第十五章 融合新趋势：CFT在治疗中的应用
第15章
驾驭第三波：将CFT融入您的治疗
这是一个成为心理健康专业人士的激动人心的时代。最近几十年证明了我们在了解人类运作方式方面的学习速度是革命性的。即使我们只探索了冰山一角，神经科学、行为科学和情感研究领域的快速增长也让我们开始对人类功能有了真正综合的理解。CFT（同情焦点疗法）旨在体现这种进化和整合的理解，即作为人类意味着什么，并将这种科学转化为强大的实用方法，帮助人们以温暖和接纳的态度面对他们的挣扎，并有效地与这些挣扎共处。
CFT治疗师是什么样的？
在撰写本书时，我试图强调那些使CFT区别于其他疗法的特点。特别是在一本“简化版”书中，空间限制不允许我深入探讨疗法的基本元素之外的内容。这就是为什么我通常选择不涵盖哪怕是一些完全符合CFT原则的同情干预措施（例如Kristin Neff和Chris Germer所著的《正念自我同情》计划；Neff & Germer, 2013）。当您阅读书中的各种案例片段时，您可能有过这样的疑问：“CFT治疗师会对这个患者使用暴露疗法吗？”“社交技能培训、活动安排和行为激活又如何呢？”“CFT治疗师是否会鼓励来访探索她的价值观？”所有这些问题的答案都是一个响亮的“是！”
CFT治疗师的核心价值之一是我们不忽视好的科学。这意味着从理论和实践的角度来看，CFT都在不断进化。例如，在过去几年中，考虑到Stephen Porges关于多迷走神经理论的出色工作（如Porges, 2011）以及其他研究表明激活副交感神经系统的力量，我们越来越重视呼吸和身体工作。CFT的应用已经发展到了考虑记忆重组的新科学（Monfils等人, 2009; Schiller等人, 2010），在暴露疗法中应用同情自我工作（Kolts等人, 2013）。我的朋友和同事Dennis Tirch、Benji Schoendorff以及Laura Silberstein致力于将CFT的同情焦点与接受与承诺疗法(ACT)的理论视角相结合（Tirch等人, 2014）。而我对关系框架理论(Hayes等人, 2001)对于理解CFT中威胁系统处理细微差别的含义也越来越感兴趣。
当听到“同情”这个词时，人们不一定想到实证主义。但从CFT的角度来看，我们可以做的最富有同情心的事情之一就是更好地理解人类痛苦的来源和动态，并且做得越来越好地研究和完善有助于缓解和预防它的强大方法。同情不仅仅是感觉上有帮助，而是有效帮助。因此，科学是同情的核心，CFT治疗师很可能会利用任何有良好科学依据的工具。所以如果你想做CFT，你不必放弃你已经在做的有效的做法。
然而，可能会改变的是你执行这些做法的方式。因为CFT根植于同情。这种重点应该体现在治疗的所有方面——治疗师与来访的互动方式，以及我们如何帮助来访与自己及他人建立联系。基于我们对潜在情感系统的理解，这意味着CFT总是包含温暖（以适合来访的方式表达）、强调帮助来访以理解和善意而不是羞耻来对待自己的经历、专注于帮助来访学会在自己身上创造安全感，以及培养情感勇气去接近并处理真正让他们害怕的事物。就像ACT一样，CFT不是关于远离让我们感到不适的感觉和体验，而是关于朝着有效、富有同情心的方式存在于我们的思想和世界中前进，甚至朝向困扰我们的事物前进，以便我们能够同情地与它们一起工作。因此，无论我们在CFT中做什么，总有一个强调点在于温暖、理解、安全性和勇气。
CFT与其他模型
在写这本书时，我的意图并不是要把治疗师转换成CFT的支持者，而是为您提供一些可以用来进一步提高您作为治疗师的有效性的同情视角、理解和工具，不论您现有的模式是什么。正如您可能注意到的那样，CFT与某些其他治疗方法有许多共同之处。虽然我已经讨论了一些CFT与ACT、DBT和EFT等方法之间的共同点，但具有不同治疗背景的人也可能注意到与其他模型的相似性——比如依恋疗法、图式疗法甚至是较新的心理动力学方法。我希望来自许多其他传统的从业者会在这里找到一些东西来深化他们现有的治疗实践，尤其是在帮助来访对自己、对他们的问题和其他人保持温暖和同情的关系方面。
在考虑CFT理论上与其他方法的接口时，我认为它属于行为疗法的“第三波”，侧重于改变一个人对不舒服的想法和情绪的关系（而不是试图摆脱它们），培养正念，并优先帮助人们建立适应性强且有意义的生活（而不仅仅是减少症状）。虽然有点牵强，但我认为CFT总体上与ACT和功能性分析心理治疗(FAP)等疗法在情境行为科学(CBS)领域内相匹配。CBS的哲学核心——功能情境主义——涉及理解行为的功能（这可以包括想法，甚至可能是情绪和动机）必须在其发生的情境中被理解。在理解人类功能时，CFT扩展了“情境”的意义，不仅限于严格的行为术语，还包括影响情感、认知和行为的神经学情境，以及塑造情绪、动机及其行为表现形式的进化情境。
这既是CFT方法的优点也是缺点，取决于个人的观点。当然，这是一种权衡。我认为考虑情绪和动机的进化功能，并且基于神经科学对情绪在大脑和身体中的运作方式有所了解，在帮助解除来访面临的挑战的羞耻感方面具有巨大的力量。了解我们的情绪为何以及如何如此表现——并且这不是我们的错（因为我们没有设计这些过程）——对于帮助人们停止对自己的经历自责并学会有效地处理这些经历非常有力。
然而，诚实地讲，CFT实践者必须承认，依赖于此类解释是有代价的，从严格的实证主义角度来看。行为主义者会指出，关于情绪和动机的进化起源及其进化功能的本体论陈述很大程度上难以通过经验观察验证，他们是对的。这是合理的批评。
在我权衡这些问题时，我得出结论认为这种权衡是值得的。我认为，在进化和神经学以及行为学的背景下（尽我们所能理解的范围内）考虑我们情绪和动机的功能和动态，其益处证明了这种妥协是正当的——如果我们始终关注科学的话。达赖喇嘛曾说过一句名言：“如果科学否定了佛教的一些方面，那么佛教就必须改变。”同样的话也可以而且应该适用于CFT，或者说，我认为任何希望建立在实证基础上的方法都应该如此。在某种程度上，一种方法超出了通过扎实、可观察的科学确立的原则，该方法就必须基于新数据进行调整。（当然，希望所有的方法都能基于新数据进行调整。）教条主义对任何人都没有好处——尤其是我们的病人。另一方面，谦逊则提供了不断改进方法的可能性，以更好地消除和预防人类苦难。
将CFT带入您的治疗室
我希望您能在CFT中找到有用的东西，并希望开始将所学应用到您的治疗实践中。一种方法是选择一个临床案例，尝试按照本书中试图阐述的进程——融入关系、理解、正念意识和同情心的有意培养等不同层面。如果这感觉工作量很大，也许可以简单地尝试引入一些您在治疗中通常不做的元素。下面，我提供了一些建议，关于如何开始这样做。
考虑作为治疗师所扮演的角色
我们已经讨论了CFT治疗师承担的各种角色——教师、引导发现过程的促进者、安全依恋基础以及同情自我的榜样。当我们进行治疗时，我们可以考虑自己所扮演的角色，以及如何最好地履行这些角色。我们在治疗关系的背景下扮演什么功能？我们如何利用自己的存在来促进治疗的目标和方向？也许试着多关注一下这些角色，并思考这样做是否有助于澄清治疗中的问题，例如“我现在应该做什么？”通过这种方式，在反思治疗工作时，我们可以借鉴同情自我练习：当我们的来访抛出难题时，我们可以从教师、促进者、安全基地或同情榜样的角度考虑——“我该如何理解这里发生的事情？我该如何回应？”
偶尔引入进化模型
我们不必深入讨论进化论——事实上，通常这样并不太有帮助。但是，帮助人们认识到当他们感到威胁或被驱动与感到安全时，他们的思想和身体发生的不同反应是有益的。将威胁情绪视为进化过程中帮助我们自我保护的机制，可以帮助来访理解为什么他们会陷入这些情绪之中。这些情绪使我们的注意力、思维和心理想象集中在感知到的威胁源上，这不是来访的错。学习到帮助自己感到安全能够逆转这一过程（促进更加灵活的注意力和推理、反思性思考以及亲社会倾向）可以提高来访围绕处理这些情绪的积极性。帮助来访理解该做什么以及为什么或如何做会有所帮助，这对于建立他们尝试新事物的意愿是非常强大的。
使用苏格拉底对话来削弱自我攻击
无论是否深入探讨进化模型，我们都可以使用苏格拉底对话来帮助来访从因为内在体验而羞辱自己转变为意识到生活中有许多方面不是他们选择或设计的——这些东西实际上不是他们的错。
- “你对那种情绪的体验是什么？你是选择了生气/害怕/怨恨吗，还是那些感受只是在你的身心中自然产生的？”
- “你什么时候学会的 ？哪些经历教会了你这一点？”
- “鉴于我们知道的你的/她的/他的背景，你/她/他以这种方式感到/思考/体验事情是否合理？”
- “当你因 而受到自我批评时，你的感觉如何？它激励你做什么？最终你做了什么？”
这类问题可以帮助来访开始放下对自己无法选择或设计的事情的自我攻击倾向，并在生活背景中理解他们的体验和行为。换句话说，这些问题为他们设定了一个舞台，让他们能够富有同情心地负责改善自己的生活。
用三个圆圈作为正念的促进工具
最初难以正念观察并接受自己的想法和情绪的来访有时可以通过三个圆圈的简洁性得到帮助。我曾遇到过许多来访，他们在观察思想或标记特定情绪上有很大的困难，但能够考虑这三个圆圈中哪一个在任何给定时间处于活跃状态。结合对于这些圆圈如何组织我们的思想和身体的理解（例如，威胁情绪倾向于收窄和集中注意力和思维，而安全感情绪则导致反思性、灵活性和亲社会性），对于来访来说，学习注意到“我在哪个圆圈里？”是一个强有力的事情。正如我提到的，我的一位学生，同时也是一个啦啦队教练，提出了一个简洁的方式来记住这一点：“当不确定时，就跳出圆圈！”
在与来访的互动中使用三个圆圈
我们也可以在治疗室内“跳出圆圈”。我发现，在制定治疗计划和应对治疗中出现的挑战时，考虑这三个圆圈是有用的。例如，我大致追求的是3-2-2的安全-驱动力-威胁比例：三部分安全，两部分驱动力，两部分威胁。我的目标是为来访创造一个安全体验，随着他们学会在自身创建这些体验，这种体验会增长。好的治疗也激发了驱动力系统——激励来访为改变生活而努力。最后，如果我们处理的是真实的问题，治疗中会有相当程度的威胁——但关键在于有一个平衡，以一种有意的方式唤起威胁体验，以便能够同情地处理它们。不仅仅是为了安全——我们努力实现一种灵活、流动的平衡，让不同的情感体验和动机可以根据当前情况出现并被唤起。我们希望共同恰当地处理感知到的威胁，激活并维持追求治疗目标的动力，并创造一个安全的环境，其中舒适可以被体验，意义和价值观的问题可以被反思。
当我们在治疗中挣扎或者关系似乎不如我们所愿时，考虑三个圆圈也会有所帮助。有时我们会发现，我们无意中成为了来访的威胁信号。我们可以这样考虑反移情——考虑到可能由于来访的行为或来访的某些特质触发了我们自身的威胁或驱动力系统。我们可能会观察到，我们一直过于兴奋于自己美妙的新治疗计划，以至于把来访落在了后面。当治疗似乎遇到了瓶颈或者治疗关系出现了破裂时，单独或与来访一起根据三个圆圈来考虑情况有时可以揭示挑战并提供方向：
- 我在来访身上触发了哪个圆圈？我希望触发哪个？
- 是哪个圆圈一直在主导着我？
- 在处理这种情况时，什么可以帮助我和来访恢复平衡？
有时候，仅仅命名现状并放慢节奏，进行一次过程级别的讨论，谈谈在会谈中事情是如何发展的，就能带来很大的帮助。三个圆圈可以帮助我们以同情的方式做到这一点：“看起来我们的威胁圆圈一直在相互碰撞。在处理现实生活问题时，这种情况有时会发生。让我们花一分钟来做些舒缓的节奏呼吸，并考虑我们下一步怎么走。”
使用同情自我的视角
关于同情自我练习的一个好处是，一旦建立了这种善良、智慧、勇敢的视角，我们就可以将其作为锚点来促进治疗的其他方面。让我们考虑几个例子：
同情自我作为锚定点
对行为激活在创造情绪变化中的价值的认识正在不断增长。简单地让来访朝着基于价值观的目标前进（这是ACT的主要焦点）可以非常强大，大多数针对焦虑和抑郁问题的有效治疗方案都涉及动员来访的行为，帮助他们处理可能一直在回避的生活领域。对于那些动机方面存在困难的来访来说，这可能会很具有挑战性，也许是因为他们深陷于回避之中、习惯性拖延或非常抑郁。如果治疗师自视为“首席激励者”，可能会无意中在治疗中设置一个强制性的环境，这反而会削弱来访的自主权，甚至促使他们抗拒治疗师的努力。然而，一旦这些来访与同情自我的视角建立了联系，这种视角就可以有助于将激励者的角色从治疗师转移到来访身上。“你的同情自我知道你需要做什么？”“如果那个善良、智慧、勇敢的你在这里，她会给你布置什么家庭作业？”这些问题可以帮助来访从回避和抗拒的视角转变为由直觉智慧驱动的视角——这种方式也帮助他们通过转换到同情自我的视角，并从这个视角采取行动来增强自己的力量。
在暴露疗法中的同情自我
历史上，暴露疗法是我们最有效的治疗方法之一，但也是临床医生最常避免的方法之一。由于接触恐惧的记忆和情境对于来访来说可能是一种相当厌恶的经历，因此对于临床医生来说，激励来访和自己参与暴露练习可能会很有挑战性。然而，有大量的文献支持暴露作为许多不同问题治疗的核心组成部分。
在CFT中，同情自我不仅可以作为参与暴露的动力来源，也可以作为一种手段，使暴露过程对来访和治疗师都更加可接受。首先，问题“你的同情自我知道我们需要做什么？”有助于建立进行暴露的动力。许多来访凭直觉知道（或者可以通过苏格拉底式的探索来意识到），面对恐惧是他们为了实现目标而需要做的事情。
此外，一些初步的工作已经尝试将同情自我练习融入暴露疗法本身，并取得了有希望（尽管尚未发表）的初步结果 (Kolts, Parker, & Johnson, 2013)。多年来，各种理论家已经在暴露疗法协议中加入了想象元素。最近，关于记忆再巩固的新研究（例如Monfils等人, 2009; Schiller等人, 2010）表明，暴露不仅能够添加新的学习内容，而且在考虑某些时间限制并在暴露过程中加入新的非恐惧元素的情况下，还能够改变原始的恐惧记忆。研究人员观察到，在初次想象性地重新接触到恐惧记忆后大约十分钟内，似乎会出现一个“再巩固窗口”，在此期间恐惧记忆本身变得有些可塑。在这段时间内，可以引入新元素，允许“重写”记忆，从而使恐惧不再表达出来 (Schiller等人, 2010)。
在CFT中，这可以通过让来访最初唤起一个恐惧记忆来完成——比如急性创伤记忆或“热点”（较长创伤记忆中特别令人恐惧的部分）。再巩固文献指出，从最初的恐惧记忆回忆到它变得可以通过新信息更新的时间间隔大约需要十分钟左右。我们可以利用这段时间帮助来访转向同情自我的视角，例如，进行一分钟的安抚节奏呼吸、五分钟的正念呼吸和五至七分钟的同情自我练习 (Kolts, Parker, & Johnson, 2013)。然后，指示来访以标准方式回到恐惧记忆，关注记忆的感觉部分以及当前存在的感受和想法。当记忆生动起来时，我们可以提示来访放慢呼吸，切换到同情自我的视角，并想象自己作为现在的同情自我处在那种情境中——观察记忆中脆弱的自己，对自己感到恐惧的那个版本表示同情，并以任何被认为最有帮助的方式提供支持和安慰。重点放在创建温暖、善意的感受上，以及想要帮助受苦自我的愿望，并向这个脆弱的自我提供支持和鼓励。“你会如何支持那个脆弱的你？”“你希望那个脆弱的自我理解什么？”“你如何在那里为她加油并鼓励她？”
随后，可以提示来访在同情自我的视角（现在置于记忆的情境中）和经历事件的脆弱自我的视角之间来回切换。来访想象自己回到了那个情境，所有事件的可怕方面仍然存在，但同时也有未来那个善良、智慧、勇敢的自我在那里——提供善意、鼓励和支持，也许还有一定能度过难关成为这个未来自我的信心。治疗继续进行，通过主观痛苦评分作为跟踪来访痛苦程度的锚点，在这两个自我版本之间来回切换。
虽然这种变体的暴露疗法的有效性需要通过研究系统地评估，但它符合最近关于记忆再巩固的科学发现，初步观察似乎表明它可以显著减少来访的痛苦和回避行为，同时产生与传统暴露疗法相似的效果。少数案例还展示了与再巩固研究一致的轶事证据，来访说：“记忆还在那里，但取代了以前的恐惧，有一种被支持的感觉——不是孤单一人” (Kolts, Parker, & Johnson, 2013)。
知识点进一步阐述
同情自我作为锚定点
同情聚焦疗法(CFT)强调了“同情自我”这一概念，指的是个体内部一种积极的、充满同情心的形象。当来访面临挑战，特别是感到缺乏动力时，通过引导他们进入同情自我的视角，可以帮助他们在内心深处找到行动的力量。这种方法不仅有助于提升个人的内在动力，还能培养出一种更加积极健康的自我对话模式，从而促进心理健康和个人成长。
暴露疗法中的同情自我
传统的暴露疗法主要集中在直接面对恐惧源以减少恐惧反应。然而，这种方法有时会让来访感到极度不适。CFT提出了一种创新方法，将同情自我练习融入到暴露过程中，使整个过程变得更加温和且有效。通过引导来访在恐惧记忆中想象一个同情自我的形象，可以减轻恐惧感，同时帮助来访学会如何以理解和同情的态度对待自己的恐惧。这种方法不仅有助于改善症状，还能促进心理上的恢复和成长。
这种方法结合了最新的神经科学研究成果，尤其是关于记忆再巩固的研究，表明在特定条件下，恐惧记忆是可以被修改的。通过在暴露过程中引入同情自我等正面元素，可以有效地“重写”记忆，使得恐惧不再那么强烈。这种方法既保留了暴露疗法的有效性，又增加了对来访的关怀和支持，体现了CFT的整体性和人文关怀精神。
CFT（Compassion Focused Therapy，同情聚焦疗法）是一种现代心理治疗方法，它结合了神经科学、进化心理学以及行为科学的知识，旨在通过培养个体的同情心来帮助他们应对心理问题。CFT强调了温暖、理解、安全和勇气的重要性，同时也提倡将科学证据作为治疗的基础。此外，CFT被认为是一种“第三波”行为疗法，它注重改变个体与自身负面情绪和想法的关系，而非简单地尝试去除它们。
CFT（Compassion Focused Therapy，同情聚焦疗法）是一种注重培养个体内部同情心的心理治疗方法，它不仅关注患者与治疗师之间的互动，还特别强调患者对自己的态度。通过上述提到的方法，如明确治疗师的角色、引入进化模型解释情绪的作用、使用苏格拉底式的对话来减少自我批判、运用三个圆圈的概念来促进正念和理解情绪状态的变化，以及采用同情自我的视角，治疗师可以帮助患者更好地理解和接纳自己的情绪，从而达到治疗的目的。
C H A P T E R 15 Riding the Third Wave: Integrating CFT into Your Therapy This is an exciting time to be a mental health professional. Recent decades have proven revolution- ary in terms of how quickly we’re learning new things about how human beings work. Even as we’ve only explored the tip of the iceberg, the rapidly growing bodies of research in neuroscience, behav- ioral science, and emotion are allowing the beginnings of a truly integrative understanding of human functioning. CFT seeks to represent this evolved, integrated understanding of what it means to be a human being, and to translate this science into powerful, practical methods for helping people turn toward their struggles with warmth and acceptance, and work with these struggles effectively.
WHAT DOES A CFT THERAPIST LOOK LIKE? In approaching this book, I’ve attempted to emphasize the aspects of CFT that distinguish it from other therapies. Particularly in a “Made Simple” book, space prohibits me from exploring much more than the basic elements of the therapy. This is why I’ve generally chosen not to cover even compassion interventions that, while entirely CFT-consistent, are well covered in other places (such as in Kristin Neff and Chris Germer’s excellent Mindful Self-Compassion program; Neff & Germer, 2013). While reading the various case vignettes in the book, you may have had questions like, “Would a CFT therapist use exposure therapy with this patient?” “What about social skills training, activity scheduling, and behavior activation?” “Would a CFT therapist prompt a client to explore her values?” The answer to all of these questions is a resounding “Yes!” A core value CFT therapists hold is that we don’t ignore good science. What this means is that CFT is constantly evolving from both a theoretical and a practice perspective. For example, over the past few years, we’ve placed increasing emphasis on breath and body work in consideration of Stephen Porges’ excellent work on polyvagal theory (e.g. Porges, 2011) and other research demon- strating the power of engaging the parasympathetic nervous system. Applications of CFT have been developed that consider the new science of memory reconsolidation (Monfils, Cowansage, Klann, & LeDoux, 2009; Schiller et al., 2010) in applying Compassionate Self work within exposure therapy (Kolts, Parker, & Johnson, 2013). My friends and colleagues Dennis Tirch, Benji Schoendorff, and Laura Silberstein have worked to integrate the compassion focus of CFT with the theoretical perspective of acceptance and commitment therapy, or ACT (Tirch, Schoendorff, & Silberstein, 2014). And I’m increasingly intrigued by the implications of relational frame theory (Hayes, Barnes- Holmes, & Roche, 2001) for understanding the nuances of threat system processing in CFT. When one hears the word “compassion,” one doesn’t necessarily think empiricism. But from the perspective of CFT, one of the most compassionate things we can do is to get better and better at really understanding the sources and dynamics of human suffering, and do a better and better job at researching and refining powerful ways to help alleviate and prevent it. Compassion is about helping effectively, not just about feeling helpful. In this way, science is core to compassion, and the CFT therapist is likely to draw upon any tools that have good science behind them. So if you want to do CFT, you don’t have to give up any of the things you already do that work. What may change, however, is how you do them. Because CFT is rooted in compassion. This emphasis should be present in all aspects of the therapy—the way the therapist relates to the client, and how we help clients relate to themselves, and to others. Rooted in our understanding of under- lying affective systems, this means that CFT will always contain warmth (expressed in ways that work for the client), an emphasis on assisting clients to relate to their experiences with understand- ing and kindness rather than shame, a focus on helping clients learn to create feelings of safeness in themselves, and the development of the emotional courage to approach and work with the things that really scare them. Like ACT, CFT isn’t about moving away from feelings and experiences that make us uncomfortable. It’s about moving toward effective, compassionate ways of being in our minds and in the world, and even moving toward the things that bother us, so that we can compas- sionately work with them. So whatever we’re doing in CFT, there is always an emphasis on warmth, understanding, safeness, and courage.
CFT AND OTHER MODELS In writing this book, it wasn’t my intention to convert therapists to CFT, but to provide you with compassionate perspectives, understandings, and tools that you can use to further develop your effectiveness as a therapist, regardless of your existing modality. As you may have noticed, CFT has a good deal in common with some other therapy approaches. While I’ve discussed some of the common ground between CFT and approaches such as ACT, DBT, and EFT, those of you with different therapeutic backgrounds may notice similarities with other models as well—attachment therapy approaches, schema therapy, and even newer psychodynamic approaches spring to mind, for example. It’s my hope that practitioners from many other traditions will find something here to deepen their existing therapy practices, particularly in helping clients relate warmly and compas- sionately to themselves, to their problems, and to other people. In considering where CFT interfaces theoretically with other approaches, I see it falling within the “third wave” of behavior therapies, with an emphasis on changing one’s relationship to uncom- fortable thoughts and emotions (rather than trying to get rid of them), the cultivation of mindful- ness, and a priority placed on helping people build adaptive, meaningful lives (versus simply reducing symptoms). While it’s a bit more of a stretch, I also see CFT generally fitting alongside therapies like ACT and functional analytic psychotherapy (FAP) within the realm of contextual behavioral science (CBS). The philosophical core of CBS—functional contextualism—involves understanding that the function of a behavior (which can include thoughts and perhaps even emotions and motives) must be understood within the context in which it occurs. In understanding human functioning, CFT expands the meaning of “context” from strict behavioral terms to include the neurological contexts that influence affect, cognition, and behavior, as well as the evolutionary contexts that have shaped how emotions, motivations, and their behavioral manifestations play out in our lives. This is both a strength and a weakness of the CFT approach, depending upon one’s perspec- tive. It’s certainly a trade-off. I think that considering the evolved functions of emotions and motives and having a neuroscience-based understanding of the ways emotions operate in our brains and bodies has tremendous power in helping to deshame the challenges faced by our clients. Understanding why and how our emotions play out the way they do—and that this is not our fault (as we didn’t design these processes)—can be quite powerful in helping people stop beating them- selves up for their own experiences and learn to work with these experiences effectively. However, the intellectually honest CFT practitioner must admit that drawing upon such expla- nations comes with sacrifices, from the standpoint of strict empiricism. Behaviorists would note that ontological statements about the evolutionary origins and evolved functions of emotions and motives in large part defy empirical observation, and they’d be right. It’s fair criticism. In weighing these issues for myself, I’ve concluded that the trade-off is worth it. I think the benefits of considering the functions and dynamics of our emotions and motives within evolution- ary and neurological, as well as behavioral, contexts (as best we understand them), justify this compromise—if we keep a steady eye to the science. The Dalai Lama is well known for having said, “If science disproves some aspect of Buddhism, then Buddhism must change.” The same can and should be said for CFT, or, I would argue, for any approach that aspires to be empirically based. To the extent that an approach extends beyond tenets that have been established through solid, observable science, that approach must be amenable to change based on new data. (Of course, the hope is that all approaches would be amenable to change based on new data.) Dogmatism benefits no one—our patients least of all. Humility, on the other hand, offers the promise of approaches which can be continually refined in the service of doing an ever-better job at eliminating and pre- venting human suffering.
BRINGING CFT INTO YOUR THERAPY ROOM It’s my hope that you’ve found something useful in CFT, and want to begin bringing what you’ve learned into your therapy practice. One way to do this would be to select a clinical case and try to follow the progression I’ve attempted to lay out in this book—incorporating the various layers of relationship, understanding, mindful awareness, and purposeful cultivation of compassion. If that feels like a lot, perhaps simply try to incorporate one or more of the elements you’ve found here that falls outside the things you normally do in therapy. Below, I’ve included a few suggestions about how you might begin to do this.
Consider the Roles You Are Inhabiting as the Therapist We’ve discussed the various roles served by the CFT therapist—teacher, facilitator of a process of guided discovery, secure attachment base, and model of the compassionate self. As we do therapy, we can consider the roles we are inhabiting, and how best to do that. What function are we serving within the context of the therapeutic relationship, and how can we use our presence to facilitate the goals and direction of the therapy? Perhaps try to pay a bit more attention to these roles, and consider whether doing so helps clarify questions in the therapy such as What should I do now? In this way, we can borrow from the Compassionate Self practice as we reflect on the thera- peutic work outside the session: when our clients throw us a curveball, we can consider—from the perspective of the teacher, facilitator, secure base, or compassionate model—How would I understand what is happening here? How might I respond?
Occasionally Bring in the Evolutionary Model We don’t have to go into deep discussions of evolution—in fact, those generally aren’t helpful. But helping people recognize the different things that happen to their minds and bodies when they feel threatened or driven versus when they feel safe can be helpful. Considering threat emotions as having evolved to help us protect ourselves can help clients understand why they get so “stuck” in these emotions. It’s no accident that these emotions narrow our attention, thinking, and mental imagery onto perceived sources of threat, and it’s certainly not the client’s fault that this happens. Learning that helping themselves feel safe reverses this process (facilitating more flexible attention and reasoning, reflective thinking, and prosocial tendencies) can improve client motivation around working with these emotions. Helping clients understand what to do and why or how it will be helpful can be very powerful in building their willingness to do something new.
Use Socratic Dialogue to Undermine Self-Attacking With or without going into the evolutionary model, we can use Socratic dialogue to help clients shift from shaming themselves for their internal experience to the awareness that there are many aspects of their lives that they neither chose nor designed—things which are quite literally not their fault. • “What was your experience of that emotion? Did you choose to get angry/afraid/resent- ful there, or did those feelings just arise in your mind and body?” • “When did you learn that you ? What experiences taught you that?” • “Given what we know about your/her/his background, does it make sense that you/she/ he would feel/think/experience things in this way?” • “When your self-critic attacks you for , how do you feel? What does it motivate you to do? What do you end up doing?” Questions like these can help clients begin to let go of the tendency to attack themselves for things they didn’t choose or design, and to understand their experiences and behaviors in the context of their lives. In other words, the questions set the stage for them to compassionately take responsibility for making their lives better.
Use the Three Circles as a Facilitator for Mindfulness Clients who initially struggle with mindfully observing and accepting their thoughts and emo- tions can sometimes be helped by the simplicity of the three circles. I’ve had numerous clients who had great difficulty observing thoughts or labeling specific emotions, but who were able to con- sider which of those three circles was active at any given time. Combined with an understanding of how those circles organize our minds and bodies (for example, that threat emotions tend to narrow and focus attention and thinking, and safeness emotions lead to reflectiveness, flexibility, and pro- sociality), it can be a powerful thing for a client to learn to notice what circle am I in? As I’ve men- tioned, a former student of mine who was also a cheerleading coach came up with a pithy way to remember this: “When in doubt, circle out!”
Use the Three Circles in Considering Your Interactions with the Client We can also “circle out” in the therapy room. I’ve found it can be useful to consider the three circles both in my treatment planning and in working with challenges that arise in therapy. For example, I roughly shoot for around a 3-2-2 safeness-drive-threat ratio in therapy: three parts safe- ness, two parts drive, two parts threat. My goal for the therapeutic environment is to create an experience of safeness for my clients that grows as they learn to create these experiences in them- selves. Good therapy also gets the drive system going—inspiring and motivating clients to work for change in their lives. Finally, there will be a good bit of threat in the therapy if we’re working with real issues—but the key is that there is a balance, with threat experiences evoked in an inten- tional manner so that they can be compassionately worked with. It’s not just about safeness—we’re striving for a flexible, fluid balance in which different affective experiences and motivations can arise and be evoked as they serve the situation at hand. Together, we want to appropriately work with perceived threats, activate and maintain motivation around pursuing therapeutic goals, and create a context of safeness in which comfort can be experienced and questions of meaning and values can be reflected upon.
Considering the three circles can also be helpful when we’re struggling in therapy or the rela- tionship doesn’t seem to be going as well as we’d like. Sometimes we’ll find that we’ve inadvertently become a threat cue for the client. We can think of countertransference in this way—considering that perhaps our own threat or drive systems have been triggered by the client’s behavior, or some- thing about that client that triggers our own previous conditioning. We may observe that we’ve been so much in drive—excited by our wonderful new treatment plan—that we’ve left our client behind. When therapy seems to have hit a sticking point or there’s a rupture in the therapeutic relationship, considering the situation in terms of the three circles either on our own or together with the client can sometimes shed light on the challenge and provide direction: • Which circle am I triggering in my client? Which do I want to be triggering? • Which circle has been running the show for me? • What would help to bring balance to both me and the client as we work with this situation?
Sometimes, simply naming the situation and slowing things down to have a process-level dis- cussion of how things have been playing out in the session can be a great help. The three circles can help us do this in a compassionate way: “Looks like our threat circles have been bouncing off of one another. This happens sometimes when dealing with real-life issues. Let’s take a minute to do some soothing rhythm breathing and consider how we want to proceed.” Use the Perspective of the Compassionate Self One nice thing about the Compassionate Self practice is that once this kind, wise, courageous perspective has been established, we can use it as an anchor-point to facilitate other aspects of the therapy. Let’s consider just a couple of examples:
THE COMPASSIONATE SELF AS AN ANCHOR-POINT There’s a growing appreciation of the value of behavioral activation in creating emotional change. Simply getting clients moving in the direction of value-based goals (a major focus of ACT) can be tremendously powerful, and most good treatment protocols for problems of anxiety and depression involve mobilizing client behavior to help them address life areas they may have been avoiding. This can be challenging with clients who struggle with motivation, perhaps because they are deeply entrenched in avoidance, habitually procrastinate, or are very depressed. Therapists who take it upon themselves to be “motivator in chief” can inadvertently set up a coercive environ- ment in therapy that can disempower clients or even invite them to resist the therapist’s efforts to get them moving. However, once such clients have connected with the perspective of the compas- sionate self, this perspective can be useful in shifting the role of motivator from the therapist to the client. “What does your compassionate self know that you need to do?” “If that kind, wise, coura- geous version of you were here, what home practice would she assign?” Questions like these can help clients shift from a perspective of avoidance and resistance to one that is driven by intuitive wisdom about what they really need to work on—in a way that also helps them empower them- selves by shifting into the perspective of the compassionate self, and acting from that perspective.
THE COMPASSIONATE SELF IN EXPOSURE THERAPY Exposure therapy is historically one of the most effective treatment methods we have at our disposal, as well as one of the most avoided by clinicians. Because coming into contact with feared memories and situations can be quite an aversive experience for the client, it can be challenging for clinicians to motivate their clients and themselves to engage with exposure practices. However, there’s quite a lot of literature supporting exposure as a core component in the treatment of many different problems.
In CFT, the compassionate self can be used both as a motivator to engage with exposure and as a means to make it more palatable to clients and therapists alike. First, the question “What does your compassionate self know that we need to do?” can be helpful in building motivation for the exposure. Many clients intuitively know (or can come to realize through Socratic exploration) that facing their fears is something they need to do to progress toward their goals.
Additionally, some preliminary work has been done to incorporate Compassionate Self work into exposure therapy itself, with promising (albeit unpublished) preliminary results (Kolts, Parker, & Johnson, 2013). Over the years, various theorists have utilized the addition of imaginal elements to exposure therapy protocols. Recently, exciting new research on memory reconsolidation (e.g. Monfils, Cowansage, Klann, & LeDoux, 2009; Schiller et al., 2010) has demonstrated that exposure can be done in a way that not only adds new learning, but can produce alterations in original fear memories by considering certain time constraints, and adding in new, nonfearful elements during the expo- sure process. These researchers have observed that a “reconsolidation window” appears to open approximately ten minutes following an initial imaginal reexposure to a fear memory, during which time the fear memory itself becomes somewhat malleable. During this time, new elements can be introduced, allowing the “rewriting” of memories so that fear is no longer expressed (Schiller et al., 2010).
In CFT, this can be done by having the client initially bring up a fear memory—for example, an acute trauma memory or “hot spot” (particularly fearful piece of a longer trauma memory). The reconsolidation literature indicates that a period of ten minutes or so needs to pass between the initial recall of the fear memory and the point at which it becomes malleable to updating via new information. We can spend this time assisting the client to shift into the perspective of the compas- sionate self, say, by doing one minute of soothing rhythm breathing, five minutes of mindful breath- ing, and a five-to seven-minute Compassionate Self exercise (Kolts, Parker, & Johnson, 2013). Then, the client is instructed to return to the fear memory in standard fashion, keying into both the sensory aspects of the memory and the feelings and thoughts that are present. Once the memory is vivid, we can prompt clients to slow down their breathing, shift into the perspective of the compassionate self, and imagine that they are in the situation as their current, compassionate self—observing the vulnerable version of themselves in the memory, feeling compassion for that scared version of themselves, and offering support and reassurance in whatever way would be expe- rienced as most helpful. Focus is placed on creating feelings of warmth, kindness, and a desire to help the suffering self, and on offering support and encouragement to this vulnerable self. “How would you support that vulnerable version of you?” “What would you want that vulnerable self to understand?” “How might you be there for her and encourage her?”
Then the client can be prompted to shift back and forth between the perspective of the com- passionate self (now placed into the context of the memory) and the perspective of the vulnerable version of the self that experienced the event. The client imagines himself back in the situation, with all of the scary aspects of the event still present, but also having the future kind, wise, coura- geous version of the self there as well—offering kindness, encouragement, support, and perhaps the certainty that you will make it through this, to become this future self. The therapy then progresses, shifting back and forth between these two versions of the self, using subjective distress ratings as anchor-points for tracking the client’s distress.
While the efficacy of this variant of exposure therapy needs to be systematically evaluated through research, it is consistent with recent science on memory reconsolidation, and preliminary observations seem to indicate that it can significantly reduce client distress and avoidance while producing similar gains to traditional exposure therapies. These few cases have also demonstrated anecdotal evidence consistent with the reconsolidation studies, with clients saying things like, “The memory is still there, but instead of the fear that used to be there, there is an experience of being supported—of not being alone” (Kolts, Parker, & Johnson, 2013).