very simple and direct way, therapists can also use the process of guided discovery to help clarify the focus of compassionate action and increase clients’ motivation to approach challenging situations. As an example, consider a client who suffers from anxiety. The therapist may first allude to how the client may have given up because of anxiety and avoiding feared situations. Then the therapist might ask about specific costs of avoidance behaviors and have the client reflect on or even write out the answers. Here are a few questions a therapist might ask in this situation: • How much has your struggle with unwanted emotions cost you in terms of your personal relationships? Have you avoided relationships, or have they become strained due to the limits your attempts to avoid or control your emo- tions have placed upon you? • Have you avoided situations because of the feelings you thought you might have, and as a result missed out on meaningful opportunities? Have you made decisions that had a negative impact on your work life or finances due to avoidance? • Has your struggle with your experience limited the amount of freedom you have to pursue the things you enjoy? Have you given up recreational activities, travel, or hobbies due to avoidance behaviors? How much time and energy have been absorbed by negative emotions involved with your struggle? • What has your struggle with unwanted experiences and emotions cost you overall in your life? After exploring these kinds of questions, it’s important to provide encour- agement and hope by reminding clients that they are now taking steps to change this dynamic and to get their life back. Help them remember their aims: to reclaim their life and free themselves to experience life with kindness, courage, and authority. Keeping sight of these aims is of paramount importance, especially when engaging in compassionate practices, wherein therapists ask clients to accept the fact that they are likely to feel more distress at first. In this way, therapists can help clients cultivate the willingness to experience some distress in the short term so that they might better overcome these struggles in the long term. The threat-­detection system can activate suddenly, and due to the accompa- nying physical sensations, emotions, and thoughts, the resulting reaction is not easily controlled or suppressed. Thus, it is important for therapists to emphasize to clients that the key is to approach this work with courage and an ever-­growing ability to tolerate distress, which will build skill in meeting similar situations in the future. In CFT, this gradual approach to compassionate exposure is some- times referred to as “challenging but not overwhelming.” During or after the work of guided discovery outlined above, therapists can work with clients to record and examine the costs and benefits of engaging in compassionate gradual exposure, perhaps using a formal worksheet such as the one we provide below. For a downloadable version, please visit http://www .newharbinger.com/30550 (see the last page of the book for instructions on how to access it). Costs and Benefits of Facing My Feared Emotions and Experiences Use this worksheet to list the specific costs and benefits that you might face. Costs of facing my fears 238 Benefits of facing my fears After reviewing the costs and benefits for the client, you might want to follow up with some questions along these lines: • What have you discovered after reviewing and listing the costs and benefits of facing challenging situations? • Have you created a clear mental vision of how your life would be improved by coping with your difficulties? • How might you describe the ways in which your life would be improved by being able to cope with distressing situations in a more mindful and compas- sionate way? Seeing One Another Through Compassionate Eyes As we bring a compassionate focus to case conceptualization, we may discover aspects of our clients’ lives and suffering that would otherwise have remained hidden. And as we engage in a systematic process of assessment and case con- ceptualization from a compassion-­focused, ACT-­consistent perspective, our sensitivity to the suffering we see in our clients may grow, as may our deep motivation to alleviate and prevent the suffering they experience. As we connect with their struggle and realize that so much of their pain truly is not about them and not their fault, our motivation to see them flourish and live larger and more fulfilling lives may deepen. This cycle, in which one person’s pain awakens another’s compassion and this compassion in turn gives rise to a shared, deep desire to alleviate suffering for all beings, is perhaps uniquely human. And it may very well represent the best of what we can see in ourselves and in each other.
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