第十五章 融合新趋势：CFT在治疗中的应用
193C 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 questionsCFT Made Simple 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 196Riding the Third Wave: Integrating CFT into Your Therapy 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 197CFT Made Simple 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. 198Riding the Third Wave: Integrating CFT into Your Therapy 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 199CFT Made Simple 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: 200Riding the Third Wave: Integrating CFT into Your Therapy 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 201CFT Made Simple 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).