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“This book is not just simple. It is elegant and powerful. Through engaging didactics and detailed clinical examples, Russell Kolts demonstrates how we can bring compassion to clients’ lives by applying innovative and precise techniques of compassion-­focused therapy (CFT). You will learn to use perspective-­taking shifts and imagery techniques formally and through natural conversa- tions. You will learn to help clients understand and overcome their struggles using evolution and contextual sciences. Be kind to yourself and to your clients: read CFT Made Simple.” —­Matthieu Villatte, PhD, coauthor of Mastering the Clinical Conversation “An excellent book. Well written, easy to read, insightful, and inspiring. And bursting with practi- cal ideas that will be useful for any health professional with an interest in compassion and mindful- ness. A valuable contribution to the field of health and well-­being.” —­Russ Harris, author of The Happiness Trap and ACT Made Simple “A clinician’s ability to be compassionate, to help clients face their pain with kindness and courage, is at the core of all effective therapies. Bringing together evolutionary psychology, affective neuro- science, attachment theory, behaviorism, and mindfulness approaches, Russell Kolts provides a compendium filled with heartfelt wisdom, step-­by-­step guidelines, and exercises that therapists of any orientation can use immediately to help their clients reclaim warmth, affiliation, safeness, and hope in their lives. This indispensable volume is a must-­have in any clinician’s library.” —­Robert Kohlenberg, PhD, ABPP, and Mavis Tsai, PhD, codevelopers of functional analytic psychotherapy (FAP) “CFT is a revolutionary new approach to therapy firmly rooted in ancient wisdom and modern science. The author has an uncanny ability to present this multidimensional model in a practical, straightforward manner without losing any of its subtlety. This book is a wonderful resource for clinicians who wish to dive deeply into CFT, or who simply want to integrate key aspects of the approach into their existing practices. Drawing directly on our innate capacity for compassion, CFT offers compelling insights for therapy and how we may live our daily lives more fully. Highly recommended!” —­Christopher Germer, PhD, author of The Mindful Path to Self-­Compassion, and coeditor of Mindfulness and Psychotherapy “This is a phenomenal book that manages to convey the complex theory underlying CFT into extremely simple ideas and practices that translate directly into clinical practice. This book will be an essential tool for any therapist wanting to effectively incorporate compassion into their work with clients.” —­Kristin Neff, PhD, associate professor in the department of educational psychology at the University of Texas at Austin, and author of Self-­CompassionThe Made Simple Series Written by leaders and researchers in their fields, the Made Simple series offers accessible, step-by-step guides for understanding and implementing a number of evidence-based modalities in clinical practice, such as acceptance and commitment therapy (ACT), dialectical behavior therapy (DBT), compassion-focused therapy (CFT), functional analytic psychotherapy (FAP), and other proven-effective therapies. For use by mental health professionals of any theoretical background, these easy-to-use books break down complex therapeutic methods and put them into simple steps—giving clinicians everything they need to put theory into practice to best benefit clients and create successful treatment outcomes. Visit www.newharbinger.com for more books in this series.CFT made simple A Clinician’s Guide to Practicing Compassion-Focused Therapy RUSSELL L. KOLTS, P h D New Harbinger Publications, Inc.Publisher’s Note This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold with the understanding that the publisher is not engaged in rendering psychological, financial, legal, or other professional services. If expert assistance or counseling is needed, the services of a competent professional should be sought. “On Pain” from THE PROPHET by Kahlil Gibran, copyright © 1923 by Kahlil Gibran and renewed 1951 by Administrators C.T.A. of Kahlil Gibran Estate and Mary G. Gibran. Used by permission of Alfred A. Knopf, an imprint of the Knopf Doubleday Publishing Group, a division of Penguin Random House LLC. All rights reserved. The table in the section “Compassionate Thinking and Reasoning” in chapter 10 is adapted from Kolts, THE COMPASSIONATE MIND GUIDE TO MANAGING YOUR ANGER (2012), with permission from Little, Brown Book Group. Distributed in Canada by Raincoast Books Copyright © 2016 by Russell L. Kolts New Harbinger Publications, Inc. 5674 Shattuck Avenue Oakland, CA 94609 www.newharbinger.com Cover design by Sara Christian; Acquired by Melissa Kirk; Edited by Gretel Hakanson; Indexed by James Minkin All Rights Reserved Library of Congress Cataloging-in-Publication Data on file Printed in the United States of America 18  17  16 10   9   8   7   6   5   4   3   2   1 First printingFor my dear friend, colleague, and mentor Paul Gilbert. Paul, your brilliant work, inspiration, nurturance, and tutelage have made this book possible, and have given me a professional life that is more meaningful and rewarding than I had ever dared to dream.Contents Forewordvii Introduction1 1Origins and Basic Themes13 2Introducing Compassion25 3Compassionate Relating: Roles of the Therapist in CFT33 4Compassionate Understanding: How Evolution Has Shaped Our Brains49 5Compassionate Understanding: Three Types of Emotion61 6Compassionate Understanding: The Social Shaping of the Self75 7Compassionate Awareness: Cultivating Mindfulness91 8Committing to Compassion: Working with Self-­C riticism107 9Cultivating the Compassionate Self115 10Compassionate Thinking and Reasoning129 11Using Compassionate Imagery141 12Embodying Compassion: Chair Work in CFT155CFT Made Simple 13Compassionate Integration: Case Formulation in CFT171 14Exploring Affect: The Multiple Selves Practice181 15Riding the Third Wave: Integrating CFT into Your Therapy195 Conclusion203 Afterword: Unpacking the Compassionate Mind205 Acknowledgments207 Appendix: Reproducible Forms209 References217 About the author223 Index225 viForeword In this beautifully and skillfully written book, Russell Kolts uses his experience to outline the key themes in compassion-­focused therapy (CFT). It’s very easy to think that compassion approaches to psychological therapies are just about helping people be kind to themselves and others. In reality, the center of compassion—­particularly in the therapeutic arena—­is courage. Russell himself has worked with anger problems in prison inmates and has developed a CFT approach that he calls the True Strength program, highlighting compassion as the strength and courage to turn toward our suffering, and that of others. I must confess that I was dubious about “making therapies simple” because this can easily be seen as dumbing them down. It’s important to note that compassion-­focused therapy is in some ways very complex: based in consideration of basic scientifically established psychological pro- cesses; the ways in which emotions, motives, and cognitions operate; and the manner in which humans are deeply socially embedded and organized through their social relationships. So when you read this in terms of “made simple,” don’t think that Russell is saying the therapy is “simple.” Rather, he is outlining some of the crucial concepts of CFT in the hope that they will be useful to you, and perhaps excite you to learn more. I’m delighted to say that Russell achieves his goal brilliantly and in a way I never could. I am one of those people who tend to see complexity rather than simplicity. So here is a wonderful guide to introduce you to the realities of the toughness, difficulties, and complexities of CFT—­but, as Russell says, creating the layers and building blocks in relatively straightforward and simple ways. As explained in this book, CFT began in a relatively simple and straightforward way in the 1980s. It started with just noticing the importance of understanding the emotional tone people created in their heads when they tried to be helpful to themselves. For example, imagine you are trying to generate helpful thoughts when you’re feeling depressed. But imagine “hearing” and experiencingCFT Made Simple these thoughts in a very hostile way, as if you are irritated and contemptuous even as you say them in your mind. How will that be? Even an encouraging phrase like You can do it becomes venomous when communicated in a hostile mental “tone of voice.” You might try saying that to yourself in a contemptuous, sort of hostile way and notice how that feels. Notice whether you feel encouraged. Then imagine that you can really focus on warmth and empathic understanding in the words, focusing on the feeling—­maybe as if you were hearing somebody who really cared about you say it with a heart that wishes for you to be free of your depression, or maybe as if hearing your own voice as supportive, kind, and validating with the same intention. Actually doing exercises like this is helpful, because in CFT getting personal experience by doing the practices yourself is key to the development of your therapeutic skills. What I found all those years ago was that while people could “cognitively” learn to generate new perspectives and coping thoughts, they often did so with a contemptuous or hostile, irritable tone. Indeed, they often found it very difficult to experience coping thoughts that involved two important aspects that are now recognized as being core to our understanding of compassion. First, they struggled to direct these thoughts toward themselves with a heartfelt motivation that is based on empathic concern to address the deeper causes of the difficulties (compassionate motiva- tion). Many patients actually blamed themselves, or thought they did not deserve compassion, or that compassion was weakness in some way—­just too soft! Sometimes they were very avoidant of the causes of their suffering—­for example, not wanting to address the traumatic experiences underpinning their depression, or the fact that they needed to make life changes. It takes courage to begin working on these difficult issues. Second, they tended to struggle with generating sup- portive, kind, understanding, and validating emotions when they actually created those thoughts in their mind (compassionate action). So CFT began with trying to think about how to help clients generate compassionate motivation and care-­orientated emotions, and also within that motivation, to create certain kinds of emotional balancing within the mind. As Russell says, we use a standard definition of compassion—­one that captures the heartfelt wish for suffering to cease, a preparedness to develop “sensitivity to suffering of the self and others with a commitment to try to alleviate and prevent it.” The prevention part is important, because the training that we do is aimed at reducing suffering both in the present and in the future. So the first psychology of compassion is about how we begin to address our suffering and really start to understand it. As Russell outlines here, there are many competencies that we are going to need, such as how we pay attention, how we experience being in contact with distress, how we tolerate our distress, and how we empathically understand it without being judgmental or critical. The second psychology of compassion is really about developing the wisdom of knowing how to be genuinely helpful. True helpfulness requires the development of wisdom—­we must under- stand the nature of suffering before we are well equipped to work with it. Minds are very tricky and are full of conflicted motives and emotions. Also, although warmth and gentleness can be part of compassion, compassion requires a certain toughness, assertiveness, and a great deal of courage as well. Parents are prepared to argue with their children over their diets or going out late at night viiiForeword because they want to protect them, even though this may cause conflicts. In some therapy encoun- ters, clients are frightened of their anger or anxiety or grief. Therapists may then need to encour- age these clients to experience such emotions, even when a client is reluctant to do so, and even when doing so may not be pleasant at the time, because that is what’s required to help this client learn to experience and work with these difficult feelings. It’s a therapeutic skill and wisdom that allows the therapist to know how and when to do this. Indeed, some years ago, studies showed that some of the warmest therapists were behaviorists! That makes sense, because behavior therapy often has to encourage clients to engage with things they’d rather not connect with. CFT also uses evolutionary functional analysis to help us understand how our emotions work. As Russ clearly outlines, we consider emotions in terms of three functionally distinct types of emotion-­regulation system: there are emotions for dealing with threats and trying to protect us, emotions that are stimulating us to go out and achieve and acquire resources, and emotions that give rise to feelings of contentment, safeness, and slowing down—­which are sometimes linked to the parasympathetic functions of rest and digestion. Many of our clients are very out of balance with these emotions, and the capacity for contentedness and peaceful feelings can be almost impos- sible for them to access. Studies of the parasympathetic nervous system have shown that this system is out of balance in many people with mental health problems, with the major emotion-­ balancing and regulating systems not operating appropriately. In such cases, we have to help them get these feelings of safeness online. In this way, building and cultivating the capacity for slowing down, grounding, and experiencing safeness, connectedness, and affiliation are central treatment targets for CFT. This creates the competencies and strengths for people to then engage with feared material—­be these things they need to do in the outside world, or in the internal one. Given that CFT is an evolutionary-­based therapy, it will not be surprising to hear that it draws from attachment theory and its extensive research base. Attachment theory tells us that relation- ships with caring others can provide a secure base (which can be the platform to enable us to go out and try things, take risks) and a safe haven (a safe and secure base where we can be soothed, helped, and supported when we’ve gotten into difficulties). CFT helps clients begin to experience and develop this internalized secure base and safe haven. Once a person understands the nature of those three different types of emotion we visited earlier, then a lot of things fall into place. For example, when soldiers are trained, their secure base and safe haven can shift away from their families and toward their combat buddies—­because that is indeed the source of their safeness in combat. When they go out on sorties they will be in high-­ stakes arousal, and when they come back they will calm down and find that safe haven within the company of their buddies. So the soothing systems have been rewired to respond in connection with these combat buddies. When they come home, they can then lose the secure base and safe haven that their brains have gotten wired up for, and there will be fewer intense “dopamine rushes.” Even though they are now at home with their families in a physically safe environment, it can be very difficult and even stressful, because those families are not now the source of the secure base and safe haven. ixCFT Made Simple CFT outlines these kinds of processes clearly because it contains an emotional model capable of dealing with that degree of complexity. This example is reflective of a common aspect of CFT: the CFT therapist is very interested in how patients are able to calm and ground themselves, feel connected to a secure base and safe haven, and then develop the courage necessary to engage with feared and avoided experiences. Key too is the development of the internal affiliative relationship; that is, one learns to relate to oneself in a friendly, supportive way rather than in a critical manner that will continue to stimulate the threat system. Good therapists want to know the evidence behind the therapies they utilize. Given the purpose of this book, Russell has not overwhelmed it with evidence, but makes clear that a lot of the evidence for CFT is process evidence. That is, we don’t have many theoretical concepts, but rather try to understand and draw upon what the science tells us about things like motivation and emotion—­for example, what we know about the importance of the frontal cortex and how that develops during childhood or is affected by trauma. We know that the affiliative motives (such as attachment or group belonging) and emotions played a very major role in mammalian evolution and in particular the evolution of human intelligence. We also know that affiliative relationships are very powerful regulators of motives and emotions. It follows, therefore, that these would be targets for therapeutic intervention. The backbone of CFT is found in detailed knowledge of how our brains have become the way they are, understanding the evolutionary function of emotions, understanding core regulating pro- cesses of motives and how motives are linked to self-­identity, and understanding how self-­identity can be cultivated in the therapeutic process. All over the world now, we are beginning to recognize that the human mind is full of complex emotions and conflicts partly because of its evolved design—­an awareness that is increasingly reflected even in popular culture, such as the Disney movie Inside Out (2015). The human brain is very tricky, easily pushed into doing bad things to others and harmful things to ourselves. Compassionate motives, however, help to bring harmony and reduce the risks of both. CFT is an integrative therapy, which makes use of many evidence-­based intervention strate- gies. These include Socratic dialogue, guided discovery, identification of safety behaviors, focus on avoidance and exposure, inference chaining, reappraisal, behavioral experiments, mindfulness, body/emotion awareness and breath training, imagery practices, supporting maturation—­and more besides. However, CFT also features a number of unique features: • Psychoeducation about our evolved “tricky” brains • Models of affect regulation with special focus on affiliation and the parasympathetic nervous system • A specific focus on the complex functions and forms of self-­criticism and self-­conscious emotions, highlighting distinctions between different types of shame and guilt • Building compassion-­focused motives, competencies, and identities as inner organizing systems xForeword • Utilizing self-­identity as the means for organizing and developing compassionate motives and competencies • Working with fears, blocks and resistances to compassion, positive feelings, and espe- cially affiliative emotions One of the key aspects of CFT is the idea that motives are major organizers of our minds. They are linked to phenotypes in complex ways that are beyond the scope of the current discussion. But for example, imagine that you are invited to a party and you are motivated by competitive social rank. You want to impress the people there, and avoid making mistakes or being rejected, and you want to take any opportunity you can to identify the more dominant members of the group and impress them. Now let’s change that motivation and imagine you have a motivation that’s focused on caring or friendship. Now your attention is not on who is dominant or whom you can impress (or how you can impress them), but on finding out more about them. You are interested in sharing values, and perhaps developing friendships. You will be considering people in terms of whether you like them and want to spend time with them or not. The ways we think, pay attention, and act are guided by motivations. Of course, beliefs and things like organizing schemas come into it—­in fact, these are linked to motives—­but the crucial issue is motivation. When we see how powerful these motives can be in organizing our minds, it becomes clear why compassion and prosocial motivations are central in CFT. Research has revealed that many people with mental health problems are motivated primarily through competitive social rank systems which play out in terms of harsh self-­judgments, self-­criticizing, and worries of being seen as inferior or incompetent in some way and rejected, often with intense feelings of loneliness. These individuals may often feel they are stuck in low-rank, low-status, or undesirable positions. Of course, there are others who are hyper-­focused on attaining dominance; focused on getting ahead and taking control regardless of the impact it has on others. Switching to caring-­focused or compassionate motivations can be a revelation to such clients, but can also be quite frightening. Different types of clients can experience resistance toward cultivating compas- sionate and prosocial motives rather than competitive social rank–focused ones. CFT teaches people how to think about different motivational and emotional states and to practice switching between them. When we learn how to create within us a wise, strong, compassionate motivation and then to anchor that motivation at the center of our sense of self, we discover that it brings with it a wisdom for how to deal with life crises, orienting us to our own suffering and those of others in very different ways. We discover that it’s a way of liberating ourselves from suffering and learning how to tolerate that which can’t be changed. A very simple depiction of the essence of why devel- oping a compassionate sense of self is important can be seen in “Compassion for Voices,” a very short film about how people who hear voices can develop a compassionate self: https://www .youtube.com/watch?v=VRqI4lxuXAw. Russell guides readers through the processes by which we need to pay attention to our bodies, learn how to identify which emotion motivational systems are operating through us (motives which can be activated quite automatically and exert considerable control over our thoughts and xiCFT Made Simple behaviors unless we develop more mindful awareness), and cultivate care-­focused motives, emo- tions, and self-­identity using a range of techniques drawn from standard therapies, contemplative traditions, and acting traditions. As Russell makes clear, the details of CFT can indeed be complex, but the layered approach presented here helps to organize these complexities in a straightforward, understandable way. I’m delighted to see Russell write this book in such a clear and easy-­to-­ understand, step-­by-­step way. I hope it will entice you to learn more—­perhaps to get more train- ing, and perhaps even motivate you to cultivate an ever-­deepening compassionate motivation within yourself. As Russell points out, there’s nothing like personal practice and insight to see how these processes work. All that I can do now is to leave you in the talented and capable hands of your author and hope this inspires you to learn more about the nature of compassion and how we can bring it into therapy, and of course, into all aspects of our lives. —­Paul Gilbert, PhD, FBPsS, OBE xiiIntroduction And a woman spoke, saying, “Tell us of Pain.” And he said: Your pain is the breaking of the shell that encloses your understanding. Even as the stone of the fruit must break, that its heart may stand in the sun, so must you know pain. And could you keep your heart in wonder at the daily miracles of your life, your pain would not seem less wondrous than your joy; And you would accept the seasons of your heart, even as you have always accepted the seasons that pass over your fields. And you would watch with serenity through the winters of your grief. From The Prophet, by Kahlil Gibran Compassion involves allowing ourselves to be moved by suffering, and experiencing the motivation to help alleviate and prevent it. Compassion is born of the recognition that deep down, we all just want to be happy and don’t want to suffer. In this book, you’ll learn about compassion-­focused therapy (CFT), a therapy that focuses on the purposeful cultivation of compassion, the skills and strengths that flow from it, and how to use these to work effectively with human suffering. When we see what we’re up against—­the situation we’re all in together, just by the virtue of having human lives—­there’s a deep realization that can arise: With all the potential suffering and struggle that we and all humans will face, compassion is the only response that makes sense. Why do we need compassion? We need compassion because life is hard. Even if we’re born into a relatively advantaged existence, with ready access to food, a comfortable place to live, peopleCFT Made Simple who love us, education, and opportunities to pursue our goals—­even if we have all of this—­we will all face tremendous pain in our lives. We’ll all get sick, grow old, and die. We’ll all lose people we love. We’ll all sometimes do our very best in pursuit of goals we desperately desire, and fail. Most of us will have our hearts broken, if not once, then several times. To have a human life means we will face pain. It’s the price of admission. Life is hard, for everyone. But we can forget this. We can forget that all of us hurt, and that these feelings are universal—­ part of what binds us together as human beings. Many of us, and many of those we seek to help, can instead experience these struggles and emotions as isolating, as signs that there is something wrong with me. Instead of reaching out for help, we may pull back from others. Instead of supporting, encouraging, and reassuring ourselves, we may meet our struggles with criticism, attacks, and shame. And even when we know better, it can be hard for us to feel reassured. This business of being human can be tricky indeed. And for some people—­such as the psychotherapy clients we seek to help—­things are exponentially more difficult. COMPASSION-­FOCUSED THERAPY It was observations like these that inspired my dear friend and colleague Paul Gilbert to develop compassion-­focused therapy. CFT was designed to assist therapists in helping clients understand their mental suffering in nonshaming ways, and to give them effective ways to work with this suf- fering. Over the last few years, CFT has been increasingly used by mental health providers—­first in the United Kingdom where it was developed, and increasingly in other parts of the world as well. It’s also been the focus of a growing body of empirical work. What Is CFT and How Is It Useful? CFT represents the integration of various science-­based approaches for understanding the human condition with mind-­training practices that are literally thousands of years old. Finding its scientific footing in evolutionary psychology, affective neuroscience (particularly the neuroscience of affiliation), the science of attachment, behaviorism and cognitive behavioral therapy (CBT), and the growing body of literature supporting the efficacy of mindfulness and compassion practices, CFT is focused on helping clients relate to their difficulties in compassionate ways and on giving them effective methods for working with challenging emotions and situations. CFT was originally developed for use with patients who have a tendency toward shame and self-­criticism, who may struggle in treatment even while engaging in evidence-­based therapeutic protocols such as CBT (Gilbert, 2009a; Rector et al., 2000). For example, such patients may be able to generate thoughts such as I know that what happened wasn’t my fault, but struggle to feel reassured by such thoughts. A focus of CFT is to create an emotional congruence between what clients think (for example, helpful thoughts) and what they feel (for example, reassured). CFT helps patients learn to engage with their struggles and those of others in warm, accepting, and encouraging ways, 2Introduction to help themselves feel safe and confident in working with challenging affects and life difficulties. CFT has been applied to a growing list of problems including depression (Gilbert, 2009a; Gilbert, 2009b), psychosis (Braehler et al., 2013), binge-­eating disorder (Kelly & Carter, 2014; Goss, 2011), anxiety (Tirch, 2012), anger (Kolts, 2012), trauma (Lee & James, 2011), social anxiety (Henderson, 2010), and personality disorders (Lucre & Corten, 2013). The CFT Approach A growing body of empirical research supports the potential use of compassion interventions in psychotherapy (Hofmann, Grossman, & Hinton, 2011). One thing that distinguishes CFT from other therapies that incorporate compassion is our focus on helping clients understand their chal- lenges in the context of evolution (how our brains evolved to produce basic motives and emotions), the dynamics of how emotions play out in the brain, and the social factors that shape the self, par- ticularly early in life. None of these factors are chosen or designed by our clients, but they play a huge role in their struggles. In this book, you’ll learn to help clients apply these understandings to their problems, so that they can stop shaming and attacking themselves for things that aren’t their fault, and focus on taking responsibility for building better lives. Whereas shame is linked with avoidance that can contribute to our clients’ struggles (Carvalho, Dinis, Pinto-­ Gouveia, & Estanqueiro, 2013), compassion can give them a way to approach their difficulties with acceptance and warmth, to face them and work with them. In CFT, clients learn about how different emotions and basic motives evolved to serve certain functions, exploring how these emotions play out in ways that can create interesting challenges when combined with modern environments and new-brain capacities for imagery, meaning-­making, and symbolic thought. For example, clients learn how the confusing dynamics of threat emotions like anxiety and anger make complete sense when viewed through the lens of evolution. Such understanding reveals why it’s so easy to get “stuck” in such emotions, which can help lessen clients’ tendencies to shame themselves for their feelings. CFT also explores how social contexts and attachment relationships can serve to transform our underlying genetic potential into challeng- ing behaviors and emotions. This exploration creates a context for self-­compassion to take root, as patients begin to realize how many of the factors that create and maintain their problems were not of their choice or design, and hence, not their fault. In CFT, this de-­shaming process is accompanied by a simultaneous building of responsibility and emotional courage through the cultivation of compassion. Patients learn to work with evolved emotion-­regulation systems to help themselves feel safe and confident as they approach and actively engage with life challenges. They are guided in developing adaptive, compassionate strategies for working with emotions, relationships, and difficult life situations. In CFT, the emphasis is on helping clients learn to stop blaming themselves for things they didn’t get to choose or design, and to skill- fully work with the factors they can impact to build a repertoire of skills for working with life chal- lenges and building fulfilling, meaningful lives. As we will explore, this is done through both implicit 3CFT Made Simple aspects of the therapy, such as the therapeutic relationship and the therapeutic emphasis upon guided discovery, as well as specific techniques such as imagery, compassion cultivation practices, and the development of compassionate reasoning. The Evidence Base for CFT One of the most important movements in the field of mental health over the past century or so is the emphasis on having our treatments grounded in solid science. The evidence base in support of CFT is twofold: First, there is the growing body of research supporting the efficacy of CFT interventions. Second, there are several underlying bodies of literature that provide the scientific basis for the theory behind CFT as well as the process-­level components of the therapy. While the focus of this book is on learning the therapy, I wanted to take a moment to briefly introduce you to the science underlying CFT. EVIDENCE FOR CFT INTERVENTIONS Of course, the first question to consider is Does CFT work? There is a relatively small but rapidly growing body of research documenting the efficacy of CFT interventions. Research has shown that CFT can help to reduce self-­criticism, shame, stress, depression, and anxiety (Gilbert & Proctor, 2006; Judge, Cleghorn, McEwan, & Gilbert, 2012). Other studies have documented posi- tive outcomes using CFT with people suffering from psychotic disorders (Braehler et al., 2013; Laithwaite et al., 2009), eating disorders (Kelly & Carter, 2014; Gale, Gilbert, Read, & Goss, 2014), personality disorders (Lucre & Corten, 2013), problematic anger (Kolts, 2013), and traumatic brain injury (Ashworth, Gracey, & Gilbert, 2011), and in conjunction with eye movement desensitization and reprocessing for the treatment of trauma (Beaumont & Hollins Martin, 2013). The primary limitation of the current literature supporting the efficacy of CFT is the relative lack of randomized controlled trials (RCTs) documenting its effectiveness. At the time of this writing, there are two such RCTs in print. One of these (Kelly & Carter, 2014) showed significant impacts of CFT in reducing binges, global eating disorder pathology, and eating and weight con- cerns, and increasing self-­ compassion in individuals with binge-­ eating disorder. The second (Braehler et al., 2013), documented the impact of CFT upon clinical improvement in patients suf- fering from psychosis relative to controls, along with increases in compassion that were associated with reductions in depression and perceived social marginalization. A recent systematic review of the literature on CFT (Leaviss & Uttley, 2014) concluded that CFT shows promise in treating psy- chological disorders, particularly for highly self-­critical individuals, but notes that more high-­ quality clinical trials are needed before definitive statements can be made about CFT being an evidence-­based treatment approach. We in the CFT community agree with this assessment, believ- ing that a therapy model is only as good as the science behind it, and are committed to the growing production of rigorous research examining CFT’s effectiveness. 4Introduction THE SCIENCE UNDERLYING THE CFT MODEL A second question to ask in considering the science behind CFT is Where does CFT come from? In developing CFT, Paul Gilbert’s goal was not to create an entirely new model of psychotherapy in competition with other therapy models, but to integrate and build upon what existing science tells us about how humans get to be the way they are, and how we can best help them work with suffer- ing when things go wrong (personal communication, 2009). As such, CFT finds its roots in a large and varied body of scientific research, including the neuroscience of emotion and affiliation (e.g. Depue & Morrone-­Strupinsky, 2005; Cozolino, 2010), the existence and dynamics of basic evolved emotion-­regulation systems (e.g. Panksepp, 1998; Panksepp & Riven, 2012), and the social shaping of the self through attachment relationships (e.g. Schore, 1999; Siegel, 2012). In its approach to understanding the dynamics of emotion, CFT also draws heavily on behav- iorism (e.g. Ramnerö & Törneke, 2008) and upon cognitive science regarding things like the working of our implicit and explicit memory and emotion systems (e.g. Teasdale & Barnard, 1993). Likewise, in structuring our approach to treatment, CFT draws upon science documenting the social regulation of emotion (e.g. Cozolino, 2010; Porges, 2011) and growing evidence supporting the use of compassion practices (Hofmann, Grossman, & Hinton, 2011) and related therapeutic strategies in the treatment of psychological disturbances—­strategies such as mindfulness, mental- ization, and other interventions we’ll explore in this book. We won’t dive too much more deeply into the scientific basis of the therapy here, as the focus of this book is on the application of CFT, and there are existing resources that provide a detailed articulation of both the theoretical basis of CFT and the science that underlies it (see Gilbert, 2009a; 2010; 2014). The Practice of CFT My goal in writing this book is to give you an accessible guide to learning and applying CFT. CFT Made Simple is primarily designed to be an entry point for mental health professionals who want to learn the CFT model and begin applying it in their clinical practice. It may also be useful for clients, or anyone who is interested in CFT and wants to learn more about it and how it is used in therapy. LAYERED PROCESSES AND PRACTICES My hope is that after reading this book, you will understand CFT not as a collection of tech- niques, but as a set of layered processes and practices that interact and strengthen one another. These layered processes and practices are aimed at helping clients to establish and elaborate upon two common themes: developing compassion for themselves and others, and cultivating a repertoire of compassionate capacities for working courageously with suffering. This book will be loosely orga- nized to mirror this layered approach to CFT. Many of our clients will enter therapy with deeply seated shame and self-­criticism, or with lives that are defined by experiences of threat and 5CFT Made Simple emotional distance, volatility, and ambivalence. In the beginning, such clients may not be ready to benefit from diving into traditional self-­compassion practices. As with the practice of master gar- deners, the first few layers of CFT are designed to prepare the soil, so that when planted, the seeds of compassion will flourish. Let’s explore this layering: Therapeutic Relationship Compassionate Understanding Mindful Awareness Compassionate Practices Figure 1: Layered Processes and Practices in CFT After a brief orientation to the origins and basic concepts of CFT in chapter 1, chapter 2 will provide an introduction to compassion and how it is operationalized in CFT, giving us a context for what is to come. In chapter 3 we’ll focus on the first layer in our approach: the therapeutic relation- ship. In the context of an unconditionally warm therapeutic relationship designed to help clients learn to feel safe, we’ll orient ourselves to the process of the therapy. We’ll explore the presence and roles served by the CFT therapist, and the general therapeutic approach used in CFT—­one of guided discovery. This relationship forms the first layer of compassion in CFT, as clients gradually learn to feel safe in relationship to the therapist, and to experience compassion coming to them, from this person who is committed to their well-­being. In chapters 4 through 6, we’ll begin exploring the second layer of compassion in CFT: compas- sionate understanding. We’ll learn how CFT helps clients to begin to understand their emotions and life experiences in nonblaming, compassionate ways. This work is done via the development of understanding about how their minds and lives have been shaped by forces that they neither chose nor designed—­evolution, social shaping, and the ways these interact. We’ll revisit this theme later in the book, introducing a CFT-­based model of case formulation in chapter 13. 6Introduction In chapter 7, we’ll turn our focus to compassionate, mindful awareness, which is the third layer of compassion in CFT. We’ll explore strategies to rapidly help clients increase their awareness of their emotions, thoughts, and motives. We’ll also consider ways to help our clients not get caught up in some of the common obstacles that often hamper beginners in their efforts to learn mindfulness. In chapters 8 through 15 we’ll formally turn our focus to the fourth layer: compassionate prac- tices for working with suffering. In chapter 8, we’ll explore how to help clients develop motivation to shift from a self-­critical to a compassionate perspective in working with their challenges. In chapter 9, we’ll explore how to help clients develop the compassionate self—­a wise, kind, courageous, adaptive version of themselves that will serve as a reference point from which they can develop the courage to work with the things that terrify them, and the compassionate strengths to use in doing so. We’ll then explore ways to help clients cultivate compassionate thinking and reasoning (chapter 10) and the ability to use compassionate imagery to self-­soothe and deepen compassion for them- selves and others (chapter 11), and introduce the use of chair work and perspective-­taking exercises in helping clients strengthen the compassionate self, giving it a central role in their lives (chapter 12). In chapter 14, we’ll explore the Multiple Selves exercise—­a powerful method for bringing compassion to difficult emotions and situations—­and in chapter 15, we’ll explore how the compas- sionate perspective offered by a CFT approach can fit with and enhance the tools you already use in your therapy practice. Together, these layers provide a framework for learning CFT, and for how CFT can be used in conjunction with empirically supported technologies of change such as behavior activation or exposure. Hopefully you’re beginning to realize that CFT is not simply a recycled form of cogni- tive behavioral therapy with some compassion practices pulled from Buddhism added in for good measure. We’re working to layer an interactive set of processes—­nurturing relationships, powerful understandings, deepening awareness, and the purposeful cultivation of compassionate strengths— to help clients shift away from threat-­focused ways of existing in the world and toward a perspec- tive that is kind, wise, and confident, and which draws upon a body of effective skills for working directly and courageously with life challenges. WHAT IF MY CLIENT DOESN’T BELIEVE IN EVOLUTION? One factor distinguishing CFT from other therapy models is that we consider human emotions, motives, and behavior in an evolutionary context. This understanding helps facilitate compassion for ourselves and other people, because much about how these experiences play out in us makes a lot of sense given our evolutionary history. Given the current cultural environment in the West, I thought it might be useful to consider what to do if we find ourselves working with someone who doesn’t agree with the theory of evolution. News articles indicate that approximately one-­third of Americans don’t believe in evolution theory, instead ascribing human origins to the action of a supreme being. 7CFT Made Simple In fact, evidence suggests that rates of belief in evolution may be declining in some groups (Kaleem, 2013). So it’s likely that at some point we’ll encounter clients who simply don’t subscribe to the theory of evolution. I certainly have. Is this a problem for CFT? Well, yes and no. Certainly CFT therapists do not have an agenda around challenging clients’ spiritual beliefs or religion, and there are plenty of CFT therapists who have religious beliefs of their own. Trying to change the mind of someone who is motivated to reject the idea of evolution is probably not going to be helpful, and may actively undermine the therapeutic relationship. There are a few ways we could work with this issue. We could refer such clients to clinicians who utilize approaches that don’t emphasize evolution—­which is pretty easy to do, as there are many therapies that don’t speak to it at all. Alternatively, we could continue with CFT, leaving out the evolution pieces. I don’t see either of these solutions as optimal. There are lots of people who may not believe in evolution, but who could still benefit from CFT. At the same time, evolution isn’t a small facet of the therapy—­it plays a significant role in how we conceptualize the brain, the mind, and the problems our clients bring us. I’d suggest some middle ground, which can actually help us create a model for how to work with difficult issues that will come up in therapy: Honestly discuss the issue in a way that names the situation, and enlist the client in considering how to work with it. We can also soften or omit lan- guage around evolution across species, instead emphasizing adaptation within the human species—­ referring to how our challenging characteristics may have been quite useful for our human ancestors (who faced very different threats and demands than we do now), even as these qualities play out in ways that aren’t very well suited to modern life. Here’s an example of how that conversation might take shape: Therapist: Evan, as we continue to explore our emotions and how they work, I wanted to mention that I’ll be talking about evolution—­specifically about how our emotions make sense when we look at them in an evolutionary context. I know that some people don’t accept the theory of evolution, and I wanted to touch base about that. Evan: (stiffening a bit) I don’t believe in evolution. I believe that God created humans, just as we are. Therapist: Good—­that’s what I wanted to clarify. I want to say at the outset that I don’t have any agenda around challenging or changing anyone’s religious beliefs. People have different beliefs, and there are different ways of understanding how we got here, and how we got to be the way we are. So I’m not going to try and push any beliefs on you. Evan: (visibly relaxing) Good. Because that wouldn’t have gone very well. Therapist: (smiling warmly) I don’t imagine it would have! So I want you to know that I respect your beliefs, but at the same time, the therapy we’ll be doing is based 8Introduction on science, and so I’ll sometimes be talking about things from a scientific perspective—­because it can help us make sense of how our emotions work. You don’t need to accept the theory of evolution for us to proceed. All I need you to accept is that we have brains and minds that sometimes work in tricky ways to produce emotions that can be hard for us to handle. How does that sound? Evan: That’s not hard to accept. I’ve definitely got some emotions that are hard to handle. Therapist: Most of us do. Now, I’ll probably still talk about evolution from time to time, because I come from a scientific perspective, and that’s the way I make sense of things. How about when I do that, I’ll talk about it as “from the scientific perspective,” which you can choose to agree with or disregard—­taking what is helpful and ignoring the rest. What do you think? Evan: Sounds like it’s worth a try. Therapist: We can also focus on things as they played out for humans across the years, as our societies have changed. The idea is that our brains work in ways that may have helped our ancestors—­say, humans who lived in isolated villages in a harsh world that included lots of very real physical threats—­but which can be less useful in the modern world, in which most of the threats we face are very different. What do you think? Evan: I don’t have any problem with that. I know humans have lived in different ways over time. It’s the “coming from monkeys” stuff that I don’t believe. Therapist: It sounds like we’ve got lots of room to work with, then. Also, if it does seem like this issue is getting in the way of our therapy, I’d appreciate it if you’d let me know. If that were to happen, we could explore it together and figure out a way to work with it. What I don’t want to happen is for you to be uncomfortable or unhappy with the therapy and for me to be clueless about it. Evan: Sounds good. I’ve found that once clients understand that I respect their right to hold different beliefs and am not trying to change them, the evolutionary perspective becomes much less of an issue. I’ve also found that using the phrase “from a scientific perspective…” allows me to continue talking about things in the manner we’ll explore in this book, and that clients can often accept it—­because we’re acknowledging that there are other, valid perspectives as well. I’ve even had clients come up with alternative explanations, such as “This tricky brain is a riddle that God gave me to figure out.” Sometimes, I’ve found that as clients see how the information I’m presenting fits with their lived experience and helps explain how their emotions work, they tend to soften to the evolutionary perspective (without giving up any of their religious beliefs). 9CFT Made Simple Even clients who generally reject the concept of evolution are often willing to consider adapta- tions occurring within the human race that fit better with some times in our history than others, and that’s a good thing. The evolutionary piece isn’t just about deshaming emotions by considering why we have them. It also helps us clarify and understand the ways that different emotions play out in us. When we consider that threat emotions like anger and anxiety evolved to help us identify threats and rapidly do what is needed to deal with them, it makes complete sense that when we perceive a threat, our attention, thoughts, and imagery would all be drawn to the threat until the situation is resolved—­in the harsh world faced by our ancestors, ignoring sources of threat could mean injury or death. The problem is that these threat responses are better suited to the savannahs and forests faced by our ancestors than to the boardrooms and relationships that form most of our modern-day threats—­and they are of no use at all in facing the multitude of threats dreamt up entirely via our “new-brain” capacities for thought, imagery, and fantasy. CFT AND OTHER THERAPIES One of the things I like best about CFT is that it is generally quite compatible with other therapy models. We’ll explore this compatibility in the final chapter of the book, and will highlight it along the way. Regardless of whether you want to become a “CFT therapist” or simply want to use a compassion focus to enhance and deepen your work within your current therapeutic modality, I hope you’ll find much here to draw upon. CFT isn’t intended to be an entirely new model of therapy, but rather a basis for compassion- ately understanding and working with psychological difficulties. Relative to other therapies, you may find that CFT is distinguished by its emphasis on compassion as well as on conceptualizing human problems in terms of evolution; how emotions and basic motives play out in our brains, or minds; and the ways we can learn to help ourselves feel safe as we confront and work with the things that scare us the most. At the technical level, you’ll likely find a number of new therapeutic tools here, but there will be things you’ll recognize from other therapies as well. I think it’s fair to say that CFT fits well into the “third wave” of behavioral and cognitive behav- ioral therapies, alongside acceptance and commitment therapy (ACT), dialectical behavior therapy (DBT), functional analytic psychotherapy (FAP), mindfulness-­based cognitive therapy (MBCT), and emotion-­focused therapy (EFT). As with these therapies, we rely on behavioral principles and don’t seek to change the content of problematic cognitions and emotions so much as to change our relationship to these mental experiences (while cultivating more helpful ways of attending and think- ing). As with many of these other approaches, mindfulness plays an important role in CFT. I think the experiential emphasis and perspective-­taking practices used in CFT will resonate with practi- tioners of ACT, and as with DBT, we place a significant emphasis on things like distress tolerance and learning to work with acutely difficult emotional experiences. Longstanding cognitive therapists may find new ways to approach thought work that can help to facilitate affective congruence in their clients—­so that new, reassuring thoughts feel reassuring 10Introduction to them. You may also find that the ways compassion is brought into CFT therapy have the poten- tial to “warm up” longstanding approaches such as exposure therapy, to make them more accessible for clients and more comfortable for therapists. I think practitioners will also discover aspects of CFT that can enhance and deepen their existing therapy practice—­things like considering emo- tions and motives in an evolutionary context, helping clients work with evolved affective systems to create feelings of safeness, and applying the purposeful cultivation of compassion in facilitating one’s willingness and ability to work directly with suffering. Our Current Approach Particularly in psychotherapy, I think it’s nice when a learning process models, shapes, and reinforces the content that is being learned. That’s what we’re going to strive for here. The process of CFT—­regardless of what we happen to be working on with our clients at the time—­is one of warmth, guided discovery, courage, and commitment. You’ll find that this book features a fair number of experiential exercises. Occasionally, I’ll ask you to do some of the same things that CFT therapists ask their clients to do, and I’d like to for- mally encourage you to practice all of the exercises yourself before trying them out with clients. We can learn about things like compassion, mindfulness, and safeness, but if we really want to under- stand them, we need to experience them. Personal practice can give us a depth of understanding with regard to these practices—­the nuances, potential obstacles, and how to overcome them—­that can be very difficult to get any other way. With that in mind, I’d like to begin this book with a motivation-­setting exercise drawn from my experiences learning from Buddhist teachers. These teachers believed that our motivation or inten- tion, the reason we are engaging in a particular activity, is highly related to the outcome of the activ- ity. As I’ve already mentioned, motivation is also a core component of compassion, and it’s a component that we’ll be working to help our clients cultivate. So let’s do that now. WORKING WITH MOTIVATION AND INTENTION As we go through life, we’ll do lots of different things, for lots of different reasons. Sometimes our activities will be driven by feelings of obligation, sometimes by excitement or ambition. We go through the day figuratively (and sometimes literally) checking off items on our list, doing things simply so that we can move on to the next thing that needs to be done. But motivation and intention are aspects of life we can work with. So right now, I’d like you to consider your motivation for doing this activity. Why are you reading this book? Perhaps you’ve heard about CFT and were curious to learn more? Perhaps you’ve been looking for ways to deepen or enliven your existing therapy practice? Perhaps you’re a psychotherapy client whose therapist uses CFT, and you wanted to learn more about it? Maybe something about the cover caught your eye, and you impulsively bought the book to see what it was about, as I often do. 11CFT Made Simple Compassionate motivation is something we can choose to cultivate. Now that we’ve found ourselves here together, let’s see if we can bring up a kind, committed sort of motivation as we go about exploring compassion-­focused therapy. •Consider the therapy situation. Our clients come to us at their most vulnerable, sharing their struggles and suffering, and asking, “Will you help me?” Could anyone ever pay us any greater honor than this? Open yourself to the feeling of wanting to help them work with this suffering. •Is it possible that we can do this—­me thinking, organizing, and writing; you reading, considering, and practicing—­out of a deep commitment to help alleviate suffering in our clients, ourselves, and the world? •What if we really felt that commitment to alleviate suffering—­felt a deep wish to help those who are struggling? •Don’t worry about whether you do or don’t feel it right now. Instead, simply try to imagine what it would be like if you really did feel it—­this deep desire to further your ability to help those who suffer most. •What if that were our motivation? How might it shape the way we engage in learning about and practicing CFT? Let’s see if we can carry that compassionate motivation with us as we proceed. 12CHAPTER 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.CFT Made Simple 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). 14Origins and Basic Themes 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 15CFT Made Simple 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 16Origins and Basic Themes 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 17CFT Made Simple 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. THE SOCIAL SHAPING OF THE SELF As we’ve discussed, having a human life means we’ll experience powerful emotions and motiva- tions that can sometimes be difficult to manage, particularly when we’re faced with trauma or other life challenges. Early social experiences powerfully shape the ability to help ourselves feel safe and regulate our emotions, along with many other aspects of who we are. For example, early and ongoing attachment experiences powerfully impact our ability to feel safe in connection with others (versus feeling threatened), to expect support and nurturing from others (versus expecting harm or neglect), and to relate to ourselves as lovable and worthy of care (versus unlovable and isolated) (Wallin, 2007). 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 18Origins and Basic Themes 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 19CFT Made Simple 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 20Origins and Basic Themes 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? 21CFT Made Simple 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.Origins and Basic Themes 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. 23CHAPTER 2 Introducing Compassion In CFT, we begin with a definition of compassion that is consistent with both the dictionary and the Dalai Lama: sensitivity to suffering with an accompanying motivation to alleviate or prevent it. In the context of CFT, compassion isn’t simply one of any number of values our clients might seek to pursue—­although it certainly can be chosen as a value to guide one’s life pursuits (one which we would obviously encourage). First and foremost, compassion in CFT is an orientation to suffering—­one that empowers us to approach suffering with the helpful motivation to work with it and alleviate it. Let’s take a moment to unpack this definition. In the context of compassion, we can consider sensitivity as referring to the ability to become aware of suffering, as well as the willingness to be moved by it. If our minds are unbalanced and powerfully caught up in experiences of threat or drive, we can find ourselves oblivious to suffering. It’s not that we don’t care, necessarily. It’s that we can become so powerfully focused on perceived threats or caught up in pursuing our goals that the suffering of others (or even ourselves) just doesn’t show up on the radar. Additionally, if our clients are going through the world with mind and body dominated by experiences of threat, opening themselves to suffering can be overwhelming. In such a situation, we can understand why they might resort to avoidance strategies in the effort to alleviate intensely felt distress. On the other hand, if things are balanced, with threat and drive emotions tempered by the ability to experience safeness and the mindful capacity to observe emotions without pushing them away, our clients can learn to notice their suffering, and to be warmly moved by it without becoming overwhelmed. Avoidance can give way to a willing, mindful, compassionate awareness: I’m really hurting right now. This argument with my spouse has really activated my fears of being abandoned. This is reallyCFT Made Simple hard for me. In considering this possibility, we see that a primary aspect of compassion we’ll be helping our clients develop is emotional courage—­the willingness to approach and connect with very difficult feelings, in the service of helping themselves work with these experiences. The second component of compassion involves the kind motivation to help alleviate and prevent suffering. While it may seem obvious that when presented with suffering, we’d want to help alleviate it, this isn’t always the case, particularly for clients with extensive histories of shame and self-­criticism. For such clients, observations of their struggles and pain may serve as anteced- ents not for helping but for self-­attacking, as they interpret these experiences as more evidence that there is something wrong with me—­that they are bad, flawed, or unworthy. Other clients may become fused with such experiences—so caught up in rumination and cycles of threat-­based thinking and emotion that they are unable to disengage from the experience and consider what they might be able to do about their pain. Here again, we see the importance of helping clients relate to their experience in nonshaming ways, to mindfully observe when threat responses begin to carry them away, and to connect with feelings of safeness. When this happens, it paves the way for compassionate reasoning to emerge, as ruminative thoughts like I can’t take this give way to compassionate questions, such as What would be helpful as I work with this difficult experience? Additionally, If we’re to help our clients maintain this helpful motivation to approach and work with suffering, we also need to help them develop confi- dence that they can engage in helpful action—­confidence rooted in a repertoire of useful skills for working with the pain of life. We need to give them tools, strategies, and practices that work. COMPASSIONATE ATTRIBUTES Now that we’ve explored a working definition of compassion, let’s spend a bit more time exploring how compassion is operationalized in CFT. This operationalization is depicted graphically in the Circle of Compassion in figure 9.1, below. In this figure, compassion is depicted as a collection of attri- butes, which are cultivated via the training of various compassionate skills, all of which occurs within a therapeutic context defined by warmth. Compassion in CFT involves the cultivation of various attributes that facilitate a skillful, approach-­based orientation toward pain, struggle, and suffering. Woven throughout these attri- butes is a focus on helping clients develop compassionate courage—­so that they can approach and work with the really difficult things, particularly the challenging emotions they may be inclined to avoid. Let’s briefly explore these attributes. 26Introducing Compassion Warmth Warmth SKILLS TRAINING Imagery Attention ATTRIBUTES Sympathy Sensitivity Care for well-being Feeling Compassion Nonjudgment Reasoning Distress tolerance Empathy Behavior Sensory Warmth Warmth Figure 9.1: The Circle of Compassion—­Compassionate Attributes and Skills. (From Gilbert, The Compassionate Mind [2009], reprinted with permission from Little, Brown Book Group.) Sensitivity As we’ve mentioned previously, sensitivity is a core component of our definition of compassion. In this context, sensitivity refers to helping clients open their awareness to experiences of pain, suffering, struggle, and difficulty. This openness may stand in stark contrast to the avoidance that may characterize their habitual coping methods. Sensitivity involves noticing these experiences, so that they show up on the radar. Rather than avoiding the difficult things in their lives, we help clients learn to actively and purposefully attend to them, which allows the possibility of being moved by them. Sympathy The sensitivity of compassion isn’t a cold awareness that things aren’t as we’d prefer them. It is infused with warmth—­containing a felt connection to the being that suffers, whether that being is us or someone else. Sympathy involves feeling a bit of heartbreak for the being that is suffering—­we are moved by their suffering. This sympathy is important, and it stands in stark contrast to the 27CFT Made Simple self-­criticism and shame that our clients often bring to therapy. Sympathy involves a softening of self-­to-­self and self-­to-­other relating. When clients can stop self-­attacking and allow themselves to be moved by their own suffering (or that of others), it helps them be motivated to face and work with this suffering, even knowing that doing so won’t be easy. With compassion, we are moved, and we want to help—­which brings us to the next attribute. Compassionate Motivation Compassion involves a sincere motivation to help prevent or alleviate suffering. With compas- sion, we accept and engage willingly with suffering, but we don’t wallow in it. In helping clients develop compassionate motivation, we’re helping them develop the motivation and courage to approach suffering with a specific intent—­to understand the suffering and the causes and condi- tions that lead to it, so they can engage in helpful activity to help alleviate or prevent it. We’re trying to help clients strengthen and learn to shift into a caregiving social mentality (we’ll discuss social mentalities a bit later), so that rather than being consumed by feelings of threat, their atten- tion, thinking, motivation, and behavior are focused on helping themselves and others. This moti- vation can give rise to the courage to face difficulties head-­on. This caring motivation isn’t something we’re manufacturing from scratch—­we’re working to awaken our clients’ natural capacity for caregiving and nurturance that evolved with our mammalian ancestors, enabling them to face tremendous hardship and danger to ensure the survival of their young. Distress Tolerance As we see in other therapy models, such as dialectical behavior therapy (Linehan, 1993), CFT incorporates distress tolerance as a capacity to be cultivated. In order to work directly and actively with suffering and the factors that lead to it, both clients and therapists need to be able to tolerate the discomfort that comes with doing so. Distress tolerance in CFT involves both the willingness to endure discomfort and the cultivation of the ability to self-­soothe—­to help ourselves feel safe and to make life a bit easier when there is pain that must be endured as we approach and work with suffering. Nonjudgment As we’ll see, compassion in CFT also involves helping clients develop mindful awareness. In addition to the sensitivity—­the noticing—­described above, compassion involves the ability to relate to one’s experience in accepting, nonjudgmental ways. In cultivating compassion, clients learn to replace the judging, labeling, and self-­blame that may accompany difficult experiences with a com- passionate awareness that seeks to understand these experiences. This leads us to the final compas- sionate attribute: empathy. 28Introducing Compassion Empathy Whereas sympathy involves being moved by suffering, empathy involves making efforts to understand the suffering as it exists from the perspective of the being that suffers. We want to help clients look deeply at the range of emotions arising within themselves and others. What am I actually feeling? How does it make sense that I might be feeling this way? Having suspended judgment, compassion seeks to understand the emotional landscape that is being traversed—­in therapy, and in life. Taken together, these compassionate attributes form a powerful orientation toward suffering, which unfolds from awareness to action. With compassion, we notice suffering, we are moved by it, and we want to help. In order to do this, we must work to tolerate distress, and to nonjudgmentally and empathically under- stand the causes and conditions that contribute to the suffering and difficulty. Armed with this motivation and understanding, clients and therapists are well equipped to draw upon a wide variety of powerful technologies to address psychological suffering—­which is why CFT can potentially be a helpful adjunct for those whose therapeutic work is rooted primarily in other modalities. COMPASSIONATE MIND TRAINING In helping clients cultivate the compassionate attributes described above, CFT focuses on assisting them in developing a number of compassionate skills. Let’s take a look at the skill-­training domains we’ll be targeting in helping our clients cultivate the compassionate attributes described above. Compassionate Thinking and Reasoning Compassionate thought work in CFT is twofold. First, it involves helping clients relate to thoughts mindfully—­nonjudgmentally noticing and accepting their thoughts as mental activity without getting caught up in clinging to them or pushing them away. Second, it involves the pur- poseful cultivation of compassionate ways of thinking, reasoning, and understanding—­ways of thinking that are validating, soothing, encouraging, and skillfully focused on working with suffer- ing. In CFT, compassionate ways of thinking are defined by helpfulness. These ways of thinking will be represented in multiple areas of the layered approach we’re taking in this book. First, we help clients develop compassionate understanding of their minds, emotions, and how things came to be the way they are in their lives. A bit later on, we focus on helping clients specifically cultivate com- passionate ways of thinking. Attention and Sensory Focusing A primary goal in CFT involves helping clients to work with their attention in skillful ways. First, we’ll help clients develop compassionate awareness through the cultivation of mindfulness, introduced in chapter 7. Mindfulness occupies a central role in CFT, both in increasing client 29CFT Made Simple awareness of how thoughts and emotions arise and play out in their minds, and in helping them relate to and work with these mental activities in accepting, nonjudgmental ways. CFT therapists also utilize specific sensory-­focusing exercises in training clients to focus their attention in ways that can help them soften the inertia of threat emotions, calm the body, and prepare the way for compassionate states of mind. One of the most common of these exercises is soothing rhythm breathing, introduced in chapter 4. Imagery CFT utilizes imagery extensively, both in helping clients work with difficult affective states and in developing and applying compassion in their lives. The latter is best exemplified by the Compassionate Self practice, introduced in chapter 9. This practice is an imagery-­based method-­ acting practice aimed at helping clients cultivate a compassionate, adaptive version of the self that provides an organizational framework for the development of a repertoire of compassionate strengths. We’ll also use imagery exercises to help clients learn to self-­soothe and create feelings of safeness in themselves. Feeling and Emotion One factor that perhaps distinguishes CFT from other cognitive behavioral approaches is the high premium we place on working with affect. Like other therapies, much therapeutic work in CFT is anchored around helping clients work with difficult emotions. However, CFT also involves a very intentional focus on the purposeful cultivation of compassionate feelings—­warmth, kindness, courage, affiliation (to self and others), and safeness. Both sides of this work cross many of the layers of therapy mentioned earlier—­the therapeutic relationship as a basis for the development of relational safeness, compassionate understanding and mindful awareness of our affects and how they play out in us, and the cultivation of compassionate skills for emotional soothing and for working with difficult emotions and experiences via chair work, exposure exercises, and imagery. Behavior The second component of compassion—­the motivation to help address and prevent suffer- ing—­is incomplete without compassionate action. In CFT, there is a strong focus on helping clients develop a repertoire of compassionate behaviors. Behavioral work in CFT is focused both on helping clients understand and work skillfully with sources of suffering and on building lives that are filled with meaning, fulfillment, and good relationships. In this work, CFT therapists draw upon behavioral theories of learning to understand the historical roots and conditions that maintain client difficulties, and to help clients relate to these challenges in compassionate ways—­as learned responses and coping strategies that were shaped by social forces they didn’t get to choose or control. 30Introducing Compassion Additionally, CFT therapists make use of a wide range of empirically supported behavioral interventions—­including behavior activation, exposure work, and social skills training—­depending upon the needs of the client. In CFT, all of these strategies are couched within an organizing framework of compassionate motivation and understanding. The idea is that we’re warming up the techniques, with the goal of softening their threatening aspects and potentially increasing client motivation and utilization. We want clients to experience these behaviors and strategies not as something I have to do (that I’d really rather not do) but as compassionately motivated efforts to care for themselves and develop strengths and competencies in the service of having good lives. SUMMARY In this chapter, we’ve introduced a working definition of compassion, and have explored how CFT operationalizes compassion in terms of attributes we help clients cultivate and specific skills we’ll be working to develop in therapy. As we saw in the introduction, CFT Made Simple takes an approach defined by layers of treatment: the therapeutic relationship, the development of compassionate understanding, the cultivation of mindful awareness, and the specific development and application of compassion. Each of these layers is centered around laying the groundwork for clients to mani- fest compassion in their lives: creating a therapeutic environment defined by relational safeness; facili- tating our clients’ understanding of the unchosen biological and social forces that have shaped their experience in ways that were not their fault; cultivating accepting, nonjudgmental awareness of their expe- riences; and purposefully working to develop a repertoire of compassionate strengths. In the next chapter, we’ll explore the first of these layers: the therapeutic relationship in CFT. 31CHAPTER 3 Compassionate Relating: Roles of the Therapist in CFT It is well established that one of the most important predictors of therapy outcome is the relation- ship between the therapist and the client (Martin, Garske, & Davis, 2000). The process of therapy can be a scary and difficult one for many clients, as they confront, explore, and work with the parts of their lives that are most troubling, and the things they like least about themselves. A good thera- peutic relationship can help clients have the courage to explore and work with difficult emotions and traumatic memories, support the self-­acceptance and confidence needed to confront them- selves when their behaviors don’t fit with who they want to be, and provide them with a valuable template of how to have and maintain good relationships with other people, even when the going gets tough (Kohlenberg & Tsai, 1991; Tsai et al., 2009; Holman, Kanter, Kohlenberg, & Tsai, 2016). Many of our clients will never have had such a trusting, safe relationship with anyone, and may even have learned to feel unsafe in connection with others. Additionally, there are a number of therapeutic tasks in CFT that require the therapist to serve a number of different but related roles within the context of the therapeutic relationship. In this chapter, we’ll explore the various roles of the therapist in CFT, and how the CFT therapist can embody them. DIFFERENT ROLES FOR DIFFERENT TASKS In a typical course of CFT, there are a number of processes that the therapist seeks to facilitate. The overall process of CFT is one of guided discovery, in which clients learn about how and why their emotions work the way they do, and how to relate to and work compassionately with theseCFT Made Simple experiences. Compassion and mindfulness are both taught and modeled, within the context of a safe therapeutic relationship that allows the client to explore and work with scary emotions and life situations. In this way, the process and content of CFT are consistent and serve to deepen and reinforce one another. In CFT, therapists function as teachers of the evolutionary model, as facilita- tors of a process of guided discovery, as a secure base for exploration, and as models of a compas- sionate self. Let’s explore these roles. Teacher of the CFT Model As they go through CFT, our clients will do a lot of learning. One thing that distinguishes CFT from other therapy approaches is its firm rooting in the evolutionary model. As we’ll see in chap- ters 4 and 5, an initial goal of the therapy involves helping clients understand their basic motives and emotions within the context of evolution. Looking through the lens of evolution, clients can make a lot more sense of confusing emotions and motives. Rather than seeing them as personal flaws, clients can see how these emotions had great survival value to our ancestors, allowing them to pass their genes on to us. They also learn about the evolutionary functions served by different emotions, and relatedly, how these emotions play out in terms of our attention, thinking and rea- soning, mental imagery, bodily experience, motivation, and behavior. Clients also learn about the tricky ways our “old-brain” emotions and motivations can interact with “new-brain” capacities such as mental imagery, symbolic thought, and rumination, as well as how these dynamics are shaped by the social forces in our lives. These realizations set the stage for compassion for the self and others in CFT, as clients develop a growing awareness that many of the factors which powerfully shape our mental experience and development are not of our choosing or design (Gilbert, 2009a; 2010; 2014). In helping our clients understand themselves and their minds better, we’ll also touch on other things, which can include exploration of the client’s learning history, attachment history, and other factors and experiences which can contribute to the social shaping of the self. At each stage, there will likely be some teaching involved, as we work to help our clients develop greater insight into the causes and conditions that have contributed to who they are, and how their minds work. We’ll also be teaching our clients about compassion—­what it is, what it isn’t, and how we can apply it in working with challenging emotions and life situations. So particularly in the beginning, CFT can feel a bit content-­heavy in comparison to other therapy models, with the CFT therapist serving as the teacher, helping clients to make the realiza- tions described above. As you might imagine, if done unskillfully, this teaching could come off as quite invalidating to our clients. Imagine anxiously making the courageous step to come into therapy, finally ready to share the most difficult aspects of your life with a therapist, only to find yourself receiving a lecture about evolution! So it’s important that we find ways to do this teaching that not only help clients learn about their minds, but also validate their experience, convey com- passion, and help to establish and strengthen the therapeutic relationship. Let’s explore a few ways of doing this. 34Compassionate Relating: Roles of the Therapist in CFT RELATING THE MODEL TO THE CLIENT’S LIVED EXPERIENCE As is seen in other models such as functional analytic psychotherapy (FAP), perhaps the best way to teach the CFT model is via an interactive process in which we’re helping clients relate it to lived experience of their emotions, motivations, and social history (Kohlenberg & Tsai, 1991; Tsai et al., 2009; Holman et al., 2016). This can involve conducting what we call an evolutionary func- tional analysis (Gilbert, 2014), helping clients to consider the evolutionary origins of their emotions in relation to how these emotions play out in their current lives. In this way, teaching clients the evolutionary model can be woven into the most foundational elements of the therapy, such as getting a thorough description of the client’s presenting problem. We’ll discuss this in more detail later, but to give one example, clients are guided to explore how the dynamics of the emotions they struggle with (such as fear or anger) make sense when considered in an evolutionary context. For example, threat emotions narrow one’s attention and reasoning to the source of a perceived threat. This narrowing can be frustrating for us when the threat is a social interaction we had days earlier that we can’t stop ruminating about, but we can see how such narrowing would have survival value to our ancestors who were faced with physical threats that needed to be immediately attended to if they were to survive to pass along their genes. This process can be very powerful. Consistent with the research on therapist credibility, I’ve found that when the information I’m providing clients clearly reflects their experience of how emo- tions play out in their own minds (and deepens their understanding of why), my credibility as a therapist goes up rapidly, which increases my therapeutic influence (Hoyt, 1996). Clients are much more likely to walk with us along difficult emotional roads when what we’re saying fits with their lived experience. When it comes to teaching our clients about compassion, while CFT includes numerous imagery and perspective-­taking practices, we can also use present-­moment affective work in therapy. If we pay close attention, we’ll sometimes observe our clients being moved in the present over suffering that they or others have experienced in the past. If we choose to look through the lens of compassion, we can see these emotions—­sadness, grief, even anger—­as wonderful examples of the first component of compassion, which involves being moved by suffering, and can point this out to the client. Therapist: You became emotional when describing how difficult it was for you growing up—­how terrible it was to be bullied at school, and to face your father’s rages at home. Josh: Yeah. It was awful. I just wanted to be a kid, you know. I just wanted to play and not be scared all of the time. To not have to worry about who’s gonna kick the shit out of me. (Makes pensive expression and shakes head slowly back and forth.) Therapist: It’s moving, isn’t it, to imagine that childhood version of you…that little boy who only wanted to play, have friends, and be safe. It’s heartbreaking to recognize how terrible that was for him—­how terrible it was for that younger version of you. 35CFT Made Simple Josh: (going quiet) I never thought about it like that. I guess it was terrible. No kid should have to go through that. (Shakes head; becomes slightly teary.) Therapist: I guess I find myself wondering if there might be a whole lot of hurt and sadness behind this anger you’ve been struggling with. Sadness about what that younger version of you went through. Josh: I guess it is sad, you know. Why couldn’t I have had a dad who took care of me, and friends who played with me rather than bullies who beat me up? Every kid should have better than that. Therapist: Do you hear that, Josh? What you just said? That is compassion. That’s what it is. It’s opening our hearts to the suffering of that little boy—­to your suffering—­and wishing that we could do something to help him. This anger, pain, and sadness that you feel—­how much of that is rooted in knowing just how hard it was for that boy, and not wanting to ever feel vulnerable like that again? Josh: Lots of it. Therapist: So what if we could experience that pain and heartbreak—­maybe even the anger—­as a compassionate sensitivity to that pain you went through? Instead of attacking yourself for having those feelings, what if we could use them as a prompt to help us really commit ourselves to helping you work with this suffering—­to help you feel safe and work on becoming the sort of man you want to be? Josh: (Makes considering expression and nods.) That sounds good. Helping clients see the links between their present emotional challenges and their previously experienced suffering can reinforce their understanding of what compassion is, and it can help depathologize their emotions—­softening shame or negative reactions they may have in relation to these feelings. Clients can come to understand previously avoided emotions as reactions that are not only natural, but potentially useful prompts for the second part of compassion—­helpful rea- soning and action. PROVIDING SUPPLEMENTARY MATERIALS One way to ease the “teaching load” is to provide the client with materials they can read, listen to, or view outside of the session. Examples of patient handouts, guided audio practices, and other resources for clinicians can be found on the New Harbinger website for this book: http://www .newharbinger.com/33094. The international Compassionate Mind Foundation (http://www .compassionatemind.co.uk) website also includes instructions for joining the CFT e-mail list, through which numerous CFT clinicians will readily share resources they’ve developed. Many CFT therapists begin using materials developed by others, and then adapt their own to fit the 36Compassionate Relating: Roles of the Therapist in CFT needs of their clients—­I’d recommend you consider doing the same, and then share what you’ve developed on the CFT mailing list, to contribute the growing set of resources we have to help our clients. Finally, the Compassionate Mind series of self-­help books tailor the CFT model to specific client problems such as anxiety, social confidence, trauma, anger, and eating disorders, and can be readily used alongside individual psychotherapy. Such resources can help clients deepen their understanding of the model between sessions. Ultimately, we need to keep in mind that the “teaching” in therapy is done via a process of guided discovery, which is a nice segue to the next role the therapist takes on in CFT—­that of facilitator. Facilitator of Guided Discovery The overall process of CFT is one of guided discovery, in which clients learn to relate to them- selves, their mental experiences, and other people from a perspective of compassion. As we explored in chapter 2, the development of compassion in CFT is a multifaceted process. The therapist acts as the facilitator of this process, working to create opportunities for experiential learning that will help clients develop capacities such as compassionate understanding and reasoning, empathy, men- talization, distress tolerance, and wisdom (Gilbert, 2009a; 2010). In this role as facilitator, the therapist operates from a perspective of both wisdom and inquisitiveness—­she has an understand- ing of the overall process that will be facilitated, but works collaboratively with her clients to dis- cover the specific dynamics that play out in their lives. This role is emphasized in the following types of verbal interactions and interventions used in the therapy. SOCRATIC DIALOGUE As with a number of other therapy models, CFT makes extensive use of Socratic dialogue to help clients explore their experience. Such interactions involve questions and reflective restate- ments designed to prompt clients to look deeply into the feelings, motives, and behaviors of them- selves and others, as well as the causes and conditions that serve to create and maintain those experiences. There are myriad uses for Socratic dialogue, including increasing clients’ awareness of their own thoughts and emotions, teaching the evolutionary model, facilitating mentalization, doing functional analysis of behavior, and facilitating shifts to a compassionate perspective—­as we saw in the case example of Jenny in chapter 1. Here are a few common examples of Socratic dia- logue that I find myself using a good bit in my own practice of CFT: • Given what we know about your history, how does it make sense that you might feel/ think/act in that way? • (After noticing nonverbal behavior signaling an emotional shift): What just happened there? What feelings came up for you just then? 37CFT Made Simple • If you were to… (name behavior the client has been avoiding), what would be the threat in that? What would you be afraid might happen if you did that? • What might help you feel safe as you work to address this challenge at work? • If someone you really cared about and wanted to help were struggling with… (name a situation similar to what the client is facing), what would this kind, wise, confident version of you want her to understand? How might you comfort or encourage her? The idea behind Socratic dialogue is to facilitate the client’s exploration of his experience (and that of others) in an active manner, so that realizations are being made from the client’s side, rather than interpretations being provided by the therapist. EXPERIENTIAL EXERCISES Much of the latter half of the book will be spent presenting techniques employed by CFT therapists, many of which are centered around creating opportunities for experiential learning and the development of compassionate capacities in the client. Examples of such strategies include mindfulness practices, guided imagery work, perspective-­taking exercises, chair work, and thought and behavioral experiments. We’ll be exploring these in depth as we go on, but the role of therapist-­ as-­facilitator is consistent throughout: setting the stage for the exercise by offering preparatory instruction, guiding the client through the experience, assisting in identifying and working with obstacles that may arise, and prompting client exploration of the experience afterward. Considering mindfulness training, for example, the therapist begins by giving the client basic instructions on the practice, as well as specific instructions designed to circumvent common obsta- cles (we’ll explore these in chapter 7). He then guides the client through the mindfulness practice, offering more extensive description and prompts initially, then phasing these out as the client becomes more familiar with the practice. Following the exercise, the therapist and client have a discussion in which they explore the client’s experience of the exercise—­what they observed and learned—­as well as any obstacles that may have come up during the practice. EXPLORING INTERPERSONAL DYNAMICS As in other therapy models, it isn’t unusual for CFT therapists to shift the discussion to focus on patterns of interaction playing out within the therapeutic relationship. Often, clients manifest repetitive relational patterns in therapy that mirror their outside relationships (Teyber & McClure, 2011). Rather than reacting to client resistance, capitulation, or passivity, we want to consider what it means. Shifting the discussion to what is happening between us in therapy can bring awareness to these dynamics, and set the stage for considering how best to work with problematic relational patterns of which the client may not previously have been aware. This can be done in a collaborative, non- shaming way: “I’m noticing that we seem to be falling into a pattern where I’m making lots of 38Compassionate Relating: Roles of the Therapist in CFT suggestions that don’t seem to be helpful to you—­I feel like I’m getting ‘shot down’ a lot. Could you share your experience so we can figure out how best to go forward?” or “I’m noticing seems to be happening in our relationship. Have you ever noticed patterns like this playing out in other relationships?” WORKING COLLABORATIVELY WITH OBSTACLES You’ll note that in the mindfulness example given above, much attention was given to potential obstacles, both in preparation for the practice and in the discussion afterward. This is important, as obstacles and roadblocks will frequently arise in therapy—­frequently enough that entire books have been written to help therapists work through them (e.g. Leahy, 2006; Harris, 2013)—­so we need to be prepared to work with them. Sometimes obstacles involve vague understandings or misconceptions on the part of the client regarding what is to be done. Sometimes it’s a motivational block. At other times, there are pragmatic factors in the client’s life that get in the way (such as not remembering to practice). We can never fully anticipate what anyone’s experience of a given prac- tice is going to be, but we can be assured that it will often go far awry of what we may hope for when introducing a practice or homework exercise. In CFT, we always want the therapeutic relationship to be a collaborative one, in which the client and therapist work together to discover ways to address challenges in the client’s life and to facilitate compassionate growth. This is particularly true when it comes to working with obstacles. When challenges arise in therapy, it can be easy to fall into roles in which therapist and client both feel a bit threatened and become rigid—­the therapist on one side, trying to get the client to do something, and the client on the other side, resisting. If allowed to play out, this dynamic can easily lead to ruptures in the therapeutic relationship. In CFT, we consider things in terms of evolved emotion-­regulation systems and also consider social mentalities—­evolved motivational orientations that organize our interactions with others (Gilbert, 2014; 2010). In the language of CFT, if a client is operating out of the threat system (feeling threatened, anxious, or angry in relation to the therapist or therapy) and relating to the therapist via a defensive social mentality (in other words, her interactions with the therapist are organized around defending herself or her position), it can be easy to get stuck in therapy. We want the therapist and client to be on the same side, collaboratively working together to explore and address the obstacles that will inevitably come up in the therapy. We start by assuming that there are valid reasons behind clients’ reactions, emotions, and behaviors, and so when obstacles come up, we try to model compassionate reasoning. Instead of judging and labeling the client as resistant (which they very well may be, for very valid reasons), we seek to understand the resistance, using the same process of guided discovery that permeates the rest of the therapy—and engaging in some mentalization as we work to understand the experience from the client’s side. How does it make sense that this client is responding in this way? What would be helpful as we seek to address this obstacle? This brings us to the next role of the therapist, that of a secure base for exploration. 39CFT Made Simple Secure Base As I’ve mentioned, a basic goal in CFT is learning to work with evolved emotions and motiva- tional systems. As the evolved roots of emotional safeness lie primarily in our connections with others (particularly in nurturing relationships with caregivers), John Bowlby’s attachment theory is core to the therapy (Gilbert, 2010). Bowlby viewed the attachment behavioral system as being designed by evolution to facilitate survival and reproductive success by aiding organisms in responding to perceived threats (Bowlby, 1982/1969; Wallin, 2007; Mikulincer & Shaver, 2007). Attachment theory informs many aspects of CFT, beginning with the nature of the therapeutic relationship itself. In attachment theory, a secure base operates as an interpersonal context that fuels exploration (Wallin, 2007; Ainsworth, 1963). Such secure bases, in the form of secure attachment figures offer- ing characteristics such as proximity, accessibility, and availability, provide individuals with a nur- turing place to return to when things become overwhelming. Having such a secure base facilitates exploration of the novel, the unknown, and the threatening, because the individual knows that should he need assistance or comfort, it is available to him. A particularly important piece here is the individual’s felt sense of security: the perception that the caregiver is emotionally responsive and will be there when needed (Bowlby, 1973; Sroufe & Waters, 1977; Wallin, 2007). Attachment theory posits that over time, individuals develop attachment-­based internal working models—­internal representations of attachment relationships that impact how they will experience threats and respond to them in the future (Wallin, 2007). These can be played out in terms of attachment styles, which are relatively enduring but can vary across different relationships (Wallin, 2007; Mikulincer & Shaver, 2007). These attachment styles have implications not only for how individuals respond to threats, but also how they experience other people (as available and helpful or as unavailable) and themselves (as worthy of kindness and caregiving or as unworthy and flawed). Many of our psychotherapy clients will present with insecure attachment histories. They may have learned that others are unavailable when needed, or that they are unpredictable, or that they are likely to respond to the client’s communications of distress with escalation rather than comfort. Some clients will have been harmed or abused by those who should have cared for them, and have learned to associate connection and affiliation with threat rather than safeness. Increasingly, we’re learning the importance of the therapist functioning as a secure base for clients to explore and work with difficult experiences (Wallin, 2007; Knox, 2010). This function is particularly important in CFT. A primary goal in CFT is to assist clients in getting the safeness emotion-­regulation system online and working for them—­to help themselves access feelings of safeness, even in the face of threatening experiences and emotions. Human beings evolved to feel safe in the context of affiliation, such as that offered through warm, secure attachment connections (Gilbert, 2009a, 2010, 2014). In addition to promoting exploration, secure bases also facilitate con- fidence and self-­development (Feeney & Thrush, 2010). Consistent with CFT’s emphasis on assist- ing clients in developing compassionate characteristics, Mario Mikulincer, Philip Shaver, and their colleagues have conducted a series of studies linking the experience of attachment security to 40Compassionate Relating: Roles of the Therapist in CFT increases in compassion, empathy, and altruistic behavior (Mikulincer et al., 2001; Mikulincer & Shaver, 2005; Gillath, Shaver, & Mikulincer, 2005). In serving as a secure base for clients, the CFT therapist seeks to embody certain qualities within the therapy session. We want the overall context of the therapy to be one of warmth, in which the client feels accepted, heard, supported, and encouraged as she contacts and explores difficult emotional material. Mikulincer & Shaver (2007) characterize the role of therapist as secure base in this way: Therapists should provide safety, comfort, and unconditional positive regard, and help the client manage the distress associated with exploring and articulating painful memories, thoughts, and feelings. They should also affirm the client’s ability to handle distress and problematic life situations, not interfering with exploration by offering inap- propriate interpretations, and admiring and applauding the client’s efforts and achievements in therapy. In other words, like a good parent, a good therapist [assures] the client that the therapist can be relied upon for safety and support, while the client becomes increasingly capable of dealing with distress autonomously. (p. 410–­411) To create this overall context requires that the therapist be reliable, attentive, and empathic—­ able to understand the emotional perspective of the client (Bowlby, 1988). From a CFT perspective, which deliberately targets the development of self-­compassion as a treatment goal, the ability of the therapist to take on the role of a secure base and to foster attach- ment security in the patient is particularly important. Difficulties experiencing self-­compassion have been linked with insecure attachment histories and styles (Pepping, Davis, O’Donovan, & Pal, 2014; Gilbert, McEwan, Catarino, Baiao, & Palmeira, 2013). Many of our clients may present with difficulties accepting compassion from others and directing it to themselves—­difficulties that have been referred to as fears of compassion (Gilbert, McEwan, Matos, & Rivas, 2011). A growing body of literature documents the relationship between such fears of compassion and experiences of depression, anxiety, and stress (Gilbert et al., 2013), with research indicating that creating attach- ment security experiences for others can lead to increases in their self-­compassion (Pepping et al., 2014). So in relation to the goal of increasing our clients’ ability to engage courageously with dif- ficult life experiences and cultivate compassion for themselves and others, the therapist’s ability to serve as a secure base is important. We can take this even further with the next role served by the therapist in CFT: a model of the compassionate self. Models of the Compassionate Self CFT emphasizes helping clients develop compassionate qualities that will enable them to have happy, meaningful lives. As we explored in chapter 2, in CFT, compassion is operationalized in the form of attributes to be cultivated through specific practices, which will be presented in the latter chapters of this book (Gilbert, 2010). CFT also seeks to assist clients in developing other, related compassionate capacities, such as mindfulness and emotional courage, which we see as necessary for the skillful application of compassion. Overall, the goal is to assist clients in cultivating an 41CFT Made Simple adaptive, resilient, compassionate version of themselves, which serves as a framework for the inte- gration of all of these capacities. In CFT, we call this the compassionate self, and when we’re at our best, CFT therapists serve as a living embodiment and model of this compassionate self. If that sounds like a tall order, I’m not trying to suggest that as therapists we have to be perfect, compassionate, enlightened beings. In fact, if we were to succeed in creating that impression, our clients probably wouldn’t be able to relate to us very well at all. Psychologist Kristin Neff (2011, 2003) includes common humanity as a core component of self-­compassion; we’d like our clients to experience us both as competent helpers and as real human beings who have sometimes struggled with some of the very things that trouble them. This common humanity is also reflected in our own ability to grasp our clients’ experience; we can understand and connect with their suffering in part because we’ve experienced aspects of it in our own lives—­sadness, fear, anger, uncertainty, insecu- rity, and struggle. So the point isn’t to be perfect models of compassion. Rather, we want to practice what we teach—­to model and cultivate in ourselves the very strengths that we’re seeking to help our clients develop. Such an approach has a number of potential advantages. First, it provides clients with a living example of the compassionate characteristics they’re trying to develop in therapy, and what such characteristics actually look like in the context of working with suffering. We’re not working toward a compassion that is vague and aspirational—­we have to put it into practice in the real world, devel- oping these strengths by applying them to working with real challenges and emotions. Second, because they’re the recipients of our compassion, clients get to have the experience of receiving compassion within the context of a safe therapeutic environment, helping them gradually learn to feel safe in the context of a relationship with another person who genuinely cares about them. This can be both comforting and challenging for those clients with insecure attachment styles, who may have great difficulty feeling safe in connection with others. Even for people who are generally able to feel safe in relationship to others, therapy work often involves overcoming tendencies to avoid difficult emotions and situations and learning to instead approach and work with them. In this way, compassion involves the development of emotional courage—­the willingness to engage directly with difficult experiences. As therapists, we can both model this courage and kindly support our clients in developing it for themselves. The courage of compassion—­the confident willingness to engage with and explore the hurts and the scary stuff—­ needs to be held within a relational context of warmth and genuineness. Warmth is a particularly important quality for us to model so that clients feel socially safe in exploring the things that scare them (Gilbert, 2010), and so that they can learn to relate warmly to themselves when they observe themselves struggling. Of course, the degree and manner in which this warmth is expressed will vary considerably based on individual client characteristics, attachment styles, and ability to toler- ate connection with others. As therapists, we’re sensitive to the fact that we’re asking our clients to explore very uncom- fortable territory, and we keep moving forward, knowing that we’re doing so for very good reasons. This process exemplifies the meaning of compassion itself—­sensitivity to suffering combined with the willingness to approach it and do what is necessary to address it. In this way, compassion 42Compassionate Relating: Roles of the Therapist in CFT represents the union of strengths: kindness and perseverance; warmth and resolve. One thing I took away from my early experiences with dialectical behavior therapy (Linehan, 1993) were the dialec- tics surrounding the therapeutic relationship—­the ability of the therapist to be both warm and confrontational; both a genuine, real human being and a knowledgeable authority of sorts; both rever- ent and playful. To that last piece, I’ve found that compassion works much better when it contains lightheartedness. In conducting CFT in a wide variety of settings (including with angry men in prison—­not exactly people we might think of as keen on compassion work), I have consistently received feed- back from clients that tells me that the experience of receiving compassion from me and other thera- pists was an important part of the work, opening them up to having compassion for themselves. When we care about others and believe in them, after a while they can begin to care about and believe in themselves. When they know we won’t judge and attack them, they can take more risks and be more honest with us—­and with themselves. Finally, serving as models of compassion in this way creates a resonance and consistency in the therapy—­the process of the therapy reinforces the content, and vice versa. So I’d like to suggest that if we want to help our clients cultivate compassion in their lives, part of our preparation should involve working to purposefully cultivate these qualities in ourselves. While the empirical literature on therapist use of compassion meditation is in its infancy, there is research linking such meditation with increased empathic accuracy (Mascaro, Rilling, Negi, & Raison, 2013). I also think CFT therapists specifically will benefit from cultivating compassion because it gives us an inside view of how the practices work, as well as a sense of the obstacles and challenges that come up, and it enhances our ability to model compassionate presence with our clients. So how do we actually do this? Probably the most important piece is to practice committedly engaging in the various compassion practices that we intend to utilize with our clients—­many of which are featured in the remainder of this book. Doing this, we’ll see how challenging it is to create space for the practices in our lives. We’ll be faced with resistance that we’ll have to learn to work with. And we’ll see the benefits of cultivating compassion firsthand, giving us a deep under- standing of just why the process is worth it. As guides for further exploring CFT practices from the inside out, I’d recommend Mindful Compassion (Gilbert & Choden, 2013) and The Compassionate Mind (Gilbert, 2009a). There are also other resources available that provide clear, direct instruction for the cultivation of compassion (Kolts & Chodron, 2013) and mindful self-­compassion (Neff, 2011; Germer, 2009). For those who’d like a head start for their compassion practice, here’s a brief imagery practice that we can use to begin cultivating various compassionate qualities in our daily lives—­consider it a preview of the Compassionate Self practice we’ll learn about later. We’ll get into the nuances of imagery practice in chapter 11, but for now, just keep in mind that we’re trying to create a mental experience—­it’s not about constructing vivid visual images, so much as felt experiences in the mind. 43CFT Made Simple CONNECTING WITH COMPASSIONATE QUALITIES To begin, let’s sit quietly, and allow our breathing to take on a slow, soothing rhythm. Let’s spend thirty seconds to a minute breathing in this way, focusing our minds on the sensation of slowing…slowing down the body, slowing down the mind. When you’re ready, bring to mind a compassionate quality you’d like to develop. Perhaps it’s the kind motivation to be helpful. Perhaps it’s the confidence and courage to stay and work with difficult situations, even when things get tough—­the knowing that whatever arises, you can find a way to work with it. Perhaps it’s the ability to tolerate distress. There are many other compassionate qualities you might choose to cultivate, like patience, kindness, warmth, wisdom, or perseverance. Choose one of these qualities, and bring it to mind. Imagine what it would be like to be filled with this quality. As you prepare to go about the rest of your day, imagine how you might think, feel, and behave as you embody this compassionate quality. Bring to mind a specific task you might do. How would this quality impact how you understand and go about this activity? Imagine yourself in the activity—­thinking, feeling, and acting from a compassionate place of kindness, confidence, wisdom, patience, or gratitude. Spend five to ten minutes, or as long as you like, in this way. As you finish the practice, try to keep this quality in mind as you go about your day, and see if you can bring it into the actual moments that present themselves in your life. The above practice is similar to the intention-­setting exercise we did earlier, except that we’re anchoring our intention to a specific quality we want to cultivate. Later, in the Compassionate Self exercise, we’ll broaden our scope to contain multiple compassionate qualities, but the goal is the same. We want to help ourselves and our clients activate and establish mental patterns associated with compassionate ways of feeling, thinking, and behaving. With a bit of practice, this exercise can be done in just a few moments. You might even consider doing it first thing in the morning, between waking and getting out of bed—­what we in CFT circles call “compassion under the duvet” (Gilbert, 2009a). Putting the Roles into Play In this chapter, I’ve presented four roles embodied by the CFT therapist: teacher, facilitator, secure base, and model of the compassionate self. While it may sound like a lot, I’m betting that you already have many of the qualities involved in these roles. Many of them are common to most modern therapeutic approaches—­ things like genuineness, reliability, accessibility, empathy, warmth, and unconditional positive regard. The process of guided discovery in CFT makes exten- sive use of the skills provided in therapist training programs, including empathic understanding, Socratic dialogue, validation, and reflection of feelings. Taking on the roles of secure base and compassionate model aren’t so much about learning a new way to be a therapist as they are about bringing a bit more intentionality and awareness to the things we already do. For example, basic therapeutic responses like noting a shift in client nonverbal behavior that signifies an affective shift (“Could you say something about what just happened there for you?”) or reflecting back the 44Compassionate Relating: Roles of the Therapist in CFT client’s feeling (“So it sounds like you’re feeling really anxious about this”) demonstrate attunement and connection, imply caring, model confident willingness to explore emotions, and warmly prompt exploration. As we explore CFT together, you’ll learn many things that will relate to the experiences your clients tell you about, and to the experiences of your own life. As we go I’ll be offering examples and suggestions that will help us deepen our use of these roles and bring them to life in the therapy room. For now, perhaps consider what we’ve explored so far, and how you might bring what you’ve learned into your work with current clients, or your clinical training, or your daily life. It’s also worth noting that although I’ve discussed them separately, these roles overlap, deepen, and support one another. While we’re teaching the CFT model—­introducing many of the con- cepts we’ll explore in the next chapter—­we’ll be doing so via a process of guided discovery. As we use Socratic dialogue to prompt clients to explore difficult experiences and to consider their chal- lenging emotions through the lens of evolution, we’ll do so warmly and compassionately—­serving as a secure base while modeling the kind willingness to approach and work with the things that can make us most uncomfortable. I often find that the process of therapy is like a dance that unifies these roles: we move forward to confront and work with really difficult material; we step back to self-­soothe and shift into a compassionate perspective; we move forward again to work compas- sionately with the scary or uncomfortable stuff… Keeping in mind the therapeutic roles we’ve discussed, let’s revisit the case of Jenny, who we met in chapter 1. Therapist: Jenny, in our last session we spent some time discussing your anxiety around social situations, and it sounded like you connected these fears to some experiences in your childhood. Those experiences seemed important, and during that session we talked about revisiting them today. How would you like to proceed? Jenny: (Facial expression shifts noticeably; looks down.) Therapist: (Leans slightly forward; speaks with a gentle, curious tone of voice.) What just happened for you there, Jenny? What are you feeling right now? Jenny: (slightly tearful) It’s just that…when you said that, I could imagine being back in that room in sixth grade, with those girls glaring at me. Pointing at me and talking about me. It feels terrible. Therapist: So the image of being back in that room, it brings up some powerful feelings in you right now. Could you talk about that? Jenny: (crying) I guess so. I feel so sad. I just wanted them to like me. I just wanted to fit in. Therapist: You just wanted to be liked and accepted, and instead you were rejected. Jenny: (still crying) Yes. It was so hard. 45CFT Made Simple Therapist: (Remains silent; leans in, with a kind, attentive facial expression.) Jenny: (After a minute or so, crying softens and breathing starts to stabilize.) Therapist: Jenny? Jenny: Yes? Therapist: I wanted to make an observation. Do you remember when we talked about those two parts of compassion—­about being moved by suffering, and wanting to help? Jenny: Yes. Therapist: I wanted to point out that the sadness you felt just now…that’s the sadness of compassion. When you brought to mind that sixth-­grade version of yourself, sitting there, being ridiculed when all she wanted was to be accepted—­sadness came up in you. You were moved by her suffering. You could see how terrible that was for her, and it made you sad. Does that make sense? Jenny: Yes. It was terrible for her—­for me. It makes me so sad to think about it, and scared that it could happen again. Therapist: So you feel sad for that sixth-­grade self, and it feels very threatening that you could be rejected like that again? That does sound scary. Does it make sense to you that remembering this would bring up such strong feelings? Jenny: Yes, I guess it does. That experience was so awful. Of course it would bring up strong feelings in me. Therapist: I’m wondering if we might be able to have compassion for both of those versions of you—­the sixth-­grade version of you sitting in that classroom, and the adult version of you sitting here, feeling sad about what your childhood self had to experience, and afraid that it could happen again. Could we try to understand both of those perspectives, and see if we could find a way to work with that fear and sadness? Jenny: I think I’d like that. In the brief example above, we see aspects of all the various roles described earlier. The thera- pist serves as a secure base by demonstrating availability and attunement with Jenny’s experience, kindly supporting her as she comes face-­to-­face with a difficult memory and feels the emotions associated with it. Compassion is modeled throughout, in both verbal and nonverbal expressions of warmth and support, as well as in modeling emotional courage around exploring a difficult memory and related emotions. In doing this, Socratic questioning was repeatedly used to facilitate the 46Compassionate Relating: Roles of the Therapist in CFT process of exploring the memory, identifying the emotions, and introducing the shift to a compas- sionate perspective. Finally, an opportunity was used to teach an aspect of the CFT model—­in this case, the definition of compassion—­in a way that related it to the client’s present emotional experience. THERAPIST USE OF SELF-­DISCLOSURE In considering the roles we’ve discussed above, we should visit the topic of therapist self-­disclosure. The appropriate use of self-­disclosure can help clients understand the therapist as a real human being. It can also be experienced by clients as validating and depathologizing, emphasizing the common humanity emphasized by Neff (2003) as a core component of self-­compassion. On the other hand, if used unskillfully, it can distract from the therapeutic work, shift the focus from the client to the therapist, muddy the boundaries of the therapeutic relationship, and even shift the client into the role of the caregiver. As I mentioned earlier, the CFT therapist is both a real, genuine human being and a knowledgeable guide. We need to be relatable, and at the same time perceived as knowledgeable enough, wise enough, and kind enough to serve as a secure attachment figure who can respond confidently and assertively to our clients’ distress. There are no hard-­and-­fast rules about when and how often one should use self-­disclosure in CFT, and it’s safe to say that CFT therapists (like other types of therapists) vary considerably from one another in this regard. I sometimes use self-­disclosure in my own practice of CFT, but I do so fairly sparingly. In considering your own potential use of self-­disclosure, I’d encourage you to apply the following guidelines. These can be useful in considering other potential therapy practices that you might be wondering about as well. • Imagine that at any point, a colleague, supervisor, or trainee could walk into the therapy room, magically stop time—­freezing the client in place—­and ask, “What is it you are doing with this client, and how does it relate to your conceptualization of his case and the direction of therapy?” (Or less dramatically, imagine a supervisor reviewing a video of the session, and pausing and asking the same question.) Can you answer that question? • Relatedly, consider your motivation for the disclosure. If it’s based more in affect—­in other words, you just feel like you want to tell the client these details about yourself—­ refer back to the point above before continuing. Our own affective responses aren’t irrelevant or necessarily faulty, but a feeling of urgency around disclosure or another intervention could signal that this behavior is driven by our own threat or drive responses (we’ll explore this more in chapter 5), rather than what will best serve the therapy process. • Consider whether you would feel comfortable talking about this self-­disclosure with your supervisor or in peer-­supervision with your colleagues. If the answer is Absolutely, 47CFT Made Simple because it relates to the therapy in this way…that’s a pretty good indicator. If the answer is I’m not sure…then I’d recommend consulting before using the self-­disclosure. And if the answer is a feeling of discomfort accompanied by some variant of rationalization like Well, they really wouldn’t understand the context…it may mean that you’re working to convince yourself to do something in therapy that is rooted more in your own needs than in those of the client and the therapy. • When in doubt, discuss things with a colleague beforehand. Colleagues can often give us valuable perspectives that dramatically expand our understanding and expose our own blind spots. The process of peer-­supervision and asking for help or advice can also help us deepen our own compassionate qualities, like courage, distress tolerance, and humility. SUMMARY The first layer of compassion in a course of CFT is the therapeutic relationship. In this chapter, we explored the various roles embodied by the CFT therapist, and touched on how they can be inte- grated into the session. Cultivating these roles is a gradual process that develops over time. Let’s lightly keep these roles in mind as we explore the foundational pieces of CFT therapy in the next few chapters. In the next chapter, we’ll begin exploring the second layer of compassion in CFT: compassionate understanding. 48CHAPTER 4 Compassionate Understanding: How Evolution Has Shaped Our Brains As I’ve mentioned, shame and self-­criticism underlie a wide range of mental health problems (Gilbert & Irons, 2005; Gilbert, 2014). A primary goal in CFT is to help clients shift the relationship they have with their internal experiences from a perspective of judgment and condemnation to one of understanding and compassion. A core theme in this work is to help clients recognize that many aspects of their experience are not their fault—­things that they neither chose nor designed—­while helping them take responsibility for working directly and actively to improve their lives. This shift to compassion begins with helping clients understand their emotions and motives in relation to how their brains and minds have evolved, and how evolution has presented human beings with some interesting problems. So in CFT, compassion begins with understanding the mind. OLD BRAINS AND NEW BRAINS In the 1990s, Paul Maclean introduced the concept of the triune brain (Maclean, 1990), which described the human brain in terms of three parts, reflecting different stages of brain evolution. The triune brain included a reptilian brain, which is responsible for basic bodily functions as well as aggressive and reproductive drives; a paleo-­mammalian brain—­the limbic system, having to doCFT Made Simple with memory, emotion, and learning; and the neo-­mammalian brain (the cerebral cortex), which does the heavy lifting in terms of things like self-­awareness, symbolic thought, problem solving, and other higher-­order cognitive processes. While the reality of how the brain works isn’t quite so straightforward (Cozolino, 2010), Maclean’s work highlights some of the challenges presented by how evolution has shaped our brains, and gives us a nice way to explore these dynamics with our clients. In CFT, we discuss this concept with clients using the language of “old brain” and “new brain” (Gilbert 2010). In therapy, it can sometimes be useful to use the term “emotional brain” synony- mously with “old brain” when we’re specifically talking about the dynamics of emotion. Because different parts of the brain evolved at different times in our evolutionary history and served differ- ent purposes for our ancestors, the ways our old brains, new brains, and bodies interact can be tricky and can create problems for us. Understanding this can be very freeing for our clients, as it helps clarify why their emotions can feel so out of control, and why it’s not their fault. Let’s look at some ways to explore this idea with clients. When we’re introducing it, we want to provide information, but not go on with lengthy monologues. Here’s an example of how we might initially approach the concept with Josh: Therapist: Josh, we’ve been discussing your anger, which you’ve struggled with for some time. In learning to work with emotions like these, it can be useful to explore where they come from, and how they work in our brains and minds. How about we chat about that for a bit? Josh: All right. Therapist: If we look through the lens of evolution, we see that the human brain is actually very tricky. It’s kind of like we have an old brain, which takes care of all the stuff that kept our ancient ancestors alive—­basic emotions and motivations that helped them protect themselves from threats and do the things needed for survival—­and a new brain, responsible for things like problem solving, mental imagery, self-­awareness, and deep thinking—­about what sort of person we want to be, what it all means, that sort of thing. Does that make sense? Josh: Yeah, I think so. Therapist: Let’s think about this in terms of a situation you’ve discussed. You mentioned that you sometimes become angry at work. Could you talk a bit about that? Josh: It’s mostly when my coworkers question me, or don’t do something they said they were going to do. I get really pissed off then. Therapist: So your coworkers question something you’ve asked them to do, and your old, emotional brain registers that as a threat, and here comes the anger. Does it come up pretty quickly? 50Compassionate Understanding: How Evolution Has Shaped Our Brains Josh: Oh yeah. I get angry sometimes even before they ask a question. If they make a face, or look at me like they disagree with what I’m saying, I start getting angry. I just want to set them straight, like “Can’t you ever just shut up and do what you’re asked to do?” Therapist: From an evolutionary perspective, our old, emotional brains are designed to help us identify and respond to threats—­just like they did for our ancestors, who lived in a world with lots of real physical threats. You know—­lions, tigers, bears, and the like. Anger is a threat emotion that prepares us to fight. It sounds like your emotional brain has learned that your coworkers questioning you or not doing what they’ve agreed to do are potential threats, and your brain responds like they’re tigers out to get you. Josh: (With a look of consideration.) I guess so. I mean, it is threatening. Therapist: Let’s explore that. Let’s explore what’s going on in your new brain while this is happening. When your coworkers are questioning you or fail to do what you’ve asked of them, what thoughts are going through your mind? What are you thinking? Josh: (Pauses, thinking.) I’m thinking that they’re challenging me—­like they don’t respect me or trust me. If they respected me, they’d just do what I ask, right? And then I’m thinking that things aren’t going to get done, or aren’t going to get done right, which will then come back to me. My boss is going to let me have it, even though I did everything I was supposed to do. Therapist: (Nods.) Is there any mental imagery—­like pictures or movies playing out in your mind—­that goes along with those thoughts? Josh: (Thinks for a moment.) Yes. It’s like I can see it happening in my mind. I can picture them rolling their eyes, talking about me behind my back, and blowing me off. I can just see my boss coming to me, asking me what the problem is—­blaming me for stuff not getting done. It’s maddening, you know? Therapist: (Nods and speaks sympathetically.) That does sound maddening. So in addition to that old-­brain anger, the new brain is piling on a lot of other stuff—­thoughts of being mocked and blown off, and images of the consequences—­your boss coming down on you. There’s a lot of stuff going on when that anger comes up. Josh: Yeah, I guess there is. 51CFT Made Simple The Old Brain: Powerful, But Not Very Wise One thing you’ll frequently hear CFT therapists say when exploring the idea of the old brain and the new brain with clients is that our “old, emotional brains are very powerful, but they aren’t very clever or wise.” Many of us may have experience explaining the basic cognitive behavioral model to our clients and using Socratic dialogue to explore how different patterns of thinking can lead to different types of emotion and behavior (and vice versa). In CFT, we want to understand and explore these dynamics in relation to the evolved brain. Our old brains evolved to motivate our ancestors to do what was necessary to survive, and they did this via the evolution of basic emotion systems (fear, anger, desire, lust, and so on; Panksepp & Biven, 2012; Panksepp, 1998) and archetypal motives (caregiving, competitive, sexual), many of which are socially oriented (Gilbert, 2010; 2014). When triggered by an external or internal stimu- lus, working through the action of various neurotransmitter and hormonal systems, these emotions and motives can very powerfully orient and shape our attention, thinking and reasoning, mental imagery, and motivation (Panksepp & Biven, 2012; Gilbert, 2010). We’ll discuss this process further in chapter 5, but the idea is that these old-­brain emotions and motives can organize our minds and bodies in ways that make it easy for us to feel trapped inside challenging affective experiences. For example, when Josh is feeling anger related to his coworkers’ behavior, he experiences a narrowing of attention onto the perceived threat (their questioning him, things not getting done, the idea of being humiliated and reprimanded), threat-­related perseverations in the form of thoughts and imagery, and the motivation to set his coworkers straight. Of course, our old, emotional brains are also associated with patterns of bodily experience as well, patterns which play a large role in shaping how the emotion is felt. While the old, emotional brain is powerful in how it can organize our minds, it’s not very good at distinguishing thoughts and fantasies from actual stimuli coming in from the external world. Our emotions occur largely as a result of implicit (nonconscious) processing systems that are triggered by various inputs—­information from the outside environment; from our own thoughts, memories, and imagery; and from our bodily experience (Gilbert, 2010). As a result, our emotional brains and underlying biological systems can respond powerfully to thoughts and imagery, almost as if they were real. This is why we engage in things like sexual fantasies—­sexual imagery stimulates parts of the brain and endocrine system that produce sexual feelings, with corresponding activity in the body to produce sexual responses. Changing emotion is all about working with and changing implicit inputs to the emotional brain. The good news is that we can choose to focus our thoughts and mental imagery in ways that help produce the sorts of affective experiences we want to have. We’ll be exploring this dynamic a great deal in the second half of this book. The challenging news is that interactions between old brain, new brain, and body can create an emotional inertia, in which conditioned emotional activation in the limbic system triggers new-brain thoughts, imagery, and memories (as well as bodily responses) that then feed back to old-­brain structures like the amygdala to fuel the very emotional response that created them. Of course, it can work the other way around, beginning with a memory, thought 52Compassionate Understanding: How Evolution Has Shaped Our Brains (he doesn’t respect me), mental image, or bodily sensation that the old brain registers as a threat, leading to related emotional experiences, with the process continuing. This is fertile ground for exploration with clients, as they begin to understand how different emotions and motives are associated with specific patterns of attention, thinking, imagery, motivation, and bodily experience, and then learn skillful ways to work with these experiences and the emotions and motives that underlie them. This is a simplified version of how things play out in the brain, but it’s based in affective neuro- science research (e.g. Panksepp & Biven, 2012). Learning about these brain and body interactions can also have a number of positive effects for our clients, all of which fit with our focus on compassion: • Shifting from judging and avoiding their challenging emotions to curiously examining and understanding how they play out in the mind. • Recognizing that the way their emotions work isn’t their fault, but occurs because of how our brains evolved and the ways different parts of our brains and bodies interface with one another. • Giving clues as to how they can begin to compassionately work with their emotions—­ through creating new, helpful inputs to their old, emotional brains. Let’ consider how we might introduce this concept: Therapist: Jenny, I’d like to chat a bit more about this old-­brain/new-­brain piece, because I think it might help us understand your anxiety a bit better. To start, I’d like to use an analogy. Do you have any pets? Jenny: Yes, I love pets. I have a dog named Penelope. Therapist: Penelope—­what a wonderful name! We have a dog named Sadie. Do you have a fenced-­in yard for Penelope? Jenny: Yes, I’ve got a fenced backyard. Therapist: We don’t—­the area behind our house is wooded, so we’ve decided to leave it open, to enjoy the view of the woods. Jenny: Nice. Therapist: It is nice, but it sometimes presents challenges. We let Sadie outside sometimes, and she’ll hang out in our backyard. But because we don’t have a fence, sometimes another dog will wander through—­you know, sniff around, pee on a few rocks, that sort of thing. Jenny: (Nods.) 53CFT Made Simple Therapist: When another dog wanders in, Sadie can get pretty defensive. Jenny: She’s defending her territory. Therapist: Exactly! So she’ll sort of size up the other dog. If she thinks she can take it, she’ll make a threat display—­stand tall, with the hackles on the back of her neck standing up, growling a bit. On the other hand, if the dog looks big and scary, she might make a submissive gesture instead—­maybe cowing down, as if to say, “No need to have any trouble here.” (Makes bowing-down gesture.) Jenny: (Laughs.) Yeah, I’ve seen Penelope do the same thing at the dog park. Therapist: (Smiles.) So let’s imagine that this happens to Penelope or Sadie. Things get a bit tense, but after a little while, the other dog gets bored and wanders off to pee on someone else’s yard. Five minutes later, how is Penelope? Jenny: She’s fine. Right back to normal. Therapist: Sadie, too. While she was initially upset because this dog invaded her territory, five minutes later she’s coming to get scratched, begging for a treat. (Moves head back and forth a bit, smiling.) Jenny: Exactly. (Smiles.) Therapist: So now let’s imagine that this same thing happens to you or me. We’re at home, and a stranger walks into the house, wanders around looking at things, maybe grabs something out of the fridge, pees on the corner of the couch… Jenny: (Laughs.) Therapist: Sorry…took the dog analogy a bit too far! If this were to happen, we might respond like Sadie or Penelope. We’d likely feel somewhat threatened, and probably want to protect our territory. If the situation seemed manageable, we might get assertive—­“Hey, this is my house. I’d like you to leave at once.” Jenny: Yeah. (Nods.) Therapist: On the other hand, if the intruder seemed very dangerous—­say, he was holding a gun, we might make a submissive display. (Holds hands up in an open gesture.) “It’s okay. Take whatever you want…there’s no need for anyone to get hurt…” We’d respond in ways that aren’t terribly different from how Sadie or Penelope might. Jenny: 54 (Continues to nod along.)Compassionate Understanding: How Evolution Has Shaped Our Brains Therapist: So here’s the question. Let’s imagine that after a while, the intruder gets bored and leaves. How would you or I be doing five minutes later? Five hours later? Five days later? Jenny: (good-­naturedly) I’d be freaking out! Therapist: (smiling) I probably would, too. Why would we be freaking out? What would be going on in our minds? What thoughts or images might play out for us? Jenny: I’d be thinking about what could have happened. That he could have really hurt me. I’d be worried that he might come back, thinking about what he might do the next time. Therapist: What images might be coming up in your mind? Jenny: I’d probably be picturing it happening again and again. Therapist: And those thoughts and fantasies might fuel your fear, keeping you afraid? Jenny: They sure would. Therapist: Exactly! That’s the difference between you or me and Penelope or Sadie. It has to do with the tricky way our old and new brains communicate with each other. The dogs have those old-­brain threat reactions, but when the threat is gone, they’ll tend to calm down fairly quickly. We, on the other hand… Jenny: We keep it going. Therapist: Our thoughts and mental images feed back to our emotional brains, and fuel the fear that caused them—­like pouring gasoline on a fire. So our emotions can focus our attention and trigger thoughts and images in our minds—­ thoughts and images that can then come back and fuel the very emotions that triggered them. Does that make sense? Jenny: (nodding) Like how those thoughts I have in the classroom about people laughing at me fuel my fear. Therapist: Just like that. It’s important to realize that this isn’t our fault. You and I didn’t choose to have brains that work in such tricky ways; it’s just how they work—­ what we were born with. But if we’re going to work with emotions like fear and anxiety, it can help to know how these brains work. Jenny: Mmm-­hmm. Therapist: One last thing. Thinking scary thoughts can fuel feelings of being scared. One of the scariest thoughts we can have is, There’s something wrong with me. (Pauses.) 55CFT Made Simple Jenny: (Pauses and looks down.) I have that thought all the time. Therapist: (Pauses, then continues with a kind tone of voice.) And how does it feel when that thought comes up? Jenny: Terrible. Therapist: (Nodding.) It does feel terrible. That’s why in CFT we focus on developing compassion and kindness for ourselves and others—­we want to find ways of thinking and acting that help us feel safe, rather than threatened. Jenny: That would be really nice. Therapist: Well, let’s work on that, then. The example above demonstrates how a CFT therapist might introduce old-­brain/new-­brain dynamics with a client. The use of the dog analogy is meant to reinforce the evolutionary model, initially demonstrating the evolved aspects of our emotional responses and behaviors that are similar to other mammals, and then exploring differences (the tricky old-­brain/new-­brain dynam- ics) that set us up for unique problems. You’ll note that there was a good bit of therapist talking there, as the analogy was explained. While it’s hard to convey in print, I’ve tried to give a sense of how the therapist would monitor the client’s nonverbal behavior and use questions, pacing, body language, tone of voice, and attempts at humor to maintain engagement and create an interactive experience, even when the focus is on explanation. Whenever possible, we want to link such dis- cussions to the client’s experience early and often—­even within the analogy (which is why the therapist asked Jenny about her own dog). We also see the therapist doing some mirroring of the client’s affective experience—­using humor when she is smiling and nodding along, and then rever- ently slowing things down when the discussion bridges to the Jenny’s own experience of self-­ criticism and things get a bit heavy. In doing this, we want to keep our focus on the process we’re trying to explore with the client. Some clients might argue that the threat-­driven thoughts that accompany fear of the intruder are completely valid, and could trigger behaviors (installing an alarm system, for example) that could help us avoid victimization in the future. They’d be right about this. We’re not trying to convey that the ability of our thoughts and imagery to fuel and be fueled by our emotional brains is bad. It’s neither good nor bad—­it’s just the way things work. The point is that this dynamic can be tricky for us, and can sometimes fuel threat responses that aren’t terribly helpful. This sort of inter- change can be useful in modeling compassionate reasoning—­helping clients shift from judging and labeling (thoughts and emotions as either right or wrong, good or bad) to a perspective that instead is focused on understanding (thoughts and emotions as mental experiences, and the sometimes tricky dynamics between them). Finally, you’ll note that as the vignette concludes, the therapist links the example back to a larger theme in the therapy—­how Jenny’s self-­criticism functions to keep her threat response activated, and how compassion can help with this. 56Compassionate Understanding: How Evolution Has Shaped Our Brains Emotional Inertia As the above vignette demonstrates, we can explore how interactions among old-­brain emo- tions, new-­brain thoughts and imagery, and bodily sensations can work to maintain the energy of an emotion. For example, if a threat is registered in either the new or old brain (via a thought such as She doesn’t like me or a previously conditioned threat trigger—­like smelling the cologne that was worn by a rapist), it can trigger emotions of fear or anger, which themselves can give rise to thoughts and imagery associated with the emotion, as well as bodily sensations of arousal and tension (racing heart, shakiness, tensed jaw, tight shoulders, and so on). Once this cascade of experience occurs, each element of the system (new brain, old brain, bodily experience) can serve to trigger the others, fueling the ongoing emotional response. New-­brain images and thoughts, bodily experi- ences, and the environments we are in (themselves shaped by emotion-­driven behaviors) can all serve as ongoing inputs to the old, emotional brain—­for good or ill. This exploration can be useful to clients, as we can frame much of the work we do in therapy (and homework) as working with various inputs to the emotional brain. We work to develop com- passionate ways of thinking and compassionate imagery to help ourselves feel safe rather than threatened, and to find helpful ways of working with situations rather than threat-­based rumina- tion. We work to develop ways of behaving that are effective in getting our needs met. And we work with the body to help ourselves find balance rather than panic. In facilitating this discussion, I sometimes find it useful to draw it out on a piece of paper or whiteboard. I start by drawing a rudimentary brain. Then I’ll mark a red area in the middle of the brain, about where the limbic area is, to represent the old, emotional brain. I’ll then draw a box around the front fourth of the brain to represent the new-­brain thinking centers. While discussing things, I’ll draw arrows from the emotional brain to the new-­brain “thinking box,” and then back, to demonstrate the cyclical nature of how old and new brain can interact to fuel an ongoing emo- tional response. We can also draw similar arrows going down to and back from the body, to dem- onstrate how bodily responses can be a part of the cycle that maintains an emotion. SOOTHING RHYTHM BREATHING As I mentioned above, our emotions occur largely as a result of implicit processing systems which respond to a wide range of inputs—­information coming in from the outside world through our senses, information coming down from the newer parts of the brain that produce thoughts and imagery, and information coming up from the body. Increasingly, we’re discovering that working with that input from the body can play a powerful role in helping to balance emotions. So one of the very first interventions we introduce in CFT is specifically targeted at the body. In CFT, we call this soothing rhythm breathing (SRB), and it involves purposefully slowing down the breath. In SRB, we guide clients to slow down the pace of their breathing and focus their attention on the sensation of slowing. It’s important to note that this is different from mindful breathing, which 57CFT Made Simple we’ll introduce later, in chapter 7. With mindful breathing, we focus attention on the normal process of breathing as an anchor for the attention, and bring our attention back to the breath again and again. In SRB, the focus is on creating a sense of slowing—­slowing down the body, and slowing down the mind. This slowing can help clients soften the intensity of threat emotions by activating the parasympathetic nervous system, and hence begin to shift away from the new-­brain/old-­brain/ body inertia that drives these emotions. Let’s consider how we might introduce SRB to a client: SOOTHING RHYTHM BREATHING Now, I’d like to introduce a practice called soothing rhythm breathing. This practice involves slowing down our bodies and minds by working with the breath. Specifically, we’re going to be slowing down the breath, and focusing our minds on the sensations of slowing. •Let’s start by sitting in an upright posture, with both feet flat on the floor, and perhaps folding the hands in the lap. The head is held in an upright, dignified but relaxed posture. As you gain experience with the practice, you’ll be able to use it in all sorts of situations and body postures, but we’ll start like this, with a nice, comfortable, upright posture. •If you like, allow your eyes to close, and bring your attention to the sensation of your breath entering and leaving your body. Just notice this sensation of breathing. (Pause ten to twenty seconds.) •Now we’re going to slow down the breath. Allow your rate of breathing to slow, taking four to five seconds on the in-­breath, pausing for a moment, and then taking four to five seconds on the out-­breath. Breathing in deeply—­1—­2—­3—­4. (Pause for a moment.) Then slowly breathing out—­1—­2—­3—­4. •Let’s take a couple of minutes to breathe in this way. As we do, let’s focus our attention on the sense of slowing—­slowing down the body, slowing down the mind. If this rate of breathing is too slow, see if you can find a rate that is comfortable and soothing for you. The idea is to breathe in a way that is slowing and soothing. •(Wait two minutes, or however long you choose to do the practice. The timing should be based on making it a successful learning experience for the client—­not an aversive one in which he loses himself in thoughts about how much he hates it! So if it’s clear that the client is resistant, we can start with thirty seconds.) •When you’re ready, allow your breath to return to its normal rate, and gently allow your eyes to open. (Wait until client’s eyes are open.) Let’s explore what that was like. Once the SRB exercise is over, we’ll take a few minutes to explore the client’s experience of the practice. As with all relaxation exercises, the effects of SRB increase with practice, so we shouldn’t expect clients to have immediate dramatic effects. We can explain that slowing down our breathing 58Compassionate Understanding: How Evolution Has Shaped Our Brains in this way doesn’t make threat emotions go away, but can soften them, and create some space for other things to happen (like mindful observation of our thoughts and emotions, and shifting into compassionate ways of thinking). I usually assign SRB as homework after the first session—­often having clients practice it for thirty seconds at a time, two or three times per day. We’ll need to problem-­solve with clients around how they will remind themselves to do it, as the biggest obstacle is often forgetting to practice. Setting phone alarms can serve as a prompt for SRB practice, as can planning regular times to do it (for example, at specific times of day, or—­if the person is a televi- sion watcher—­during the first commercial of every program). SRB also provides us with a nice way to introduce the idea that therapy will involve regular home practice, and to shape homework participation—­almost anyone can find thirty seconds to practice a couple of times per day. This gives us the opportunity the create a nice routine in which we explore, at the beginning of each session, how the home practice went. We can then give them positive reinforcement for practicing, work collaboratively with them to overcome obstacles that may have arisen, and then help to develop a new home practice plan as the session winds down. Some clients may hate focusing on the breath or body, due to trauma conditioning or other factors. If this is the case, we don’t want to turn the exercise into an exposure trial (which we may very well want to explore later)—­the purpose here is to help them focus their attention in a soothing way. For these folks, we can choose one of the many excellent progressive muscle relaxation prac- tices that have been developed, or even work with them to find something they could focus their attention on that would be soothing. (One group of Paul Gilbert’s decided to hold tennis balls and focus on their texture.) The point is to come up with ways for clients to focus their attention in soothing ways that don’t take extraordinary amounts of time or effort. SUMMARY In this chapter, we explored ways to help clients consider the manner in which their brains evolved and how this can create challenges for them. The goal is to begin facilitating a shift away from judging and attacking themselves (and others) for their emotions and reactions, replacing these habits with a curiosity-­driven understanding of how and why their brains (and minds) work the way they do. In the next chapter, we’ll deepen this discussion to explore three evolved emotion-­ regulation systems, and how evolution shaped these systems to organize our minds and bodies in very different ways. 59CHAPTER 5 Compassionate Understanding: Three Types of Emotion As we’ve discussed, in CFT, the groundwork for self-­compassion is laid in helping clients under- stand their challenges in relation to the ways that our brains and minds work. In chapter 4, we explored how tricky dynamics between old brain, new brain, and body can serve to perpetuate emotional responses even when the external events that triggered them are long gone. In this chapter, we’ll introduce a model of emotions that will allow us to quickly increase clients’ under- standing of why and how their emotions work the way they do, and how this makes sense in the context of evolution. Modern research in affective neuroscience has identified a number of basic emotion systems that have evolved in humans and other animals (e.g. Panksepp & Biven, 2012; LeDoux, 1998). CFT has drawn upon this research to articulate a model of emotions that helps clients understand their feelings and related experiences as the result of human evolution. In this way, instead of seeing emotions such as fear, anxiety, or anger as something that is wrong with me, clients can instead see them as part of what helped my ancestors survive. By considering emotions and motives in terms of their survival value to our ancestors, clients can begin to see that how these experiences operate within us makes perfect sense. This process—­helping clients consider their emotions, motives, and challenges through the lens of evolution—­is sometimes referred to as evolutionary functional analysis (Gilbert, 2014).CFT Made Simple THE THREE-­CIRCLES MODEL OF EMOTION In CFT, emotions are grouped into three emotion-­regulation systems, related to their evolved functions, as shown in figure 4.1. First, we have emotions like fear, anger, and anxiety that function to help us identify and respond to threats (the threat-­protection system, or “threat system” for short). Second, the drive-­and-­resource-­acquisition system (“drive system”) emotions motivate us to pursue goals and resources, and reward us for attaining them. Finally, the safeness-­soothing-­ contentment system (“safeness system”) emotions help us feel safe, peaceful, and calm when we’re neither defending against threats nor pursuing goals. Let’s briefly consider these systems individually. Three Types of Emotion Regulation System Driven, excited, vitalContent, safe, connected Incentive/resource focusedNon-wanting/ Affiliation-focused Wanting, pursuing, achieving, consuming Safeness-kindness Activating Soothing Threat-focused Protection and safety-seeking Activating/inhibiting Anger, anxiety, disgust Figure 4.1: Three Types of Emotion-­Regulation System. (From Gilbert, The Compassionate Mind [2009], reprinted with permission from Little, Brown Book Group.) 62Compassionate Understanding: Three Types of Emotion The Threat System The threat system involves emotions that orient us toward perceived threats, assisting us in identifying and responding to things that may harm us. This system includes many emotions that our clients may struggle with, including anger, fear, anxiety, and disgust. The threat system picks up on threats very rapidly, and activates powerful bursts of feelings that alert us, orient us toward perceived threats, and motivate us to action—­fight, flight, or freezing/submission (Gilbert, 2010). Research has shown that we’re biased toward processing threat-­related information, with nega- tive information capturing our attention and memory more powerfully than does positive informa- tion (Baumeister, Bratslavsky, Finkenaurer, & Vohs, 2001). Threat emotions organize us in powerful ways, narrowing our attention, thinking, mental imagery, and motivation onto the source of threat in “sticky” ways—­we can struggle to disengage from these emotions, even when we want to. From an evolutionary perspective, it makes sense that these emotions would be equipped to push other, more positive experiences out of the way—­our ancestors faced a harsh world filled with very real dangers. These ancestors were able to survive and pass their genes along to us partially because they possessed these threat emotions, resulting in our having brains designed to prioritize threat-­ processing through the action of structures such as the amygdala and hypothalamic–pituitary axis (LeDoux, 1998). These emotions were shaped by evolution to play out powerfully within us, and they operate on a “better safe than sorry” basis. Threat-­based learning can occur very efficiently, with many of our clients experiencing significant distress stemming from a single threatening incident. As we discussed in the previous chapter, new-­brain abilities of fantasy, meaning-­making, and rumination allow us to keep this system running even in the absence of any genuine external threat. Through new-­brain activity that allows humans to form mental connections that go well beyond our original learning experiences, fear stemming from a powerful initial experience can come to impact many areas of our clients’ lives. In this way, new advances in our understanding of learning, such as relational frame theory (Hayes, Barnes-­Holmes, & Roche, 2001; Törneke, 2010), have har- rowing implications for how experiences of threat can be magnified and multiplied in our minds. (We’ll explore this more in chapter 6.) When it’s balanced with the two other systems, the threat system helps alert us to potential threats and obstacles we need to deal with, to keep our lives moving in desired directions. However, it’s easy for this system to take up more than its share of mental energy, so we need to help clients learn to find balance when they’ve spent lots of time living in states of threat. The Drive System In addition to defending themselves from threat, our ancestors also needed to acquire the things needed to survive and prosper—­things like food, shelter, comfort, mates, and social posi- tion. This is the job of the drive-­and-­resource-­acquisition system (or “drive system,” for short), which is associated with feelings like excitement, lust, and ambition. Through the activity of 63CFT Made Simple chemicals like dopamine, this system alerts us to opportunities for pursuing goals and resources, helps focus and maintain our attention on pursuing them, and is associated with experiences of pleasure when goals are attained (Gilbert, 2009a; 2010). Like the threat system, this system can be very activating and motivating, and can powerfully focus our attention on what we are pursuing—­ which can be tricky when the blind pursuit of our goals can be harmful to others or ourselves. We can also develop powerful cravings for the intermittent rushes of pleasure that come when goals are attained—­likely one reason things like videogames can be so addictive. However, when it’s bal- anced with the two other systems, the drive system helps keep us activated in the pursuit of impor- tant life goals. The Safeness System In Western cultures at least, our clients will likely be familiar with emotional experiences associ- ated with the previous two systems. Experiences of threat and drive are powerfully motivating, a fact used liberally by advertisers and political groups to activate people around their products and platforms. These emotions are important, but they can also be linked with problems when the systems are out of balance—­mapping nicely on to the sources of suffering described in Buddhist psychology: attachment (going after what I want) and aversion (moving away from what I don’t want). Unlike these systems (which activate us), the safeness system is associated with feelings of being safe, calm, peaceful, and content. These emotions help balance us out when there are no threats to defend against and no goals that must be pursued. Safeness emotions are experienced positively, but are very different from the activating experiences of the drive system (Gilbert, 2009a; 2010). As you may suspect after our discussion of the roles of the therapist in chapter 2, the safeness system is typically linked with experiences of affection, acceptance, kindness, and affiliation. Such interactions soothe us, and can help us feel safe and calm. Through the action of chemicals like oxytocin and the endorphins, these interactions can reduce stress, affect pain thresholds, impact immune and digestive functioning, and reduce threat activation in the amygdala (Gilbert, 2010; Depue & Morrone-­Strupinsky, 2005). In contrast to a mind that is narrowly focused on threats or goals, when we feel safe, we can experience relaxed, reflective attention and we tend to be explor- atory, prosocial, and altruistic (Gilbert, 2009a, 2010). Fueled by warm connections with others, the safeness system helps balance out the other two systems, helping us approach life in an open, kind, and reflective fashion. The linkage of the safeness system to social connectedness presents therapists with both chal- lenges and opportunities. Unfortunately, many of our clients will present with maladaptive attach- ment histories or interpersonal trauma, from which they will have learned to feel unsafe in connection to others. Closeness then becomes associated not with safeness, but with threat. This presents us with a primary challenge—­what to do when our clients’ experience has taught them to fear the very connections that should help them feel safe (evolutionarily speaking). As we’ll see, the linkage 64Compassionate Understanding: Three Types of Emotion between safeness and social connection makes the therapy room a perfect laboratory to do exactly this work. Done skillfully, therapy can be utilized to help clients “get the safeness system online” and help them face sources of threat in their lives, and in their minds. ORGANIZING OUR EXPERIENCE If you spend much time in CFT circles, you’ll quite commonly hear therapists talk about how dif- ferent emotions and motives “organize the mind.” It can be very useful to introduce this concept to clients while we’re helping them understand the three-­circles model. The diagram in figure 4.2 illustrates what we mean by this. Attention Thinking and Reasoning Emotional Experience Fear Imagery and Fantasy Motivation Behavior Figure 4.2: How the Threat System Organizes the Mind. (From Kolts, The Compassionate Mind Approach to Managing Your Anger [2012], reprinted with permission from Little, Brown Book Group.) The idea is that different emotions (such as anger, excitement, safeness) and related motives (such as aggressive, competitive, connection) are associated with distinctly different patterns of attention, felt emotion, thinking and reasoning, mental imagery, motivation, and behavior. This 65CFT Made Simple diagram can be used to guide Socratic dialogue with our clients to help them learn about how these emotions play out in them and to relate that organization to the evolutionary origins of the emotion. Let’s consider a case example: Therapist: Jenny, now that we’ve introduced the three circles, I’d like to talk a bit about how these emotions play out in us. In CFT, we talk about how different emotions can “organize the mind” in different ways, as I’ve demonstrated in this “spider diagram” here (points at diagram)—­although that’s kind of a silly name because it only has six legs. Jenny: (Nods.) Therapist: In addition to the feelings we get with different emotions, we also experience differences in how we pay attention, think about things, and imagine things in our minds when these emotions come up. (Points at “attention,” “thinking and reasoning,” and “imagery and fantasy” circles on diagram, sequentially.) They also affect what we want to do (points at “motivation”) and what we actually do (points at “behavior”). So with any emotion we feel, there’s actually quite a lot going on—­which is why it can be so easy to feel trapped in a feeling. Does that make sense? Jenny: (Nods.) It’s kind of like what we talked about last time—­that different thoughts can fuel different feelings, which bring up more thoughts. Therapist: (Smiles.) Exactly! Now we’re going to explore how your threat system and safeness system organize your mind in very different ways. First, let’s consider a time when you’ve felt very threatened. You’ve brought up a couple of situations like that—­fears about going on a social outing with friends, and being afraid that you’d be called on in class. Want to focus on one of those situations? Jenny: How about going out with friends? Therapist: Sounds good. Could you briefly describe a situation that brings up feelings of threat in you? Jenny: Sure—­one happened just the other day. Some girls from my floor stopped by to ask me to go out with them this Friday night, like to eat and go to the bars, that sort of thing. Therapist: Perfect. Now let’s work our way around the spider diagram. What emotion should we put in the middle, here? Jenny: Definitely fear or extreme anxiety. Therapist: (Writes “ fear/anxiety” in the center of the circle.) Okay, so let’s start with this “felt emotion” circle. To start, it can be helpful to consider how emotions feel in the body. 66Compassionate Understanding: Three Types of Emotion Jenny: When they asked, my heart started pounding, and I had troubling concentrating. It’s like the world was closing in on me. I just sort of nodded and said I’d let them know. After they left, I calmed down a bit, but I was really tense and scared. Even now, it’s hard to think about it. Therapist: Let’s talk about that—­what you think about it. What thoughts come up when you’re feeling anxious about going out? Jenny: Like I want to do it, but also that I really don’t want to do it. I think that it would be fun, for any normal person, but that I would screw it up. I think of all the millions of things that could go wrong. I even have thoughts that they don’t really want me along—­that they’re just inviting me so they can watch me squirm, or to have someone to make fun of. Therapist: It sounds like those thoughts may have some pretty powerful images along with them. When you’re feeling anxious, what are you imagining? Jenny: That I’ll do something stupid—­wear the wrong thing, say the wrong thing, whatever—­and they’ll regret bringing me. That they’ll talk about me later, making fun of me, or even decide they don’t want me around and leave me at the bar. (Appears anxious.) Therapist: That sounds terrifying. When you’re in this space, what do you want or plan to do? What do you usually do? Jenny: I just want to stop worrying about it, to stop feeling this way. So I usually back out…tell them that I remembered that I have a big exam the next week or something. Therapist: So this whole thing (gestures toward spider diagram) is organized around how terrible this could turn out, motivating you to escape the situation—­which is what you would normally do? Jenny: (Pauses a bit, with sad look on her face.) Yes. Therapist: We can also notice that even remembering this threatening event organizes things in specific ways right now—­feeling anxious and tense, focused on the threat. It’s almost like these experiences combine to create a