第一章 起源与核心主题
第一章
起源与基本主题
在本章中，我们将简要探讨慈悲聚焦疗法（Compassion Focused Therapy, CFT）的起源及其如何从帮助遭受羞耻感和自我批评折磨的人们的需求中发展而来。我们还将探索CFT方法背后的一些基本理念，重点在于考虑CFT的理论根源——如进化心理学、情感神经科学、依恋理论、行为主义以及培养同情的力量——是如何转化为我们在治疗室中的实践。
慈悲聚焦疗法的起源
CFT的起源可以追溯到20世纪80年代，当时英国心理学家保罗·吉尔伯特（Paul Gilbert）做出了观察。保罗拥有包括认知行为疗法、荣格分析、进化心理学、神经生理学和依恋在内的多元训练背景（Gilbert, 2009a）。在他的治疗工作中，保罗注意到许多客户似乎有根深蒂固的自我批评、羞耻感和自我厌恶。他还发现，对于这些特定患者而言，传统的认知疗法练习，如认知重构，往往效果不佳。例如，这些客户能够识别出他们的适应不良思维，认定这些思维是不合理的，并且可能甚至能够根据这些思维所包含的思考错误对其进行分类。他们能够审视自己生活的现实，产生更加理性、基于证据的替代思维。但是，有一个问题：尽管做了所有这些工作，他们并没有感到更好（Gilbert, 2010）。在这些客户中，保罗观察到他们在所想与所感之间存在不一致——一种认知-情感不匹配——这阻碍了他们的治疗进展。他发现，只有当安慰性的想法能让客户感到安心时，它们才是有用的。而在高度自我批评的客户中，这种情况往往不会发生。
基于这些观察，保罗开始寻找方法来“温暖”他为客户所做的认知行为工作，并开始注意到一些动态因素，虽然在他接受的认知行为疗法培训中很少被提及，但却强烈地影响着客户的体验。例如，更仔细地观察他们的经历后，他注意到，尽管许多客户可以产生新的、基于证据的想法，这些想法看起来应该是有帮助的，但这些想法所表达的心理“语调”通常是严厉且批判性的。
由于这些观察结果，保罗逐渐发展出了后来成为慈悲聚焦疗法的方法。在此过程中，他试图帮助治疗师利用现有的改变技术，同时帮助客户以更温暖、更富有同情心的方式对待自己的经历。这种发展的方法侧重于帮助客户理解和处理他们的情绪，以帮助自己感到安全，并强调培养同情力量，使他们能够有效地面对和解决自己的困难。
CFT的核心理念
CFT有几个基本理念构成了其核心。现在让我们介绍其中一些理念。
羞耻感与自我批评可能是毁灭性的
正如我提到的，CFT最初是为了帮助那些与羞耻感和自我批评作斗争的人而开发的（Gilbert, 2010）。羞耻感可以定义为一种极度痛苦的情感状态，与对自身作为坏的、不受欢迎的、有缺陷的和无价值的负面评价有关（Tangney, Wagner, & Gramzow, 1992; Gilbert, 1998）。我们可以区分内化羞耻感——即我们对自己持有负面的个人判断——和外化羞耻感，即我们认为他人视我们为低人一等、有缺陷和不吸引人（Gilbert, 2002）。
越来越多的文献表明，羞耻感和自我批评对我们没有好处。研究表明，羞耻的记忆功能类似于创伤记忆，成为个体身份的核心部分，这与抑郁、焦虑、压力和创伤后应激反应有关（Pinto-Gouveia & Matos, 2011）。羞耻感和自我批评已被与多种心理健康问题联系起来（Kim, Thibodeau, & Jorgenson, 2011; Kannan & Levitt, 2013），包括抑郁症（Andrews & Hunter, 1997; Andrews, Quian, & Valentine, 2002）、焦虑症（Gilbert & Irons, 2005）、社交焦虑症（Gilbert, 2000）、饮食障碍（Goss & Allan, 2009）、创伤后应激障碍（PTSD；Andrews, Brewin, Rose, & Kirk, 2000）、边缘型人格障碍（Rüsch et al., 2007）及整体心理失调（Tangney, Wagner, & Gramzow, 1992）。从心理过程的角度来看，羞耻感与体验回避——不愿接触自己的私人经历如情绪——相关联，后者本身又与各种情绪障碍有关（Carvalho, Dinis, Pinto-Gouveia, & Estanqueiro, 2013）。
负面自我评价对治疗过程的影响
这些负面的自我评价似乎也影响了治疗的过程。自我污名化（self-stigma）是指个体将与内化负面群体刻板印象相关的负面评价应用于自己（Luoma, Kulesza, Hayes, Kohlenberg, & Latimer, 2014）。研究表明，自我污名化与严重精神疾病患者的住院治疗使用率较高（Rüsch, et al., 2009）、被诊断为精神分裂症患者的治疗依从性较低（Fung, Tsang, & Corrigan, 2008）、药物依从性较差（Sirey et al., 2001）以及成瘾者在康复中心的停留时间较长（Luoma, Kulesza, Hayes, Kohlenberg, & Latimer, 2014）有关。这些发现特别重要，因为这些研究中的个体所经历的自我污名化是基于对精神疾病或成瘾的群体刻板印象的认同。这显示了羞耻感在放大和加剧心理健康问题方面的强大作用，尤其是对于那些可能会因自身的心理挣扎而自我批评、羞辱和污名化的客户。CFT的一个基本目标是帮助客户将其对挑战性思维和情感的态度从谴责和评判转变为富有同情心的理解和有助于行动的承诺。通过这种方式，自我攻击和回避可以转变为温暖和承担责任。
羞耻感如何妨碍处理挑战性情感的例子
让我们考虑一个例子，看看羞耻感如何妨碍处理挑战性情感。想象一位父亲看到自己对孩子大喊大叫（可能是受到孩子害怕的表情的触发），并感到羞耻：由“我是一个糟糕的父亲”这一想法引发的剧烈情感痛苦。这是一个痛苦的想法，可能会让他陷入更多的困境。首先，从CFT的角度来看，严厉的自我批评或羞耻的归因本身就是强大的威胁触发器。它们使我们陷入威胁感中，这种感觉会以不利于做出积极改变（如改善育儿方式）的方式组织我们的思维（我们将在后续章节中讨论这一点）。这位父亲不是专注于学习更有效的应对方式，以便不再对孩子大喊大叫，而是专注于自己的无能。
伴随羞耻感的情感痛苦也可能助长回避行为——也就是说，像“我是一个糟糕的父亲”这样的羞耻想法引发的感觉如此痛苦，以至于这位父亲可能会迅速采取分散注意力、合理化自己的行为、将责任推到孩子身上，或者做任何事情来逃避这种体验。CFT非常强调帮助客户克服这种回避行为，通过从羞耻的视角转向富有同情心的视角，帮助他们面对和处理挑战。
避免对羞耻感和自我批评进行羞耻化和污名化
我们也必须避免对羞耻感和自我批评的经历进行羞耻化和污名化——我们不希望我们的客户因为感到羞耻而感到羞耻。他们可能已经学会了以这种方式应对是有道理的。我们大多数人都不会有意通过自我攻击来为自己制造问题。然而，我们生活在一个充满理想化形象的文化中，这些形象展示了人们应该如何外貌、感受和表现——这些形象很容易被我们内化，而我们却无法达到这些标准。这些严苛的比较可能因我们能够感知自己的内部体验与他人的内部体验之间的差异而被放大。我们几乎可以无限地接触到自己的挣扎——困难的情绪、任务或动机的困扰，或不符合我们价值观的思想和行为。与此同时，我们对他人的内部体验的了解非常有限——我们主要看到的是他们选择展示给我们的部分，而像我们一样，他们也希望显得有能力、聪明和有吸引力。我们都倾向于戴上“面具”。看到自己内心的混乱和挣扎，周围似乎都是看起来一切都很好的人，客户很容易感到羞耻和孤立，并得出结论：“我有问题。”这还不包括许多可能导致客户经历羞耻感的具体因素，如创伤或欺凌的历史、严厉的成长环境、学习历史，以及可能属于被污名化群体。考虑到所有这些因素，我们的客户学会自我羞辱和攻击是非常有道理的。
CFT对羞耻感和自我批评的看法
CFT对羞耻感和自我批评的看法并不意味着没有空间进行有益的自我评估。当然有——有时我们的客户确实存在问题，需要改变！只是这种自我评估在以温暖的方式呈现时效果更好，不会过度激发威胁反应。例如，富有同情心的自我纠正涉及注意到自己正在做一些有害或无益的事情，允许自己对此感到内疚，并将注意力转向未来做得更好。与其说“我是一个糟糕的父亲”，富有同情心的纠正更像是这样：“鉴于我的经历，我大喊大叫是可以理解的，但这不是我想成为的那种父亲。是时候承诺以一种能够为孩子们树立榜样、教会他们正确价值观的方式来与他们互动了。什么可以帮助我做到这一点？”
同情：面对痛苦的力量
虽然羞耻感可能导致人们关闭内心，远离他们的挣扎和痛苦，但我们需要找到方法帮助客户面对痛苦，并以有益的方式处理它。在CFT中，这是通过培养正念特别是同情来实现的。一个可能的问题是：为什么要选择同情？世界上有很多有益的美德。为什么我们要将同情作为治疗的核心？
在CFT中，我们花了很多时间来定义、操作化和应用同情，以帮助我们的客户。一个广为接受的同情定义大致如下：对痛苦的敏感性加上帮助减轻（和预防）痛苦的动机（Gilbert, 2010）。这个定义包含了两个独立但重要的组成部分：敏感性和动机。CFT之所以如此重视同情，是因为我们认为这是一种在面对痛苦、困难和苦难时特别可行的态度。
这个简单的定义中包含了很多内容。首先，它为我们提供了一种面向痛苦的方法——既包括对痛苦出现的敏感性，也强调向痛苦靠近以提供帮助。这与许多客户面临的回避行为截然不同。同情还包含温暖——痛苦是以帮助为目的来接近的。这种温暖的动机和情感基调可以帮助我们（以及我们帮助的人）在面对困难时感到安全，帮助我们从威胁导向的视角转变为开放、反思和灵活的心态。
如果我们更深入地探讨同情的定义，我们会发现它还包含其他有益的能力。为了维持这种温暖的、接近痛苦的态度，我们必须能够容忍痛苦，因此CFT，像辩证行为疗法（DBT；Linehan, 1993）一样，强调痛苦耐受和情绪调节。如果同情的行为要真正有所帮助，它必须是熟练的，因此CFT致力于帮助客户培养同理心、心理化和视角转换等能力。
最后，许多客户，尤其是那些带着大量羞耻感和自我批评进入治疗的客户，可能对自己的体验非常负面。在CFT中，我们努力为客户提供一个统一的框架，以涵盖我们帮助他们培养的各种同情方面——我们称之为同情心自我。同情心自我是自我的适应版本，体现了我们在治疗中培养的各种同情方面。在治疗初期，这表现为想象性的视角转换练习，类似于方法表演：客户想象自己处于最佳状态——最善良、最同情、最智慧、最自信——考虑如果她完全具备这些优势会是什么样子。然后，她想象这种同情版本的自己会有什么感觉、注意什么、如何推理、如何被激励以及如何行动。
随着治疗的进展，同情心自我成为客户反复进入的一种视角，考虑她如何从这种同情的视角理解和处理她的困难。与此同时，她努力培养同情的优势，并将其转化为习惯，目标是随着时间的推移，客户对“我”的概念和同情心自我之间的差距逐渐缩小，这些能力成为她日常生活的一部分。通过这种方式，CFT与接纳与承诺疗法（ACT）和积极心理学运动有共同之处。治疗的重点不仅仅是缓解症状，而是有目的性地发展优势——适应性的生活方式，这些方式是可行的，并反映了客户最积极的愿望和价值观。
同情的基石：从评判到理解的转变
正如我们所讨论的，高度自我批评和易受羞耻感影响的客户在观察到自己经历的许多方面时会攻击自己——他们的感受和想法、反应以及关系困难。虽然对自我和他人的同情是CFT的主要目标，但最初我们花较少的时间与客户谈论同情，而是更多地为同情的产生创造条件。我们通过帮助他们理解导致其挑战性情绪、动机和行为的因素来实现这一点。与其试图说服客户为什么应该对自我和他人抱有同情，我们的想法是，当他们真正理解人类生活中面临的挑战时，同情对他们来说就会变得有意义，并且很可能会自然产生，而不需要说服。当然，我们也会讨论什么是同情、什么不是同情以及为什么同情是有帮助的——但我们希望通过创造理解的背景来为这一点铺路。
在CFT中，我们认为重要的是认识到许多挣扎可能源于我们无法选择或设计的事物。这是我们希望帮助客户实现的一个更大转变的一部分——从基于威胁的指责和羞辱态度转变为同情的理解和找出什么会有帮助的态度。如果我们仔细审视人类的故事，会发现许多未选择的因素塑造了我们的体验和我们成为什么样的人。
我们进化的脑部带来的挑战
在CFT中，人类的情感和其他认知功能是在进化背景下理解的。我们将情感分为三类，根据其进化功能：识别和应对威胁的情感和动机、追求并因达成目标而获得奖励的情感，以及与他人连接时常见的安全感、满足感和平静感。当我们从进化功能和祖先赋予的生存价值的角度来考虑这些情感、动机和行为时，最初令人困惑的现象就变得更有意义。一个快速的例子是对甜、咸、油腻食物的渴望和安慰。许多人因情绪化进食而挣扎，有多少人希望自己对西兰花的渴望能像对披萨或甜食那样强烈？但在我们的祖先所面对的环境中——一个卡路里和营养相对稀缺的环境——糖、盐和脂肪赋予了生存价值，使那些在可得时容易消耗这些物质的人更有可能活下来并将基因传递给后代。从这个进化角度来看，这些渴望（以及我们可能为之挣扎的许多情感）完全有道理，尽管它们现在与我们当前的环境——一个廉价、咸、甜、油腻的食物随处可见的环境——完全不符。
我们大脑和心智的进化方式可能会给我们带来困难。从旧脑情感与新脑符号思维能力的复杂互动，到我们自动学习不同事物之间联系的轻松程度，关于我们心智运作的很多方面是我们未曾选择或设计的，但却相当难以管理。这种意识可以通过去病理化情感和体验来创造自我同情的背景，这些情感和体验单独看来可能像是“我出了问题”，但实际上是我们这个时代人类生活的组成部分。
社会对自我的塑造
正如我们所讨论的，作为一个人意味着我们会经历强烈的情感和动机，这些情感和动机有时难以管理，尤其是在面对创伤或其他生活挑战时。早期的社会经历强烈地塑造了我们帮助自己感到安全和调节情绪的能力，以及其他许多关于我们自身的特点。例如，早期和持续的依恋经历强烈影响了我们与他人连接时的安全感（而非威胁感）、期望他人的支持和关怀（而非伤害或忽视），以及看待自己是否可爱和值得照顾（而非不可爱和孤立）（Wallin, 2007）。
这些我们无法选择或设计的环境与我们的大脑学习方式强烈互动，有时会产生毁灭性的影响。通过经典条件反射、操作条件反射、社会学习，以及现代学习理论的更详细阐述，如关系框架理论（Hayes, Barnes-Holmes, & Roche, 2001; Törneke, 2010），我们的环境可以教会我们恐惧本应帮助我们感到安全的人际连接，并系统地塑造日后会束缚我们的行为。
在CFT中，我们希望帮助人们开始理解，他们感受到的许多情感甚至他们学到的应对方式并不是他们的选择或设计——这些事情不是他们的错。这并不意味着我们在推卸责任或免除人们对自身行为的责任。这是关于对自己生活中哪些因素可以控制，哪些不能控制的诚实认识。事实上，正是因为我们无法控制这些因素，我们才需要了解自己的心智，并学会如何应对我们可以影响的事物。我们的客户可能没有选择拥有因学习经历而形成的脑部，这些经历在面对某些情境时会产生使人瘫痪的恐惧和焦虑，但我们可以帮助他们培养有效应对这些情境和情感的能力，并验证和支持他们在这一过程中所做的努力。
电影《心灵捕手》中有一个强有力的场景，罗宾·威廉姆斯饰演的心理学家拿着马特·达蒙饰演的威尔的文件，文件记录了威尔多年遭受的童年虐待。对话大致如下：“我不知道很多，威尔，但我知道这一点。”他举起文件。“你知道这一切吗？这不是你的错。这不是你的错。”
在场景中，他温暖地重复这句话，一次又一次。威尔最初对这个观点持抵制态度，有些反抗，就像我们和我们的客户可能会做的那样。承认我们生活中（以及我们的头脑如何运作）有许多方面不受我们控制并不总是容易的。像威尔一样，如果客户的生活中充满了创伤、挣扎和痛苦，这种认识可能会既令人心碎又令人顿悟。但如果我们能帮助客户诚实地认识到他们生活中哪些不是他们的错——他们没有选择的经历、不由自主产生的强烈情感、违背价值观的自发想法、未能成功改变的习惯——并帮助他们停止自我攻击和责备，这可以创造一个使改变成为可能的背景。
在CFT中，我们希望帮助客户实现上述认识。然而，冗长的解释通常没有帮助，而且不像《心灵捕手》中的例子，我们通常不会把客户逼到角落里一遍又一遍地说“这不是你的错”。我们将讨论，CFT旨在成为一个引导发现的过程，广泛使用苏格拉底式对话和体验性练习，如思想实验、视角转换和椅子工作，帮助客户理解他们的经历以及如何应对这些经历。
学会感到安全的重要性
正如我提到的，CFT深受情感神经科学研究的影响。有大量的科学文献记录了人类与祖先共享的进化情感调节系统，以及这些基本情感和动机在我们的大脑和心智中如何发挥作用（Panksepp & Biven, 2012）。这不仅是CFT理论的基础部分——它直接带入了治疗过程中。客户学习不同的情感调节系统，以及基本动机和情感如何通过塑造注意力、推理、身体反应等方面的模式来组织我们的思维和身体，重点在于学习如何与这些系统合作，以平衡情感并培养客户想要达到的心境。这种学习有助于为自我同情打下基础，因为客户对挑战性情感体验的“原因和机制”的理解使他们能够理解这些情感。
在第五章中，我们将详细探讨这些基本情感调节系统，但值得一提的是，CFT的一个重要部分是帮助客户在关注威胁的情感、追求目标的情感以及与安全感和平静感相关的情感之间找到平衡。这些情感以多种方式强有力地塑造了我们的心理体验。例如，许多客户体验中占主导地位的威胁情感，如焦虑、愤怒或恐惧，与注意力的狭窄、认知灵活性的下降以及倾向于采用沉思等策略有关，这些策略加剧了而不是平息了感到受威胁的状态（Gilbert, 2009a）。相反，当我们感到安全时，心智以完全不同的方式组织——我们的注意力和思考范围扩大，我们往往会变得平静、平和、反思和亲社会（CFT认为，这样更能有效地应对困难情感；Gilbert, 2009a）。不幸的是，许多客户生活在几乎完全由威胁体验定义的世界中。因此，CFT的一个主要治疗目标是帮助客户体验安全感及其带来的心理变化。
这是一个具有挑战性的治疗任务。人类在社交环境中进化出感到安全的能力——与他人建立联系（Gilbert, 2009a）。早期的社会关系和与他人的养育联系体验帮助塑造了认知模板（Bowlby, 1982; Wallin, 2007）和潜在的神经生物学结构（Siegel, 2012; Cozolino, 2010），这些结构可以帮助我们感到安全并成功调节情感（或不）。经历过虐待、忽视或其他形式的不安全依恋环境（如DBT中的无效环境；Linehan, 1993）的个体可能已经隐性地学会了将人际关系与威胁或失望而非安慰和安全联系在一起。这种隐性关联对治疗师提出了主要挑战——如何帮助客户学会感到安全，当经验告诉他们本应帮助他们感到安全的事物（亲密关系）不起作用时？
在CFT中，我们希望将安全感融入治疗的内容和过程之中。我们将在后续章节中详细探讨这一理念。我们将同情——一种温暖、敏感和有助于应对痛苦的方法——置于CFT的核心，原因之一是我们希望帮助客户形成与自己和他人互动的习惯，这些习惯有助于培养安全感的体验，并帮助他们发展支持未来安全感心理体验的潜在神经生物学系统。
在内容层面，客户将学习多种策略，以同情的态度应对挑战并带来感到安全的体验。在过程层面，CFT中的治疗关系和治疗环境旨在通过治疗师以同情的合作、温暖、无责备和鼓励的方式与客户互动，帮助客户产生安全感和情感平衡。我们将在第三章探讨CFT治疗师的角色时进一步探讨这一点是如何工作的。
学会感到安全的重要性
在这一章中，我们探讨了许多CFT实践的核心主题。让我们通过一个案例来考虑这些主题如何在治疗过程中交织在一起：
治疗师：珍妮，我们花了一些时间讨论你害怕在别人面前做出尴尬的事情，以及这些恐惧如何影响你的社交生活。听起来你对此感到非常羞愧。我说得对吗？ 珍妮：是的。我真是个白痴。我太害怕自己会做出愚蠢的事情，以至于什么都不敢做。朋友们邀请我出去，但我总是最后一刻取消。我真是个糟糕的朋友。真不知道我怎么还有朋友。
治疗师：所以你是先计划出去，然后最后一刻取消？ 珍妮：是的。我计划出去时觉得会很有趣。但后来我开始想，如果我出去了，我会穿错衣服，或者说出一些愚蠢的话让所有人都不高兴。我太害怕了，无法忍受出去的想法，所以我就取消了，待在家里。我只是太害怕了，太软弱了。其他人都不怕这些事，他们出去玩得很开心。
治疗师：珍妮，让我问一个问题。当你担心会做出尴尬或冒犯别人的事情时，你是选择感到害怕吗？你是决定要那样感觉的吗？ 珍妮：我不太明白你的意思。 治疗师：好的，假设你有这样的想法：我会做出尴尬的事情，大家都会认为我是白痴。在这样的想法之后，你是想着：我觉得最好对这件事感到非常害怕，还是这种恐惧只是自然而然地出现了？ 珍妮：我对这种事情确实会感到非常害怕，但这并不是说我希望感到这样。谁会选择这种感觉呢？
治疗师：没错。听起来这个想法：我会做出尴尬的事情，对你来说是一个非常强大的威胁信号——当你有这种想法时，你的大脑会反应：哦，有威胁来了！然后就是恐惧。这说得通吗？ 珍妮：我想是的。 治疗师：那么，如果你并没有决定要感到你感到羞愧的这些恐惧，这些恐惧是你的错吗？ 珍妮：我想不是。但我在那里坐着，想着所有让我害怕的事情。这确实是我的错。 治疗师：（温暖地微笑）是吗？所以你坐在那里决定：我可以出去和朋友们愉快地度过一个晚上，但我更愿意坐在这里深入思考如果我那样做会不可避免地受到羞辱…… 珍妮：（微微笑了）我想我明白你的意思了。我想我也并没有选择那些事情，但我仍然会那样做。
治疗师：正如我们讨论的，进化使我们的大脑对感知到的威胁非常敏感，当这种情况发生时，它们会产生非常强烈的情感——试图保护我们。这使我们的祖先得以生存——他们非常擅长识别和应对威胁。我的意思是，如果朋友们邀请你去做一些非常危险的事情，比如在满是鳄鱼的池塘里游泳或注射海洛因，你会感到害怕是不是合理的？ 珍妮：当然合理！ 治疗师：听起来你似乎学到了在公共场合感到尴尬是非常危险的，所以即使被邀请出去也会触发你可能会做出尴尬事情的想法，这让你感到非常害怕。 珍妮：当我小的时候——比如六年级——我家搬了。在新学校有一群女孩讨厌我。我至今也不知道为什么。她们不断取笑我，散播谣言，叫我难听的名字，一遍遍告诉我没人喜欢我。这种情况持续了好几个星期。我每天哭好几个小时，上学前就开始呕吐，只是一想到在学校要面对什么。 （停顿，抽泣）我搞不懂自己到底做错了什么。我不知道自己哪里有问题，为什么她们这么恨我。
治疗师：（停顿，然后温和地说）这听起来真的很糟糕，珍妮。我很抱歉你经历了这些。 珍妮：（泪流满面）那真的太糟糕了。那是我生命中最糟糕的经历。 治疗师：所以你觉得学到了社交场合可能非常危险，这说得通吗？现在你可能会想象这种被拒绝的情况会再次发生——想象这一点会让你感到非常害怕，这说得通吗？ 珍妮：（抬头，表情稍微放松了一些）是的，这说得通。 治疗师：这是你的错吗？ 珍妮：不是。不，这不是我的错。
案例分析
在上面的案例中，我们可以看到我们讨论过的几个主题在实际中体现。珍妮同时受到了内部羞耻感（我有问题）和外部羞耻感（别人不喜欢我或将来也不会喜欢我）的困扰，这些都与她多年前经历的社会排斥有关。这种羞耻感和相关的恐惧导致她避免参加可能对她非常有帮助的社会活动。
在案例中，治疗师迅速采取两种方式探索和去病理化珍妮的情感及其引发的思绪。首先，治疗师帮助她认识到这些情感在她心中是如何产生的（她并不是选择感到害怕）。通过引用进化模型，帮助珍妮理解她的情感不是个人缺陷的表现，而是她进化的大脑对感知到的威胁的合理反应。其次，治疗师引导她探索其恐惧在她经历社会排斥的历史背景下是合理的——即她害怕社交失误和他人可能迅速对她产生负面看法是有道理的——通过这种方式，开始引入社会塑造可以非常强大地影响我们的思想和情感的概念。
虽然“同情”这个词从未被提及，但我们可以在整个过程中看到它的证据——无论是隐性的过程还是显性的内容。这种同情体现在对珍妮经历的深刻认同（她的经历有多糟糕），愿意勇敢地仔细审视她所经历的恐惧，将判断和标签的视角转变为寻求理解的视角，以及在理解背景的情况下探索珍妮的情感反应为何合理。最后，我们看到这一展开的过程似乎帮助珍妮产生了安全感和勇气，她自发地回忆并探讨了一个她本来可能回避的创伤性社交羞耻经历。
本章知识点阐述
进一步阐述的知识点
1. CFT的多学科背景
- 综合视角：CFT是一种多学科综合治疗方法，它结合了认知行为疗法（CBT）、荣格分析、进化心理学、情感神经科学、依恋理论和行为主义等多个领域的理论和实践技巧。这种综合视角使得CFT能够从多个角度理解和干预个体的心理问题，提供更加全面和个性化的治疗方案。
- 理论基础：CFT的理论基础广泛，不仅限于心理学领域，还包括生物学和社会学等。例如，进化心理学解释了为什么某些情绪和行为模式在人类中普遍存在，而依恋理论则探讨了早期人际关系如何影响个体的情感和行为。
2. 认知与情感的分离
- 认知重组的局限性：传统的认知行为疗法强调通过认知重组来改变个体的消极思维模式。然而，CFT指出，即使个体能够在认知层面上认识到自己的思维错误，并尝试用更积极的思维替代，但如果缺乏情感上的认同和支持，这种认知改变很难带来真正的情感改善。
- 情感共鸣的重要性：CFT强调在治疗过程中不仅要改变个体的思维方式，还要帮助他们建立情感上的共鸣和支持。通过培养个体的自我同情能力和正面情感，可以更有效地减轻负面情绪，提高治疗效果。
3. 羞耻感与自我批评的影响
- 心理健康问题：长期的羞耻感和自我批评不仅会导致抑郁症、焦虑症等心理障碍，还会严重影响个体的社会功能和个人幸福感。这些负面情绪会形成恶性循环，进一步加剧心理问题。
- CFT的干预策略：CFT通过培养个体的自我同情能力，帮助他们建立更加健康的心理状态。具体策略包括正念练习、同情冥想、情感调节技巧等，这些方法旨在帮助个体更好地理解和接纳自己的情感，从而减少自我批评和羞耻感。
4. CFT的应用范围
- 广泛适用性：CFT不仅适用于处理羞耻感和自我批评的问题，还被证明对多种心理障碍有效，包括抑郁症、焦虑症、社交恐惧症、饮食障碍等。这是因为CFT的核心理念和方法具有普遍性和灵活性，可以针对不同类型的个体和问题进行调整和应用。
- 个性化治疗：CFT强调根据个体的具体情况和需求制定个性化的治疗计划。治疗师会结合不同的技术和方法，帮助个体找到最有效的应对策略。
5. 心理过程与治疗机制
- 体验回避：CFT认为，体验回避（即不愿意接触自己的负面情绪和经历）是导致心理问题持续和恶化的重要原因之一。通过减少体验回避，个体可以更好地面对和处理自己的负面情绪，从而促进心理健康。
- 情感接受：CFT强调情感接受的重要性，鼓励个体接受而不是逃避自己的情感。通过正念练习和情感调节技巧，个体可以学会如何与自己的情感共处，减少负面情绪的影响。
- 长期改善：CFT不仅关注症状的短期缓解，更重视通过改变个体的内在心理过程来实现长期的心理健康改善。例如，通过培养个体的自我同情能力和情感调节能力，可以帮助他们更好地应对生活中的挑战，提高生活质量。
总结
CFT作为一种综合性的心理治疗方法，通过多学科的理论基础和灵活的干预策略，为个体提供了全面的心理支持。无论是处理羞耻感和自我批评，还是应对其他心理障碍，CFT都强调在认知和情感两个层面上进行干预，帮助个体建立更加健康和积极的心理状态。
进一步阐述的知识点
1. 自我污名化的影响
- 治疗依从性：自我污名化不仅影响个体的治疗依从性，还可能导致更高的住院治疗使用率和更长的康复时间。这说明了负面自我评价对治疗过程的负面影响。
- 心理机制：自我污名化作为一种强烈的负面情感，会触发个体的防御机制，使其难以接受和实施积极的改变。
2. 羞耻感的多重影响
- 情感痛苦：羞耻感带来的剧烈情感痛苦不仅影响个体的情绪状态，还可能导致回避行为，进一步加剧心理问题。
- 社会隔离：羞耻感可能导致个体感到孤立，认为自己与众不同，从而加剧心理负担。
3. CFT的干预策略
- 转变态度：CFT通过帮助个体从自我批评和羞耻的视角转变为富有同情心的理解和积极的行动，从而促进心理健康的改善。
- 情感调节：CFT强调情感调节的重要性，帮助个体学会接受和处理负面情感，而不是回避。
4. 避免二次伤害
- 同情心：CFT强调在治疗过程中避免对客户的羞耻感和自我批评进行二次羞耻化和污名化，帮助他们建立更健康的自我认知。
- 文化背景：理解个体所处的文化背景，认识到社会理想化形象对个体自我评价的影响，有助于更全面地理解客户的问题。
5. 有益的自我评估
- 温暖的方式：CFT认为，有益的自我评估应在温暖和非威胁的环境中进行，帮助个体认识到问题并采取积极的行动。
- 具体步骤：通过具体的步骤和方法，如富有同情心的自我纠正，帮助个体逐步改善行为和情感状态。
总结
CFT通过多学科的理论基础和灵活的干预策略，帮助个体从自我批评和羞耻的视角转变为富有同情心的理解和积极的行动。这种方法不仅有助于改善个体的心理健康，还能帮助他们建立更健康和积极的自我认知。通过减少负面情感的负面影响，CFT为个体提供了更有效的心理支持。
进一步阐述的知识点
1. 同情在CFT中的重要性
- 定义与成分：同情被定义为对痛苦的敏感性加上帮助减轻和预防痛苦的动机。这两个成分——敏感性和动机——是同情的核心。
- 面对痛苦的态度：同情提供了一种面向痛苦的方法，强调敏感性和主动帮助，与回避行为截然不同。这种态度可以帮助个体从威胁导向的视角转变为开放、反思和灵活的心态。
2. 培养同情的方法
- 正念与情感调节：CFT强调通过正念练习和情感调节来帮助个体容忍痛苦。这些技能有助于个体在面对困难时保持冷静和专注。
- 同理心与视角转换：CFT帮助客户培养同理心、心理化和视角转换的能力，使他们能够更有效地理解和应对自己的困难。
3. 同情心自我的构建
- 想象练习：通过想象性的视角转换练习，帮助客户想象自己处于最佳状态，培养同情心自我。
- 逐步发展：随着治疗的进展，同情心自我成为客户反复进入的一种视角，帮助他们从同情的角度理解和处理困难。最终，这些能力成为客户日常生活的一部分。
4. 从评判到理解的转变
- 理解背景：CFT强调帮助客户理解导致其挑战性情绪、动机和行为的背景因素，而不是简单地说服他们要有同情心。
- 适应性生活方式：治疗的目标不仅是缓解症状，更是有目的性地发展适应性的生活方式，这些方式反映了客户最积极的愿望和价值观。
总结
CFT通过培养正念和同情，帮助个体从自我批评和羞耻的视角转变为富有同情心的理解和积极的行动。这种方法不仅有助于改善个体的心理健康，还能帮助他们建立更健康和积极的自我认知。通过减少负面情感的负面影响，CFT为个体提供了更有效的心理支持。
进一步阐述的知识点
1. 进化视角下的情感和认知
- 情感分类：CFT将情感分为三类：识别和应对威胁的情感、追求目标并获得奖励的情感，以及与他人连接时的安全感、满足感和平静感。这些情感的进化功能有助于我们理解其背后的原因。
- 适应性与现代环境：虽然这些情感在进化过程中具有生存价值，但它们在现代环境中可能不再适应，甚至可能带来问题。例如，对高热量食物的渴望在资源匮乏的环境中有助于生存，但在现代环境中可能导致健康问题。
2. 心智运作的挑战
- 旧脑与新脑的互动：旧脑的情感和新脑的符号思维能力之间的复杂互动可能导致认知和情感上的冲突，使个体难以管理。
- 自动学习：我们自动学习不同事物之间联系的能力有时会使我们陷入不利的思维和行为模式，这些模式难以改变。
3. 社会对自我的塑造
- 早期依恋经历：早期的依恋经历强烈影响了个体的安全感、期望他人支持的能力，以及自我价值感。这些经历可以塑造个体的情感和行为模式。
- 学习理论：通过经典条件反射、操作条件反射、社会学习和关系框架理论，我们的环境可以教会我们恐惧和避免某些人际连接，这些连接原本应该是帮助我们感到安全的。
4. 去病理化与自我同情
- 非自愿的情感和行为：许多情感和行为模式是我们无法选择或设计的，这些不是我们的错。认识到这一点有助于减少自我攻击和责备，创造一个支持改变的背景。
- 引导发现：CFT通过苏格拉底式对话和体验性练习，帮助客户理解自己的经历和如何应对这些经历，而不是通过冗长的解释或强迫性的重复。
总结
CFT通过进化和学习理论的视角，帮助个体理解其情感和认知功能的背景，以及这些功能在现代社会中的适应性问题。通过去病理化和培养自我同情，CFT帮助个体认识到许多情感和行为模式不是他们的错，从而减少自我攻击和责备。最终，CFT通过引导发现的过程，帮助客户理解和应对自己的经历，实现心理健康的改善。
进一步阐述的知识点
1. 情感调节系统的科学基础
- 进化情感调节系统：人类与祖先共享的进化情感调节系统在大脑和心智中发挥着重要作用。这些系统帮助我们理解情感和动机的基本机制。
- 情感调节的影响：威胁情感（如焦虑、愤怒或恐惧）会导致注意力狭窄、认知灵活性下降和沉思等策略的使用，这些策略反而加剧了受威胁的感觉。相反，安全感会导致注意力和思考范围扩大，个体变得更平静、平和、反思和亲社会。
2. CFT中的情感平衡
- 情感平衡的目标：CFT的一个主要目标是帮助客户在关注威胁的情感、追求目标的情感以及与安全感和平静感相关的情感之间找到平衡。
- 治疗中的安全感：CFT通过治疗内容和过程两方面帮助客户培养安全感。治疗内容包括学习同情策略，治疗过程则通过治疗师的同情合作、温暖、无责备和鼓励的方式与客户互动，创造安全感和情感平衡。
3. 社会关系与安全感
- 早期社会关系的影响：早期的社会关系和与他人的养育联系体验对认知模板和神经生物学结构的形成有重要影响，这些结构帮助我们感到安全并成功调节情感。
- 不安全依恋的挑战：经历过虐待、忽视或其他形式的不安全依恋环境的个体可能将人际关系与威胁或失望联系在一起，这给治疗带来了挑战。
4. CFT的治疗策略
- 同情为核心：CFT将同情置于核心位置，帮助客户形成与自己和他人互动的习惯，这些习惯有助于培养安全感的体验，并支持未来的安全感心理体验。
- 治疗过程的设计：CFT的治疗过程设计旨在通过治疗师的同情合作、温暖、无责备和鼓励的方式与客户互动，创造安全感和情感平衡。
总结
CFT通过情感神经科学的研究，帮助客户理解情感调节系统的基本机制，并在治疗过程中培养安全感和情感平衡。CFT强调同情的核心作用，通过治疗内容和过程两方面的策略，帮助客户学会感到安全，克服不安全依恋带来的挑战。通过这些方法，CFT不仅帮助客户应对困难情感，还促进了心理健康的整体改善。
进一步阐述的知识点
1. 情感调节系统的科学基础
- 进化情感调节系统：人类的大脑经过进化，对感知到的威胁非常敏感。当感知到威胁时，大脑会迅速产生强烈的情感反应，以保护个体。
- 威胁反应的机制：威胁情感（如恐惧）会引发注意力的狭窄、认知灵活性的下降和沉思等策略，这些策略反而加剧了受威胁的感觉。
2. CFT中的情感平衡
- 情感平衡的目标：CFT的一个主要目标是帮助客户在关注威胁的情感、追求目标的情感以及与安全感和平静感相关的情感之间找到平衡。
- 治疗中的安全感：CFT通过治疗内容和过程两方面帮助客户培养安全感。治疗内容包括学习同情策略，治疗过程则通过治疗师的同情合作、温暖、无责备和鼓励的方式与客户互动，创造安全感和情感平衡。
3. 社会关系与安全感
- 早期社会关系的影响：早期的社会关系和与他人的养育联系体验对认知模板和神经生物学结构的形成有重要影响，这些结构帮助我们感到安全并成功调节情感。
- 不安全依恋的挑战：经历过虐待、忽视或其他形式的不安全依恋环境的个体可能将人际关系与威胁或失望联系在一起，这给治疗带来了挑战。
4. CFT的治疗策略
- 同情为核心：CFT将同情置于核心位置，帮助客户形成与自己和他人互动的习惯，这些习惯有助于培养安全感的体验，并支持未来的安全感心理体验。
- 治疗过程的设计：CFT的治疗过程设计旨在通过治疗师的同情合作、温暖、无责备和鼓励的方式与客户互动，创造安全感和情感平衡。
总结
CFT通过情感神经科学的研究，帮助客户理解情感调节系统的基本机制，并在治疗过程中培养安全感和情感平衡。CFT强调同情的核心作用，通过治疗内容和过程两方面的策略，帮助客户学会感到安全，克服不安全依恋带来的挑战。通过这些方法，CFT不仅帮助客户应对困难情感，还促进了心理健康的整体改善。在这个案例中，治疗师通过引导珍妮理解她的恐惧并非她的错，帮助她减少自我攻击和责备，从而为改变创造了条件。
进一步阐述的知识点
1. 内部和外部羞耻感
- 内部羞耻感：珍妮感到自己有问题，这种内在的羞耻感使她对自己产生负面评价。
- 外部羞耻感：珍妮担心别人不喜欢她或将来也不会喜欢她，这种外在的羞耻感加剧了她的社交恐惧。
2. 情感和恐惧的去病理化
- 情感的起源：治疗师帮助珍妮认识到她的情感是如何自然产生的，而不是她主动选择的。
- 进化模型的应用：通过引用进化模型，帮助珍妮理解她的情感是她进化的大脑对感知到的威胁的合理反应，而不是个人缺陷的表现。
3. 历史背景的影响
- 社会排斥的经历：珍妮过去的社交排斥经历使她对社交失误和他人的负面看法产生了强烈的恐惧。
- 合理的情感反应：治疗师引导珍妮理解她的恐惧在她的历史背景下是合理的，这有助于她减少自我攻击和责备。
4. 同情的核心作用
- 隐性的同情：治疗师通过温柔和理解的态度，帮助珍妮感到被接纳和支持。
- 显性的同情：治疗师引导珍妮从判断和标签的视角转向理解的视角，帮助她探索情感反应的合理性。
总结
在这一章中，我们探讨了CFT的起源及其指导治疗的一些核心主题。这些主题包括：去羞耻化和去病理化客户的经验，示范同情和面对及处理痛苦的勇气，促使从判断转向理解的视角转变，以及促进安全感的体验。这些主题深深嵌入了CFT的内容和过程中。在第二章中，我们将更深入地探讨同情的概念，以及它在治疗过程中的具体应用。
CHAPTER 1 Origins and Basic Themes In this chapter we’ll briefly explore the origins of CFT, and how it developed out of the desire to better help individuals who suffer from shame and self-criticism. We’ll also explore some of the basic ideas behind the CFT approach, with an emphasis on considering how the theoretical roots of CFT—found in evolutionary psychology, affective neuroscience, attachment theory, behavior- ism, and the power of cultivating compassion—are translated into what we do in the therapy room.
THE ORIGINS OF CFT The beginnings of CFT go back to the 1980s, in the form of observations by British psychologist Paul Gilbert. Paul approached psychotherapy from a diverse training background that included cognitive behavioral therapy, Jungian analysis, evolutionary psychology, neurophysiology, and attachment (Gilbert, 2009a). In his therapy work, Paul noticed that many of his clients seemed to have deep-seated self-criticism, shame, and self-loathing. He also noted that for these patients in particular, traditional cognitive therapy exercises like cognitive restructuring often didn’t work ter- ribly well. For example, these clients were able to identify their maladaptive thoughts, identify them as irrational, and perhaps even categorize them in terms of thinking errors they featured. They were able to look at the reality of their lives, and generate more rational, evidence-based alternative thoughts. But there was a problem: despite all of this work, they didn’t feel any better (Gilbert,2010). In these clients, Paul observed a lack of congruence between what they thought and what they felt—a cognition–emotion mismatch—that hampered their therapy. He found that reassuring thoughts were helpful only when they led clients to feel reassured. And in highly self-critical clients, they often didn’t. As a result of these observations, Paul set about finding ways to warm up the cognitive behav- ioral work he was doing with his clients, and began to notice dynamics that, although not often spoken to in his CBT training, very powerfully impacted his clients’ experience. For example, looking more closely at their experiences, he noticed that while many clients could generate new, evidence-based thoughts that seemed like they should be helpful, the mental “tone of voice” in which these thoughts were expressed was often harsh and critical. As a result of observations like these, Paul gradually developed what would become compassion- focused therapy. In doing so, he sought to help therapists make use of existing technologies of change while helping clients relate to their experiences in warmer, more compassionate ways. This developing approach focused on helping clients understand and work with their emotions to help themselves feel safe, and emphasized the cultivation of compassionate strengths that would help them approach and work effectively with their difficulties.
CFT: CORE IDEAS There are a few basic ideas that form the core of CFT. Let’s introduce some of these ideas now.
Shame and Self-Criticism Can Be Crippling As I’ve mentioned, CFT was originally developed to assist individuals who struggle with shame and self-criticism (Gilbert, 2010). Shame can be defined as an acutely painful affective state related to negative evaluations of the self as bad, undesirable, defective, and worthless (Tangney, Wagner, & Gramzow, 1992; Gilbert, 1998). We can distinguish between internalized shame—in which we harbor negative personal judgments of ourselves—and external shame, in which we perceive that others see us as inferior, defective, and unattractive (Gilbert, 2002). A growing body of literature has shown that shame and self-criticism isn’t very good for us. Research shows that shameful memories can function in similar ways to traumatic memories, becoming central to individuals’ identities in a manner that is linked with depression, anxiety, stress, and post-traumatic stress reactions (Pinto-Gouveia & Matos, 2011). Shame and self-criticism have been linked with a wide variety of mental health problems (Kim, Thibodeau, & Jorgenson, 2011; Kannan & Levitt, 2013), including depression (Andrews & Hunter, 1997; Andrews, Quian, & Valentine, 2002), anxiety (Gilbert & Irons, 2005), social anxiety (Gilbert, 2000), eating disorders (Goss & Allan, 2009), post-traumatic stress disorder (PTSD; Andrews, Brewin, Rose, & Kirk, 2000), borderline personality disorder (Rüsch et al., 2007), and overall psychological maladjustment (Tangney, Wagner, & Gramzow, 1992). In terms of psychological processes, shame has been linked to experiential avoidance—the unwillingness to be in contact with one’s private experiences such as emotions—which has itself been associated with various emotional difficulties (Carvalho, Dinis, Pinto-Gouveia, & Estanqueiro, 2013).
These negative self-judgments also appear to impact the course of treatment. Self-stigma, a shame-related experience in which individuals apply negative judgments to themselves related to internalized negative group stereotypes (Luoma, Kulesza, Hayes, Kohlenberg, & Latimer, 2014), has been associated with higher levels of inpatient treatment utilization in individuals experiencing severe mental illness (Rüsch, et al., 2009), lower levels of treatment adherence in patients diag- nosed with schizophrenia (Fung, Tsang, & Corrigan, 2008), poorer medication adherence (Sirey et al., 2001), and longer length of stay in residential treatment for addiction (Luoma, Kulesza, Hayes, Kohlenberg, & Latimer, 2014). These findings are particularly relevant, as the self-stigma experi- enced by the individuals in these studies was anchored to identification with group stereotypes about mental illness or addiction. This demonstrates the power of shame to magnify and exacer- bate problems of mental health in clients who may criticize, shame, and stigmatize themselves upon observing their own psychological struggles. A fundamental goal of CFT is helping clients shift the perspective they take toward their challenging thoughts and emotions from condemnation and judgment to compassionate understanding and commitment to helpful action. In this way, self- attacking and avoidance can give way to warmth and responsibility-taking.
Let’s consider an example of how shame can get in the way of working with challenging emo- tions. We can imagine a father who observes himself yelling at his children (perhaps prompted by his children’s fear-filled faces) and experiences shame: acute emotional pain prompted by the thought, I’m a terrible father. That’s a painful thought, and one that can set him up for more difficulty. First, from a CFT perspective, harsh self-criticism or shameful attributions are themselves power- ful threat triggers. They keep us stuck in feeling threatened, which organizes the mind (we’ll talk about this in future chapters) in ways that aren’t conducive to making positive changes like improv- ing one’s parenting. Rather than focusing his efforts on learning more effective ways to cope so that he doesn’t yell at his children anymore, this father is focused on his own inadequacy. The emotional pain that accompanies shame can also foster avoidance—that is, the feelings that come up following shameful thoughts like I’m a terrible father can be so painful that the father might quickly move to avoid by distracting himself, rationalizing his behavior, blaming his children for his reaction, or doing just about anything else to escape the experience. CFT places a strong emphasis on helping clients overcome such avoidance by shifting from a shaming perspective to a compassionate perspective that helps them approach and work with their challenges.
It’s also important that we don’t shame or stigmatize the experience of shame and self-criticism—we don’t want our clients to feel ashamed of feeling ashamed. It makes a lot of sense that they may have learned to cope in this way. Most of us don’t set out to create problems for ourselves through self- attacking. However, we live in a culture filled with messages presenting us with idealized images of how people are supposed to look, feel, and perform—images we can easily internalize, and to which we have no hope of measuring up. These damning comparisons can be magnified by our ability to perceive our own internal experiences versus those of others. We have almost unlimited access to our own struggles—difficult emotions, struggles with tasks or motivation, or thoughts and behaviors that don’t match our values. At the same time, we have very limited access to the internal experiences of other people—we mostly see what they choose to show us, and like us, they want to appear competent, intelligent, and attractive. We all tend to put on the “game faces.” Seeing this turmoil and struggle inside of themselves, and seemingly surrounded by people who look like they have it all together, it’s easy for clients to feel shamed and isolated, and to conclude, there’s something wrong with me. And this is before we even consider the many specific factors that can contribute to experiences of shame in our clients, including histories of trauma or bullying, harsh rearing envi- ronments, learning history, and potentially belonging to stigmatized groups. Given all of this, it makes a ton of sense that our clients may have learned to shame and attack themselves.
CFT’s perspective on shame and self-criticism doesn’t mean there isn’t room for helpful self- evaluation. There certainly is—sometimes our clients are doing things that are problematic, and they need to do things differently! It’s just that such self-evaluation works a good deal better when it’s presented in a warm manner that doesn’t overwhelm the threat response. For example, compas- sionate self-correction involves noticing when one is doing something harmful or unhelpful, allow- ing oneself to feel guilty about it, and turning the focus toward doing better in the future. Instead of I’m a terrible father, compassionate correction would look more like this: It makes sense that I would yell because of my own experience, but that’s not the sort of father I want to be. It’s time I committed to interacting with my kids in ways that model the things I’d like them to learn. What might help me do that?
Compassion: The Strength to Move Toward the Pain While shame can lead people to shut down and turn away from their struggles and suffering, we need ways to help clients move toward their pain, and work with it in helpful ways. In CFT, this is accomplished through the cultivation of mindfulness and particularly compassion. One question that may come up is Why compassion? There are lots of helpful virtues out there. Why are we choos- ing to make compassion the central focus of our therapy?
In CFT, we’ve spent a good deal of time working to define, operationalize, and apply compas- sion in working with our clients. A generally accepted definition of compassion reads something like this: sensitivity to suffering combined with the motivation to help alleviate (and prevent) it (Gilbert, 2010). This definition includes two separate but important components: sensitivity and motivation. CFT emphasizes compassion so greatly because we think that this is a particularly work- able orientation to have in the face of pain, difficulty, and suffering.
There’s a lot contained within this simple definition. First, it provides us with an approach orien- tation toward suffering—both in terms of being sensitive to its arising and in the emphasis on moving toward the suffering to help. This is very different from the avoidance that can drive so many of our clients’ difficulties. Compassion also contains warmth—suffering is approached with the motiva- tion to help. This warm motivation and affective tone can help us (and those we help) to feel safe in confronting difficulties, helping us shift from a threat-focused perspective to a mental state that is open, reflective, and flexible.
If we look even more deeply within the definition of compassion, we find that it contains other helpful capacities as well. If we’re to maintain this warm, approach orientation toward suffering we have to be able to tolerate it, so CFT, like dialectical behavior therapy (DBT; Linehan, 1993), places an emphasis on distress tolerance and emotion regulation. If compassionate action is to truly be helpful, it must be skillful, and so CFT works to help clients cultivate capacities like empathy, men- talization, and perspective taking.
Finally, many clients, particularly those coming into therapy with lots of shame and self- criticism, may have a very negative experience of themselves. In CFT, we try to provide clients with a unifying framework for the various aspects of compassion we’re helping them cultivate— which we call the compassionate self. The compassionate self is an adaptive version of the self that mani- fests the various aspects of compassion we work to cultivate in the therapy. In the beginning, this takes the form of imaginal perspective-taking exercises that are similar to method acting: the client imagines being at her very best—her most kind, compassionate, wise, and confident—considering what it would be like if she fully possessed these strengths. She then imagines how this compassion- ate version of herself would feel, pay attention, reason, be motivated, and behave.
As the therapy progresses, the compassionate self becomes a perspective that the client learns to shift into again and again, considering how she would understand and work with her difficulties from this compassionate perspective. All the while, she is working to cultivate compassionate strengths and establish them as habits, with the goal that over time, the space between the client’s idea of me and the compassionate self gradually diminishes, as these capacities become more a natural part of her everyday life. In this way, CFT shares ground with ACT and the positive psychology movement. The focus of the therapy isn’t simply on the alleviation of symptoms, but on the pur- poseful development of strengths—adaptive ways of living that are workable and which reflect the client’s most positive aspirations and values.
Building Blocks of Compassion: Shifting from Judgment to Understanding As we’ve discussed, highly self-critical and shame-prone clients attack themselves upon observ- ing many aspects of their experience—their feelings and thoughts, their reactions, and their rela- tionship difficulties. While compassion for oneself and others is a primary goal of CFT, we initially spend less time talking with clients about compassion, and more time setting the stage for it to arise. We do this by helping them understand the factors that lead to their challenging emotions, motives, and behaviors. Rather than try to convince our clients why they should have compassion for themselves and others, the idea is that when they really understand the challenges presented by having a human life, compassion will make sense to them, and will be likely to arise without the need for convincing. Of course, we will also talk about what compassion is, what it isn’t, and why it is helpful—but we want to set the stage for this by creating a context of understanding.
In CFT, we think it’s important to recognize that many of our struggles can be rooted in things we didn’t get to choose or design. This is part of a larger shift we want to help our clients make—one in which they move from a threat-based perspective of blaming and shaming to a compassionate stance of understanding and figuring out what would be helpful. If we look closely at the human story, we find many unchosen factors that shape our experience and the sort of people we will become.
THE CHALLENGES OF OUR EVOLVED BRAINS In CFT, human emotions and other cognitive functions are understood within the context of evolution. We group emotions into three types, according to evolutionary function: emotions and motives that center on identifying and responding to threats, those that are focused on pursuing and being rewarded for attaining goals, and emotional experiences of safeness, contentedness, and peace that are commonly linked with feeling connected with others. Emotions, motives, and behav- iors that are initially perplexing can make a lot more sense when we consider them in terms of their evolutionary function and the survival value they granted our ancestors. One quick example is the tendency to crave and be comforted by sweet, salty, fatty foods. Lots of people struggle with emo- tional eating, and how many of us have wished that we could crave broccoli the way we crave pizza or sweets? But in the environment our ancestors faced—one in which calories and nutrients were relatively scarce—sugar, salt, and fats granted survival value, making it more likely that those who readily consumed them when available would live to pass their genes along to future generations. From this evolutionary perspective, these cravings (and so many of the emotions we may find our- selves struggling with) make complete sense, even as they’re now a terrible fit with our current environment—one in which cheap, salty, sweet, fatty foods are to be found all around us.
The ways our brains and minds have evolved can create difficulties for us. From the tricky interplay of old-brain emotions and new-brain capacities for symbolic thought to the ease with which we automatically learn connections between different things, there is much about how our minds work that we didn’t choose or design, but which can be quite difficult to manage. This awareness can help create a context for self-compassion by depathologizing emotions and experi- ences which in isolation may feel like something that is wrong with me, but which in reality are part and parcel of what it means to be human in this day and age.
These environments, many of which we don’t get to choose or design, interact powerfully with the way our brains learn, sometimes to devastating effect. Through processes like respondent/ classical conditioning, operant conditioning, and social learning, as well as processes articulated through more modern elaborations of learning theory, such as relational frame theory (Hayes, Barnes-Holmes, & Roche, 2001; Törneke, 2010), our environments can teach us to fear the very interpersonal connections that should help us feel safe, and can systematically shape behaviors that will cripple us later in life.
In CFT, we want to help people begin to understand that much of what they feel and even how they’ve learned to respond was not of their choice or design—that these things are not their fault. This “not your fault” piece doesn’t mean that we’re letting anyone off of the hook or absolving people of their responsibility for their own behavior. It’s about being honest with ourselves about which factors we control in our lives, and which ones we don’t. In fact, it’s precisely because of all these factors we can’t control that we need to understand our minds and learn to work with the things we can affect. Our clients may not have chosen to have brains that were shaped by learning experiences to produce crippling fear and anxiety when faced with certain situations, but we can help them cultivate the ability to work effectively with these situations and affects, and to validate and support themselves in doing so.
There’s a powerful scene in the movie Good Will Hunting in which Robin Williams, playing a psy- chologist, holds up his client’s (Will, played by Matt Damon) file, thick with documentation of years of childhood abuse that Will had experienced. The dialogue went something like this: “I don’t know much, Will, but I know this.” He holds up the file. “You know all this shit? It’s not your fault. It’s not your fault.”
In the scene, he warmly repeats this phrase, again and again. Will is initially resistant to this idea, and fights back a bit, just like we and our clients might find ourselves doing. It’s not always easy to admit to ourselves that there’s a lot about our lives (and the way our minds work) that is not under our control. And like Will, if our clients’ lives have been filled with trauma, struggle, and suffering, this realization can be as heartbreaking as it is enlightening. But if we can help our clients honestly recognize the things in their lives that aren’t their fault—the experiences they didn’t choose to have, the powerful emotions that arise unbidden, the spontaneous thoughts that may go against their values, the habits they’ve tried unsuccessfully to change—and help them stop attacking and blaming themselves for these experiences, it can create a context that makes change possible.
In CFT, we want to help our clients make realizations like those described above. However, going into long-winded explanations generally isn’t helpful, and unlike the example from Good Will Hunting, we don’t typically back our clients into a corner and say, “It’s not your fault” over and over again. As we’ll discuss, CFT aims to be a process of guided discovery, making extensive use of Socratic dialogue and experiential exercises such as thought experiments, perspective-taking, and chair work to help clients develop an understanding of their experiences and how to work with them.
The Importance of Learning to Feel Safe As I’ve mentioned, CFT is heavily influenced by research in affective neuroscience. There is a wealth of scientific literature documenting the existence of evolved emotion-regulation systems that humans share with our ancestors, and the ways these basic emotions and motives play out in our brains and minds (Panksepp & Biven, 2012). This isn’t just part of the theory underlying CFT—it’s brought directly into the therapy session. Clients learn about different emotion-regulation systems and how basic motives and emotions can organize our minds and bodies through shaping patterns of attention, reasoning, physical responding, and so on, with a specific focus on learning to work with these systems to help balance emotions and cultivate the states of mind our clients want to have. This learning helps lay the groundwork for self-compassion, as clients’ understanding about the “how and why” of their challenging emotional experiences allows them to make sense of them.
In chapter 5, we’ll explore these basic emotion-regulation systems in detail, but it’s worth noting at the outset that a big part of CFT involves helping clients find a balance between emotions that are focused on threats, those that are focused on the pursuit of goals, and those that are linked with feelings of safeness and peace. These emotions shape our mental experience in varied and powerful ways. For example, threat emotions such as the anxiety, anger, or fear that dominate so many of our clients’ experiences are associated with a narrowing of attention, decreased cognitive flexibility, and tendencies to engage in strategies like rumination that fuel rather than soothe the state of feeling threatened (Gilbert, 2009a). Alternatively, when we feel safe, the mind is organized in entirely different ways—the scope of our attention and thinking opens, and we tend to become calm, peaceful, reflective, and prosocial (and, CFT would argue, better able to work with difficult emotions; Gilbert, 2009a). Unfortunately, many of our clients live in a world that can be almost entirely defined by experiences of threat. So a major therapeutic goal of CFT is helping our clients experience feelings of safeness and the mental shifts that come with them.
This can be a challenging therapeutic task. Humans evolved to feel safe primarily in contexts of affiliation—in connection with others (Gilbert, 2009a). Early social relationships and experi- ences of nurturing connections with others help shape both cognitive templates (Bowlby, 1982; Wallin, 2007) and the underlying neurological architecture (Siegel, 2012; Cozolino, 2010) that can help us to feel safe and successfully regulate our emotions (or not). Individuals who have experi- enced abuse, neglect, or other forms of insecure attachment environments (as exemplified in DBT’s invalidating environments; Linehan, 1993) may have implicitly learned to associate interpersonal rela- tionships with threat or disappointment rather than with soothing and safeness. This implicit asso- ciation can present a primary challenge for therapists—how do we help our clients learn to feel safe when experience has taught them that the things that are supposed to help them feel safe (close relationships) don’t work?
In CFT, we want to infuse safeness into both the content and the process of the therapy. We’ll spend a fair bit of time exploring this idea in later chapters. One of the reasons we’ve placed com- passion—a warm, sensitive, and helpful approach to working with suffering—at the center of CFT is that we want to help clients develop habits of relating to themselves and others in ways that can help foster felt experiences of safeness, as well as assist them to develop the underlying neurological systems that will support mental experiences of safeness in the future.
On the content level, our clients will learn numerous strategies for relating compassionately to their challenges and bringing about experiences of feeling safe. On the process level, the therapeu- tic relationship and therapy environment in CFT is designed to help create feelings of safeness and emotional balance in the client, as the therapist engages with the client in a compassionately col- laborative, warm, nonshaming, and encouraging manner. We’ll explore how this works when we look at the roles occupied by the CFT therapist, in chapter 3.
In this chapter, we’ve explored a number of themes that are core to the practice of CFT. Let’s consider a case example of how these themes might be interwoven in the course of a therapy session: Therapist: Jenny, we’ve spent some time talking about the fears you have that you’ll do something embarrassing in front of others, and how these fears affect your social life. It sounds like you’re feeling pretty ashamed about this. Have I got that right? Jenny: That’s right. I’m just such an idiot. I’m so scared that I’ll do something stupid that I don’t do anything. My friends invite me out, but I always bail at the last minute. I’m such a terrible friend. It’s amazing I have any friends at all. Therapist: So you make plans to go out and then cancel at the last minute? Jenny: Yeah. I make plans thinking it’ll be fun. But then I sit around thinking about how if I go out, I’ll dress the wrong way, or say something stupid that will offend everyone. I get so scared that I can’t bear the thought of going out, and so I cancel and just stay in. I’m just terrified and weak. Other people aren’t afraid of this stuff. They just go out and have fun. Therapist: Jenny, let me ask a question. When this fear of doing something embarrassing or offensive comes up for you, are you choosing to feel afraid? Are you deciding to feel that way? Jenny: I’m not sure I understand what you mean. Therapist: Well, let’s imagine you have the thought, I’ll do something embarrassing and everyone will think I’m an idiot. After that thought, are you thinking, I think I’d better get really afraid of that happening, or does the fear just arise in you? Jenny: I get terrified at things like that, but it’s not like I want to feel that way. Who would choose that? Therapist: Exactly. It sounds like this thought, I’ll do something embarrassing, is a very powerful threat cue for you—when you have thoughts like that, your brain registers: Oh, here comes a threat!—and then comes the fear. Does that make sense? Jenny: I guess so. Therapist: So if you’re not deciding to feel all this fear that you’re feeling so ashamed of, is the fear your fault? Jenny: I guess not. But I’m the one sitting there thinking all that stuff that makes me afraid. That’s my fault. Therapist: (smiling warmly) Is it? So you sit there and decide, Well, I could go out and have a happy evening with my friends, but instead I think I’d rather sit and think deeply about the inevitable humiliation I could face if I did that… Jenny: (laughing a little bit) I think I see what you mean. I guess I don’t choose that stuff, either. But I still do it. Therapist: As we’ve discussed, evolution has shaped our brains to be very sensitive to things we perceive as threatening us, and when that happens, they can produce really powerful emotions—to try and protect us. This is what kept our ancestors alive—they were really good at identifying and responding to threats. I mean, if your friends were asking you to go out and do something really dangerous, like swimming in a pond full of crocodiles or shooting heroin, would it make sense for you to be afraid? Jenny: It sure would! Therapist: It sounds like you’ve somehow learned that being embarrassed in public is really dangerous, so even being asked to go out triggers thoughts that you could do something embarrassing, which is terrifying. Jenny: When I was young—like in sixth grade—my family moved. At my new school, there was a group of girls who hated me. I still don’t know why. They made fun of me constantly. They spread rumors about me, called me names, told me over and over that no one liked me. It went on for weeks. I cried for hours every day, and started throwing up before school, just thinking about what I’d have to face when I got there. (Pauses, sobbing.) I couldn’t figure out what I’d done wrong. I didn’t know what was wrong with me, that they hated me so badly. Therapist: (pausing, then speaking kindly) That sounds terrible, Jenny. I’m so sorry that happened to you. Jenny: (tearfully) It was terrible. It was the worst experience of my life. Therapist: So does it make sense that you would learn that social situations can be very dangerous? Does it make sense that even now, you might imagine this rejection could happen again—and that imagining this could be terrifying? Jenny: (looking up, as facial expression lightens a bit) It does. Therapist: Is that your fault? Jenny: 22 No. No, it’s not my fault. In the example above, we can see several of the themes we’ve discussed playing out. We see that Jenny is crippled by both internal shame (there’s something wrong with me) and external shame (others don’t—or won’t—like me), which she relates to her experiences of social rejection that occurred many years before. This shame, and the fear related to it, results in Jenny avoiding social activities that would probably be very helpful for her.
In the example, the therapist quickly moves to explore and depathologize Jenny’s emotions and the thoughts that prompt them, in two ways. First, the therapist helps her recognize the dynamics around how the emotions arise in her mind (that she isn’t choosing to feel afraid). The evolutionary model is also referenced, helping anchor Jenny’s understanding of her emotions not to personal flaws, but to valid reactions of her evolved brain in response to a perceived threat. Second, the therapist prompts exploration of how Jenny’s fears are valid given her history of social rejection— how it makes sense that she would have learned to be very afraid of making social mistakes and the potential for others to quickly turn on her—and in doing this, begins introducing the concept that our social shaping can very powerfully influence our thoughts and feelings. While the word “compassion” is never mentioned, we see evidence of it throughout—in terms of both implicit process and explicit content. It can be found in the kind recognition of how terrible Jenny’s experience was for her, the willingness to look closely and courageously at the fears she’s experiencing, the focus shift from a perspective that judges and labels these experiences to one that seeks to understand them, and the exploration of how Jenny’s emotional reactions make sense when we understand them in context. Finally, we see that this unfolding process seems to help create feelings of both safeness and courage in Jenny, who spontaneously brings to mind and explores a traumatic socially shaming experience that she might have been inclined to avoid.
SUMMARY In this chapter, we explored the origins of CFT and some of the core themes that guide the therapy. These themes—the importance of deshaming and depathologizing the client’s experience, model- ing compassion and the courage to approach and work with suffering, prompting shifts from judg- ment to understanding, and the facilitation of experiences of safeness—are deeply woven into both the content and process of CFT. In chapter 2, we’ll dive more deeply into the topic of compassion, and how it is brought to life in the therapy session.