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Introduzindo terapia focada em compaixão

Publicado online pela Cambridge University Press: 02 janeiro 2018

Paul Gilbert

Resumo

Vergonha e autocrítica são problemas transdiagnósticos. As pessoas que as vivenciam

podem se sentir aliviadas, tranquilizadas ou seguras. Pesquisas sugerem que um sistema
de regulação de afeto (ou sistemas) especializado sustenta sentimentos de tranquilidade,
segurança e bem-estar. Acredita-se que tenha evoluído com sistemas de apego e, em
particular, a capacidade de registrar e responder com calma e sensação de bem-estar a ser
cuidado. Na terapia focada na compaixão, a hipótese é que esse sistema de regulação de
afeto é pouco acessível em pessoas com alta vergonha e autocrítica, nas quais o sistema de
regulação de "ameaça" afeta a orientação para seus mundos internos e externos. A terapia
focada na compaixão é uma abordagem integrada e multimodal que se baseia na
psicologia evolutiva, social, de desenvolvimento e budista e na neurociência. Uma de suas
principais preocupações é usar o treinamento mental compassivo para ajudar as pessoas a
desenvolver e trabalhar com experiências de calor interior, segurança e sooing, via
compaixão e autocompaixão.

Tipo

Artigos

Informação

Avanços no Tratamento Psiquiátrico ,

Volume 15 ,
Edição 3 , Maio de 2009 , pp. 199 - 208
DOI: https://doi.org/10.1192/apt.bp.107.005264
 Direitos autorais

Direitos autorais © The Royal College of Psychiatrists, 2009

As propriedades curativas da compaixão foram escritas por séculos. O Dalai Lama muitas
vezes enfatiza que se você quer que os outros sejam felizes – concentre-se na compaixão;
se você quiser ser feliz você mesmo – concentre-se na compaixão (Dalai Lama 1995, 2001).
Embora todos os médicos concordem que a compaixão é central para a relação médico-
paciente e terapeuta-cliente, recentemente os componentes da compaixão foram olhado
através das lentes da ciência psicológica ocidental e da pesquisa (Gilbert 2000, 2005a, 2009;
Davidson 2002; Neff 2003a,b). A compaixão pode ser considerada como uma habilidade em
que se pode treinar, com evidências crescentes de que focar e praticar compaixão pode
influenciar os sistemas neurofisiológico e imunológico (Davidson 2003; Lutz 2008). A terapia
focada na compaixão refere-se à teoria e ao processo de a aplicação de um modelo de
compaixão à psicoterapia. O treinamento mental compassivo refere-se a atividades
específicas projetadas para desenvolver atributos e habilidades compassivas,
particularmente aquelas que influenciam a regulação. A terapia focada na compaixão adota
a filosofia de que nossa compreensão dos processos psicológicos e neurofisiológicos está
Article contents
se desenvolvendo em um ritmo tão rápido que agora estamos indo além das "escolas da
psicoterapia" em direção a uma ciência mais integrada e biopsicossocial da psicoterapia
(Gilbert 2009).

Foco clínico
Terapia focada em compaixão e treinamento mental compassivo surgiram de uma série de
observações. Em primeiro lugar, pessoas com altos níveis de vergonha e autocrítica podem
ter enorme dificuldade em ser gentis consigo mesmas, sentir-se auto-calor ou ser
autocomparáveis.

Em segundo lugar, há muito se sabe que os problemas de vergonha e autocrítica estão

frequentemente enraizados em histórias de abuso, bullying, alta emoção expressa na
família, negligência e/ou falta de afeto (Kaufman 1989; Andrews 1998; Schore 1998).
Indivíduos submetidos a experiências iniciais desse tipo podem se tornar altamente
sensíveis a ameaças de rejeição ou críticas do mundo exterior e podem rapidamente se
tornar auto-atacadores: eles experimentam seus mundos externo e interno como
facilmente se tornando hostis.

Em terceiro lugar, reconheceu-se que trabalhar com vergonha e autocrítica requer um foco
terapêutico nas memórias de tais experiências precoces (Kaufman 1989; Schore 1998;
Brewin 2003, 2006; Gilbert 2005b). Este trabalho pode se sobrepor substancialmente às
intervenções terapêuticas desenvolvidas para o trauma (Lee 2005; Ogden 2006; Van der
Hart 2006; Wheatley 2007).

E em quarto lugar, há clientes que se envolvem com as tarefas cognitivas e

comportamentais de uma terapia, e se tornam hábeis em gerar (digamos) alternativas para
seus pensamentos e crenças negativas, mas que ainda fazem mal na terapia (Reitor 2000).
É provável que digam: "Eu entendo a lógica do meu pensamento alternativo, mas isso
realmente não me ajuda a me sentir muito melhor" ou "Eu sei que não sou culpado pelo
abuso, mas ainda sinto que sou". Um elemento-chave da terapia focada na compaixão está
relacionado à observação de que indivíduos propensos a altos níveis de vergonha e
autocrítica podem achar muito difícil gerar sentimentos de cosntentment, safeness ou calor
em suas relações com os outros e consigo mesmos.

Evolução e as neurociências
Uma forma de abordar esse problema é focar nas funções evoluídas que sustentam certos
tipos de sentimentos e estilos de relacionação social (Gilbert 1989, 2005a, 2007, 2009).
Quais são os sistemas de efeito que nos permitem sentir-nos tranquilizados, contentes e
seguros, ou registrar o calor humano? Pesquisas sobre a neurofisiologia da emoção
sugerem que podemos distinguir pelo menos três tipos de sistema de regulação da
emoção (Depue 2005): sistemas de ameaça e proteção; sistemas de unidade, busca de
recursos e excitação; e sistemas de contentamento, reconfortante e de segurança.
Explorarei cada um desses por sua vez e sua relação com a terapia focada na compaixão.
Estes não são de forma alguma a única maneira de nosso sistema de regulação emocional
ser mapeado e conceituado, e eles podem ser subdivididos de várias maneiras (Panksepp
1998), mas oferecem uma heurística útil para o pensamento clínico. Uma simples
representação de sua interação é dada em Fig. 1.

Ameaça e proteção
Todos os seres vivos evoluíram com sistemas básicos de detecção e proteção de ameaças
(Caixa 1). A neurofisiologia desse sistema em humanos é cada vez mais bem compreendida
(LeDoux 1998; Panksepp 1998). Sua função é perceber ameaças rapidamente (através de
foco de atenção e viés de atenção) e, em seguida, nos dar explosões de sentimentos como
ansiedade, raiva ou nojo. Esses sentimentos ondulam através de nossos corpos, alertando
e instando-nos a tomar medidas para fazer algo sobre a ameaça – para nos protegermos.
As saídas comportamentais incluem luta, voo e submissão (Marcos 1987; Gilbert 2001). A
regulação genética e sináptica da serotonina desempenha um papel no funcionamento do
"sistema de proteção contra ameaças" (Caspi 2006). Em parte porque o sistema é
programado em favor de "melhor segurança do que remediar" (Gilbert 1998) é facilmente
condicionado (Rosen 1998) e é a fonte de muitos aspectos da psicopatologia.

CAIXA 1 Sistemas de proteção contra ameaças

• Todos os seres vivos evoluíram sistemas de detecção e proteção de ameaças
• Estímulos que impingem organismos devem ser verificados para uma ameaça
potencial
• As defesas dos mamíferos incluem um cardápio de emoções (por exemplo, raiva,
ansiedade, nojo), comportamentos (por exemplo, luta, fuga, congelamento,
submissão) e vieses cognitivos (por exemplo, "melhor prevenir do que remediar",
"tirar conclusões precipitadas")
• Os sistemas de proteção contra ameaças evoluíram para estar sintonizados com
certos tipos de ameaças e operar uma política melhor segura do que remediada
• Sensibilidade e resposta a ameaças específicas são o resultado de uma interação
entre genes e aprendizado
• Opções de resposta dentro do sistema de proteção contra ameaças podem entrar
em conflito, criando confusão
• Estados cerebrais coreografados a partir do sistema de proteção de ameaças
podem influenciar outros sistemas de processamento
• O excesso e o subdesenvolvimento das sensibilidades na proteção contra ameaças
sustentam muitas psicopatologias

O bom funcionamento do sistema de proteção contra ameaças pode ser difícil, pois, por
exemplo, muitas de suas opções de resposta conflitam entre si. É difícil se envolver tanto no
comportamento de luta quanto no comportamento de fuga ao mesmo tempo, e o
comportamento submisso pode envolver ficar em posição, ser passivo e inibir tanto a luta
quanto a fuga. Na terapia focada na compaixão, os médicos explicam e exploram isso com
os clientes. A formulação explora como os eventos da vida precoce podem ter sensibilizado
o sistema de proteção contra ameaças do indivíduo, levando ao desenvolvimento de
estratégias de segurança que podem operar automaticamente, como respostas
condicionadas e talvez conflitantes. Por exemplo, algumas pessoas têm estratégias de
segurança submissa bem desenvolvidas. Predispo-os a estar cientes da classificação, status
e poder dos outros em relação a si mesmos, a perceber-se como inferiores, a ser rápido em
se sentir socialmente ansioso e incerto, a se engajar em comportamentos apaziguantes e
evitar diante de conflitos interpessoais (Gilbert 2005a, 2007). Tais estratégias podem
aumentar sua vulnerabilidade à ansiedade e à depressão, diminuir sua autoestima e
interferir na sua capacidade de perseguir objetivos de vida. Assim, no modelo evolutivo, as
estratégias podem envolver combinações de estilos de pensamento, comportamento e
sentimento.

Estratégias sensibilizadas e fenótipos para detecção e proteção de ameaças podem se

tornar grandes influências sobre as maneiras pelas quais uma pessoa percebe e navega em
seu mundo. O médico identificará, historicamente, traçará e validará as funções e origens
das estratégias de segurança (em parte para desenvergonhá-las) (Linehan 1993; Ogden
2006; Van der Hart 2006; Gilbert 2007). Na terapia focada na compaixão, o foco é entender
as funções dos sintomas e dificuldades de uma pessoa em termos de estratégias de
segurança. Os primeiros aspectos da compaixão crescem dessa parte da formulação
porque ajuda o cliente a reconhecer que sua patologia e sintomas não são "culpa deles",
mas muitas vezes surgiram com estratégias de segurança. A partir daqui é possível
começar a desenvolver uma reflexão compassiva e validadora sobre o fato de que eles
precisavam desenvolver essas estratégias de segurança. Trata-se de uma abordagem
também bem desenvolvida na terapia comportamental dialética (Linehan 1993). Na terapia
focada na compaixão, uma vez que os indivíduos param de criticar, condenar e culpar-se
por seus sintomas, pensamentos ou sentimentos, eles são mais livres para se mover para
assumir a responsabilidade e aprender a lidar com eles.

Unidade e emoção
Os animais precisam de emoção e sistemas motivacionais que os direcionem para
importantes recompensas e recursos. Estes incluem alimentos, oportunidades sexuais,
alianças, ninhos, territórios e assim por diante. Assim, a função do sistema de acionamento
e excitação em humanos (Caixa 2) é nos dar sentimentos positivos que energizam e nos
guiam a buscar coisas (por exemplo, comida, sexo, amizades); é um "sistema de desejos"
que nos guia para objetivos importantes da vida (Depue 2005). If we win a competition,
pass an exam or get to go out with a desired person, we can have feelings of excitement
and pleasure. The feelings associated with this system are linked to arousal, feeling
energised and even ‘hyped up’. If people take cocaine or amphetamine this is the system
they are likely to stimulate. In Buddhist psychology, positive feelings linked to this type of
system of achievement and satisfying desires can give us pleasures but not happiness
because our pleasure feelings are dependent on acquiring rewards, resources and
achievements. In Buddhism happiness comes from cultivating a calm ‘non-striving’ mind
that is mindful and compassion focused (Dalai Lama 2001).

BOX 2 The drive system

• This system motivates and directs us to important resources
• It is a source of anticipation and pleasure
• It underpins the development of desires and some goals – both material and those
linked to self-esteem (e.g. seeking status or fame)
• It is an activating system highly stimulated by certain drugs
• The positive emotions flowing from this system are often the focus of Western
psychology and materialistic cultures

Interaction of the two systems

The drive system and the threat protection system can be linked in complex ways, especially
when we are driven to avoid negative events, which shows up in thoughts of ‘shoulds’,
‘oughts’ and ‘musts’. Some individuals pursue status, material possessions and achievement
in order to feel safe and avoid feelings of rejection, subordination or inferiority. They may
feel the need to prove themselves and to be constantly achieving. Depue & Morrone-
Strupinsky (2005) suggest that status-seeking, competitiveness and working to avoid
rejection are all linked to the drive system.

There is increasing concern that modern societies overstimulate the drive system (Pani
2000). In depression there is a toning down of the system, creating feelings of loss of
positive affect and motivation (Gilbert 2007). Compassion-focused therapy explores the
function of the client's goals and how the individual reacts if they stumble or fail to reach
them. Is there disappointment or an attack on self or others? Some individuals have a self-
identity goal to be ‘nice and liked’. The function of this goal is to win affection and avoid
rejection and conflict, and if this fails they can become self-critical.

Contentment, soothing and social safeness

When animals are not having to be attentive to, or deal with, threats and dangers, and they
have sufficient resources, they may enter states of contentment (Depue 2005). The positive
emotions of the contentment system (Box 3) are very different from those of the drive
system. Contentment is associated with a sense of peacefulness, well-being and quiescence
– a state of ‘not-seeking’. Contentment is not just the absence of threat or low activity in the
threat protection system. Rather, there seems to be a particular system, linked to the
opiates, that mediates feelings of well-being and contentment.

BOX 3 The contentment system

• When animals are not threatened and not seeking resources they can become
content
• Contentment is associated with a positive ‘calm’, positive affects and sense of well-
being; contentment is not just the absence of threat
• The evolution of attachment behaviour utilised the contentment system, and
enabled signals of caring and kindness to have soothing qualities that activate
positive affects linked to feelings of well-being, safeness and social-connectedness.
This aspect of the system may be called ‘social safeness’
• The contentment/social safeness system is internally wired to act as a regulator of
the threat protection and drive systems
• Compassion-focused therapy and compassionate mind training are directed at
facilitating development of the soothing and social safeness system

Depue & Morrone-Strupinsky (2005) point out that the contentment system has been
significantly developed with the evolution of attachment behaviour. The caring behaviour of
the parent, especially physical proximity, has a soothing effect on the infant's physiology.
Thus, compassion-focused therapy integrates findings and concepts from attachment
research (Bowlby 1969; Gilbert 2005a; Mikulincer 2007). Porges (2007) has written
extensively on the way the sympathetic and parasympathetic nervous systems have
undergone modifications in mammals to allow them to engage in close interpersonal
relationships and soothe each other. The key point is to recognise the importance of caring
behaviour in stimulating the soothing and safeness system, and thus soothing overarousal
and threat (dis)stress in the individual receiving care. Caring-affiliation operates through an
opiate and oxytocin system. Oxytocin is a neurohormone linked to feelings of affiliation,
trust and feeling soothed and calmed within relationships (Carter 1998; Uväns-Morberg
1998; Depue 2005; Wang 2005). It is also linked to social affiliation, and there is increasing
evidence that it reduces sensitivity, especially to socially threatening stimuli, in fear circuits
of the amygdala (Kirsch 2005). I have previously referred to this system as a social safeness
system linked to affection and kindness, both of which have soothing properties (Gilbert
1989, 2005a, 2007, 2009).

Balancing the systems

The neurophysiology and evolutionary concepts outlined in the previous sections are, of
course, oversimplifications of complex processes. However, they form a foundation for
compassion-focused therapy, in which the therapist's formulations and thoughts are
organised around three affect regulation systems (Panksepp 1998; Depue 2005). It is
believed that these three systems can become unbalanced, and rebalancing them is one of
the goals of therapy.

Heightened sensitivity and overactivity of the threat protection and/or drive systems is a
common problem in people with high shame and self-criticism. Individuals find it difficult to
feel content or safe within themselves and in interpersonal relationships. According to the
principles of compassion-focused therapy, the soothing system is insufficiently accessible to
them. There may be many reasons for this. A common one is that it has been
understimulated during early life. For example, a person may have received more threats
from their parents than soothing. As attachment research has shown, this can leave the
individual struggling to feel soothed. In consequence, they may develop anxious or
avoidant attachment and interpersonal styles (Mikulincer 2007). Compassion-focused
therapy proposes that it is the soothing system that also provides a sense of relief and
calming. Individuals who cannot access this system find it hard to feel reassured or
calmed/soothed when they generate (believable) alternative thoughts or engage in helpful
behaviours.

The social safeness/soothing system as a focus in the

therapy
Given this developmental, social, evolutionary and neurophysiology model, it is clear why
compassion-focused therapy focuses on the development of the social safeness system in
the therapy. As we have seen, this system is particularly sensitive to interpersonal cues of
social safeness, acceptance and being cared for. It is also key to the regulation of the drive
and threat protection systems. Thus, the role of the therapist is to help the client experience
safeness in their interactions with them, to tolerate and feel safe with what is explored in
the therapy, and to replace self-criticism with self-kindness (Gilbert 2007).
Working compassionately
Compassion and its components may be defined in many ways. In compassion-focused
therapy compassion is understood in terms of specific attributes and skills (Gilbert 1989,
2005a, 2007, 2009). Central to compassion-focused therapy is compassionate mind training:
by demonstrating the skills and attributes of compassion (Fig. 2), the therapist instils them
in the client. Thus, the client is helped to develop an internal compassionate relationship
with themselves to replace the blaming, condemning and self-critical one (Box 4).

BOX 4 The three aspects of compassionate therapeutic engagement

• The therapist uses the skills and expresses the attributes of compassion
• The client experiences their interaction with the therapist as one that is de-
shaming, compassionate and safe; ideally, the client will experience each of the
attributes and skills of compassion in, and from, the therapist
• The therapist helps the client to develop compassionate attributes and skills
directed at the self

The attributes of compassion

Care for well-being

This requires harnessing the motivation to be caring for the purpose of alleviating distress
and facilitating the flourishing and development of the target of the caring.

Sensitivity
The individual is sensitive to distress and needs, and able to recognise and distinguish the
feelings and needs of the target of their caring.

Sympathy
Having sympathy involves being emotionally moved by the feelings and distress of the
target of their caring. In the therapeutic relationship this means that the client is able to
experience the therapist as being emotionally engaged with their story as opposed to being
emotionally passive or distant.

Distress tolerance
Having distress tolerance means being able to contain, stay with and tolerate complex and
high levels of emotion, rather than avoid, fearfully divert from, close down, contradict,
invalidate or deny them. The client experiences the therapist as able to contain their own
emotions and the client's emotions. The therapist is not alarmed, shocked or frightened by
the client's emotions or, if they are, they contain it and act in an appropriate way.

Empathy
Feeling empathy involves working to understand the meanings, functions and origins of
another person's inner world so that one can see it from their point of view. Empathy takes
effort in a way that sympathy does not. Self-empathy is the ability to stand back from and
understand our own thoughts and feelings.

Non-judgement
Being non-judgemental means not condemning, criticising, shaming or rejecting. However,
non-judgement does not mean non-preference. For example, non-judgement is important
in Buddhist psychology where we learn to experience the moment ‘as it is’. However, this
does not mean we do not have preferences. The Dalai Lama would very much prefer the
world to be less cruel and more compassionate. Indeed, these can be highly pursued life
goals.

The skills of compassion

The skills of compassion involve creating feelings of warmth, kindness and support in a
range of activities which are (like the attributes of compassion) essentially multimodal and
common to many other psychotherapies. People can be taught to engage mindfully with a
whole range of therapeutic interventions that focus on thoughts, feelings and behaviours
(Mace 2007; Williams 2007). It is particularly important to teach the client to use these skills
on themselves. When probed about the emotional textures of their efforts to help
themselves, clients with high shame and self-criticism often reveal that they use a cold,
bullying or aggressive inner tone to try to change their thoughts and behaviours.
Therapists should explore whether clients are trying to force or bully themselves to change,
in contrast to being supportive and encouraging of their own efforts to do so.

Compassionate attention
Compassionate attention is the focusing of our attention in a way that helps and supports
us. For example, it may involve remembering times when we were kind to others or others
were kind to us, or it might involve compassionate imagery. If we are in conflict with
someone, we often overlook the things that we like about them: by refocusing our attention
we can regain a more balanced view. The experience of refocusing attention needs to be
associated with warmth, support and kindness.

In compassion-focused therapy, the therapist focuses on identifying the client's strengths,

positive attributes or skills, such as their courage, kindness to others or previous coping.
Clients are taught to pay attention and bring to mind their positive qualities, perhaps by
revisiting positive memories, and working on those aspects of self.

Therapists can also teach attention-directing exercises linked to the savouring of

experiences, to develop the client's appreciation and gratitude. For example, an individual
may be encouraged to spend time appreciating the taste of their food, or the colours of the
sky or a certain style of music. In many psychopathologies, the threat protection system will
be focused on problems and potential difficulties, and individuals can therefore benefit
from practising the refocusing of their attention and liberating it from this dominance.

Compassionate reasoning
Compassionate thinking involves how we reason about the world, ourselves and others. In
cognitive therapy (Beck 1979), dialectical behavioural therapy (Linehan 1993) and
mentalising (Fonagy 2006) we have a range of interventions to help people develop more
balanced reasoning. Compassion-focused therapists build on these interventions but also
devote a lot of time to ensuring that clients experience alternative thoughts as kind,
supportive and helpful. Logic is not enough: ‘evidence’ is secondary to the experience of
being helped and supported. The process of the therapy itself, whereby the therapist listens
warmly, acknowledges and validates clients' emotions and personal meanings, is important
for this (Linehan 1993).

Particularly important is how people reason, ruminate and reflect on their current mood
states, their future and their sense of self. Shame and self-critical thinking are clearly
targets in compassion-focused therapy, but it is important to understand the functions of
self-critical thinking and the fears people may have of giving it up. The therapist teaches the
problems of certain types of rumination and how to substitute compassionate refocusing in
one's thinking.

Compassionate behaviour
Compassionate behaviour is focused on alleviating distress and facilitating development
and growth. This does not mean avoiding engaging with difficult or painful realities or
behavioural tasks: courage is important in compassion-focused therapy – indeed, the word
encouraging means giving courage. Helping the client to have courage requires clear
collaboration on ‘the new behaviour’ as a compassionate intervention. Exposure work is
undertaken in the spirit of compassionate development. So, for example, when the
individual has to engage in difficult or frightening behaviour they will try to create an
encouraging, warm tone in their minds associated with the supportive thoughts. All the
time the client is taught to use warmth, compassion and gentleness as a reference point to
move into the more frightening activities. This is a repetition of what would normally
happen within a parent–child relationship, where the parent is encouraging and supportive.
In compassion-focused therapy the therapist encourages the client to take this orientation
to themselves.

Compassion-focused therapy is not just about counteracting threat-based processing or

developing different defences such as learning to be assertive rather than submissive: it
also seeks to stimulate positive affect processing. Some clients have developed a fear of
enjoying themselves or doing nice things for themselves and positive emotions can feel
threatening because (in part) they are unfamiliar and the individual feels ‘off guard’.
Behavioural tasks encouraging exposure to positive emotions can help the client to learn to
enjoy experiencing them (fear of compassion is discussed in a separate section below).

Helping people become more process-focused rather than task-focused is also important.
Following behavioural traditions, compassion-focused therapy helps people focus on their
efforts rather than their results. Thus, clients learn to attend to their effort, no matter how
small, and to appreciate that rather than focusing on how far short they fall from their goal.
Many high-shame and self-critical clients have never learnt this effort appreciation.
Unfortunately, we are living in a society that has become more contemptuous of rewarding
effort and in which many believe that ‘second is not good enough; who remembers who
came second?’

Compassionate imagery
The technique of using compassionate imagery involves a series of exercises that help the
client generate compassionate feelings for themselves. There have been many approaches
to developing compassionate feelings by using imagery (Frederick 1999; Leighton 2003; Lee
2005). In compassion-focused therapy, the therapist works to help the client create and
explore their image of their ‘ideal’ of compassion. The client may, for example, explore what
their ideal compassionate other might look like, their facial expressions, their voice tones.
The therapist guides the client through such imagery exercises, exploring feelings
associated with various images. These images are usually fleeting and never clear in the
mind, and the therapist advises the client of this. Sometimes clients prefer non-human
images such as an animal, a tree or a mountain. These too must be imagined as sentient,
with specific qualities of wisdom, strength, warmth and non-judgement. Clients often like to
imagine that their image has been through similar situations to themselves, as opposed to
being some ‘higher being’ outside of human experience.

There are also exercises related to body postures and imagining oneself as a deeply
compassionate person. This is like method acting, when one practises adopting and getting
into a particular role. The client imagines themselves as a highly compassionate person and
explores their sense of age, facial expressions, body postures, voice tones and styles of
thinking. Clients can be encouraged to practise each day at becoming ‘the compassionate
self’, with the appropriate facial expressions, voice tones and ways of thinking.

Compassionate feeling
Compassionate feeling relates to experiencing compassion from others, for others and for
the self. As noted throughout, compassionate feelings are generated in a number of ways,
for example via the therapeutic relationship and focused attention, thinking, behaviour and
imagery.

Compassionate sensation
Compassionate sensation refers to the way the therapist helps the client to explore feelings
in their bodies when they focus on being compassionate, experiencing compassion from
others and being self-compassionate. By working with and developing these skills,
compassion-focused therapy tries to help the client create within themselves feelings of
warmth, kindness and support.

The importance of self-compassion

Compassion-focused therapy follows a behavioural approach in suggesting that internal
thoughts and images can act just as external stimuli do, activating different parts of the
brain. To demonstrate and explore this with clients the therapist might draw a simple
outline of the brain and discuss the effects of both external and internal signals. For
example, if we are hungry and we see a lovely meal (external signal) this can start our saliva
and stomach acids flowing. Equally, just imagining a lovely meal (internal signal) can have
the same physiological effect. If we see something sexual on the television this can
stimulate release of hormones from the pituitary to give sexual arousal. But equally we can
just fantasise, using our own imagination to stimulate the pituitary to the same effect.

The therapist shares such facts with the client because they provide strong insight into the
physiological power of our thoughts, memories and images. The therapist asks the client to
consider how they would feel if someone kept putting them down, undermining their
confidence, becoming angry with them when things did not go well. Usually, clients are able
to identify feelings of anxiety and depression and can recognise that this is because critical
signals stimulate their threat protection system. From there the therapist can help the client
understand how switching to self-criticism, focusing/ruminating on self-criticism or
bringing to mind times when they have been criticised or put down will stimulate the threat
protection system and stress reactions. Indeed, self-criticism can be so constant in a
person's mind that it literally harasses them into depressed and anxious states. The clear
examples that the therapist has already given of how thoughts and images can stimulate
physiological systems enable the client to appreciate the potential power of their own self-
criticism.

Time spent clarifying the way our internal thoughts, images and memories can stimulate
different physiological systems, using very concrete examples, can pay off in the long term.
It also leads straight to the re-focus on compassion. The therapist points out that if we
receive understanding, kindness and gentleness from others (in contrast to bullying,
criticism and put-down) we feel much more soothed, safe and relieved. This is because
those signals stimulate particular systems in the brain; if we did not have those systems we
would not experience those feelings. It follows therefore that if we can practise generating
these (compassionate) types of thoughts, images and attention, focusing for ourselves we
may be able to stimulate and develop the contentment, soothing and safeness system.
Indeed, the idea of training the brain to think and feel certain things as a way of stimulating
physiological systems is now well established (Begley 2007).

Definitions and the evidence base

Self-focused compassion as a way of alleviating psychological disorders has gained recent
research interest. Definitions of self-compassion, however, vary. The self-esteem cognitive
therapists McKay & Fanning (1992) view self-compassion as understanding, acceptance and
forgiveness. From a social psychology and Buddhist tradition, Neff (2003a,b) sees
compassion as consisting of three bipolar constructs related to kindness, common
humanity and mindfulness. Kindness involves understanding one's difficulties and being
kind and warm in the face of failure or set-backs rather than harshly judgemental and self-
critical. Common humanity involves seeing one's experiences as part of the human
condition rather than as personal, isolating and shaming; mindful acceptance involves
mindful awareness and acceptance of painful thoughts and feelings rather than trying to
force them away or deny them. Compassion-focused therapy focuses on the skills and
attributes of compassion as depicted in Fig. 2.

A number of researchers have focused on the differences between self-compassion and

self-esteem (Neff 2003a,b, 2007; Gilbert 2005b; Leary 2007). For example, self-esteem tends
to increase when we are doing well, succeeding or achieving, whereas self-compassion is
important when we are doing badly; self-esteem can give us a sense of favourable
comparison with others, where we think in terms of social rank, whereas self-compassion
focuses on our similarities and common humanity with others. Crucially, self-compassion
focuses on generating a particular type of emotion towards the self that can loosely be
called self-warmth or self-kindness. There is limited but increasing research showing the
value of training people in self-compassion in both student (Leary 2007) and clinical
populations (Gilbert 2006; Mayhew 2008).

Fear of compassion
Many clients cannot easily access the soothing and social safeness system that underpins
compassion. In fact, much of the work in compassion-focused therapy addresses people's
fears and resistances to becoming self-compassionate and sometimes to becoming
forgiving and compassionate to others.

Attachment theorists suggest that signals of kindness and compassion from another
person (especially a therapist) will reactivate the attachment system (Mikulincer 2007).
When that happens the (complex and unresolved) memories and feelings within the
attachment system may come to the fore. Commonly, for high-shame and self-critical
people, particularly those from harsh backgrounds, the beginning of the experience of
warmth and kindness in therapy can ignite considerable sadness and grief. This is ‘distress
calling’ and despair as the social safeness system recognises that there may (now) be a
response from a caring other. Some clients are overwhelmed or even disassociate from the
pain of their grief. The compassion-focused therapist will help to normalise, validate,
contain and work with those feelings. In a recent study we found that some people find
compassion-focused imagery physiologically stressful (Rockliff 2008). There may be many
reasons for this, including the activation of powerful sadness and grief, conditioned
emotions of abuse associated with closeness or shame of closeness. These individuals can
be among the most difficult to help develop self-compassion, yet once their fears and
resistances are worked through, they may also gain greatly from compassionate mind
training – although we await research evidence for this.

As mentioned above, some clients have negative beliefs about compassion. Self-kindness
too can be viewed with suspicion, as being soft, self-indulgent or not deserved. This usually
indicates a fear of developing or experiencing self-compassion. Exploration might reveal
that the individual is afraid that if they give up self-criticism they will become lazy,
unpleasant or unlovable. Some think that they will be punished for self-compassion by
‘paying for it later’ or having it taken away. The therapist is constantly exploring the
interactions between the functions of self-criticism and the fear and avoidance of self-
compassion.

In this article I have underlined the importance of compassion in therapy, and pointed out
that compassion may also require courage and direct engagement in exposure to
threatening and feared situations, feelings or memories. Various therapies address this in
different ways (Brewin 2003; Ogden 2006; Van der Hart, 2006; Wheatley, 2007), but they
may all be easier to engage in if some compassion work is undertaken before or at the
same time as the exposures and reworking. Moreover, compassion is designed to stimulate
feelings of safeness, warmth and connectedness that have a direct soothing effect on the
threat protection system (e.g. Kirsch, 2005).

Conclusions
Compassion-focused therapy is an integrated therapy that draws from social,
developmental, evolutionary and Buddhist psychology, and neuroscience. It also draws on
many other therapeutic models that have developed interventions for specific types of
mental health problems. Compassion-focused therapy is in the traditions that seek to build
a science of psychotherapy based on research and understanding how our minds work,
rather than being focused on a particular school, model or process.

There is a long tradition of compassion-focused interventions in Buddhist psychology and

compassion-focused therapy has been profoundly influenced by that tradition. As for all
developments in psychotherapy, outcome and process research are key to the future of
compassion-focused therapy. Although there are limited data on the value of the approach
(Gilbert 2006; Mayhew 2008), there is still much to do to attract funding to research its
efficacy.
MCQs

1 Compassion-focused therapy was developed for:

a obsessive–compulsive disorder
b shame and self-criticism
c fear of flying
d depersonalisation
e hypomania.

2 Compassion-focused therapy is derived from:

a Freud's theory of the Oedipal complex
b evolutionary theory
c forensic psychology
d anxiety management
e studies of anger management.

3 Formulation in compassion-focused therapy is focused on:

a identifying maladaptive schema
b revealing unconscious conflicts
c linking background fears to safety strategies
d only current problems
e identifying behavioural deficits.

4 Compassion-focused therapy teaches people to:

a avoid things they find difficult
b practise generating feelings of warmth for themselves
c find ways to threaten their internal self-critic
d rely on logic to regulate emotion
e always express their feelings.

5 Compassion-focused therapy uses analogies of:

a every cloud has a silver lining
 b physiotherapy for the mind
c disassociating oneself from difficulties
d the ends justifying the means
e all's well that ends well.

MCQ answers

FIG 1 Affect regulation systems. From Gilbert (2005a), with permission of Routledge.

FIG 2 Multimodal compassionate mind training: the key aspects and attributes of compassion (inner ring) and the skills
training required to develop them (outer ring). From Gilbert (2009) with permission of Constable and Robinson.

Footnotes
Declaration of Interest

None.

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