Compassion Focused Therapy

Clinical Practice and Applications

Paul Gilbert, Gregoris Simos, Paul Gilbert, Gregoris Simos

• Publisher: Routledge
• Year: 2022
• ISBN:
  9781000481358
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

Compassion Focused Therapy: Clinical Practice and Applications offers evidence-based guidance and extensive insight into the science behind compassion focused therapy.

The first section of the book explores the evolution and physiological infrastructures of caring, and how compassion arises when humans use their complex cognitive competencies to address suffering deliberately and intentionally. With this framework and basis, the next sections of the book explore CFT applied to groups, specific interventions such as chair work, the importance of applying the principles of the therapy to oneself, the CFT therapeutic relationship, and a chapter offering a systematic review of the evidence for CFT. The third section offers a series of multi-authored chapters on interventions for a range of different mental health problems such as depression, anxiety, trauma, and many others.

Being the first major clinical book on compassion focused therapy, with leading international researchers and clinicians addressing central problems, this landmark publication will appeal to psychotherapists from a variety of schools as well as being a vital resource for compassion focused therapists.

Section ICompassion focused therapyAn evolved biopsychosocial approach

Paul Gilbert

10.4324/9781003035879-1

1Setting the scenePsychotherapy at a crossroads and a compassionate way forward

Paul Gilbert

DOI: 10.4324/9781003035879-2

The emergence of an evolution-informed, biopsychosocial science of psychotherapy

The first nine chapters of this edited book offer an outline and map of the basic science of compassion focused therapy (CFT). Central to CFT is its concern to integrate knowledge from different disciplines, from anthropology through to genetics, philosophy to neuroscience, because knowledge of the human mind, and how to help it, does not reside in one discipline or one school of therapy (Gilbert, 1989, 1995, 2019; Siegel, 2019). Wilson (1999) coined the term consilience for an integrative science across disciplines. At the root of this integration is the recognition that we are an evolved species like all other species, and therefore we can start our journey with another quote from Wilson (1992) that sets the framework for CFT:

Our troubles arise from the fact we do not know what we are and cannot agree on what we want to be. The primary cause of this intellectual failure is ignorance of our origins. We did not arrive on this planet as aliens. Humanity is part of nature, a species that evolved among other species. The more closely we identify ourselves with the rest of life, the more quickly we will be able to discover the sources of human sensibility and acquire the knowledge on which an enduring ethic, a sense of preferred direction, can be built. (Wilson, 1992, p. 332)

Creating caring connections. Ken Bailey and I used this quote over 20 years ago to contextualise our evolutionary approach to psychotherapy. It remains a core issue for psychotherapy (Gilbert & Bailey, 2000). Today we are homing in on what the ‘sources of our sensibility’ are that make us human. We are recognising that our minds are not autonomous, individualised units but are evolved to be complex processing systems of interconnectedness with other minds (Cozolino, 2014; Dunbar, 2014; Siegel, 2016, 2020). As noted in Chapter 2, clearly our human intelligence and cognitive abilities are special human features, but more than anything else it is due to our passionate interest in, competencies to, and the way we create caring social connections that today we see the human brain as an essentially social brain (Dunbar, 2014; Lockwood, et al., 2020; Porcelli et al., 2019; Silston et al., 2018). There have been major adaptations to the autonomic nervous and immune systems that regulate health and happiness emerging from the evolution of close relationships (Cozolino, 2014; Haslam, Jetten, Cruwys, Dingle, & Haslam, 2018; Porges, 2007, 2017; Siegel, 2020). There is now considerable evidence that when we are embedded in supportive, close relationships, many physiological functions such as the immune, cardiovascular, and autonomic nervous systems, along with key neurocircuits, telomere length, and our epigenetic profiles are all positivity affected (for a major review, see Slavich, 2020). In contrast shaming, bullying, and oppressiveness, along with loneliness, and social disconnection, and hostile self-critical relationships with ourselves, are detrimental to health. Despite neoliberal claims, we are not autonomous units but are evolved for social living and flourish best on a diet of caring social connections of giving and receiving between self and others. In physical medicine too there is growing awareness that difficulties such as blood pressure and other chronic health conditions are made much worse in the context of loneliness and/or hostile self–other relationships. Community medicine is therefore focusing more and more on how to build integrated caring, social communities and are seeing radical drops in emergency admissions and increases in general well-being (Able & Clarke, 2020). Around the world, health is being promoted by facilitating caring community relating. For example, facilitating female support groups significantly reduces post-natal depression, infant mortality, and offers many other health benefits (Costello, 2018). There is increasing scientific evidence for the importance of this social approach to mental health (Haslam et al., 2018 and see below). Early beginnings of CFT can be traced back to writings on brain state approaches (Gilbert, 1984) and social motives as in Human Nature and Suffering (Gilbert, 1989). It is rooted in the fact that we are a social species with complex, and at times different and conflicting social motives, both helpful and unhelpful. Although CFT has been identified as a third-wave cognitive therapy and as only focused on self-compassion, these are incorrect. The essence of CFT is to create caring-compassionate connections with self and others that recruit the physiological ingredients for caring, to support a healthy and helpful mind. A self-compassionate individual who has no interest or capacity for helping others or being helped by others will in the end struggle and is problematic to their communities.

A quick look at the current challenges of psychotherapy and why it needs to be socialised

The progress of psychotherapy over the last 50 years has been exciting but also something of a chaotic journey. Different therapies, rooted in different conceptions, and focusing on different micro skills and interventions, have proliferated in multiple branching directions. Some have compared this to what happens in religions (Epstein, 2006). Many recognise there is something fundamentally concerning that we have over 400 different schools of psychotherapy often pursuing slightly (and sometimes not-so-slightly) different themes without much unity on understanding the mind we are working with (Norcross & Lambert, 2019; Zarbo, Tasca, Cattafi, & Compare, 2016). Indeed, many have noted that a ‘fragmentation crisis’ emerges when there is no consistent science which allows different groups to split into subgroups to form their own tribes with their own models, qualifications, and group identities (Gilbert, 1995, 2019; Gilbert & Kirby, (2019); Shamdasani & Lowenthal, 2020; Siegel, 2006). The ‘tribes’ have become businesses with their own trainings, accreditations, conferences, journals, and offering a sense of belonging and self-identity, and competing for research monies, often against each other (CFT too). Norcross and Lambert (2019) call this turf wars. This is no one’s fault, but many now agree that we need to study the precise processes that give rise to specific states of suffering and take a multifactorial approach to intervention and prevention. The root of the problem is, as Wilson (1992) says, our failure to agree on a basic science, and this accounts for another problem, which is the efficacy of our psychotherapies.

As innovative and valuable as many of these multiple approaches are, whether one is a purest to one’s own tribe or attempts to be more integrative, the evidence of their effectiveness is not as good as we would like to believe. Watkins and Newbold (2020) note that, while progress has certainly been made in the psychotherapies:

Many patients do not have sustained improvement, and treatments need to scale up to tackle the global burden of mental health […] For example, psychological treatments for depression only achieve remission rates of 30%–40% and have limited sustained efficacy (at least 50% relapse and recurrence) […] Further, it is estimated that current treatments, if delivered optimally, would only reduce the burden of depression by one third […] As such, psychological treatments for depression need to be significantly enhanced. (p. 2)

This again raises the issue of whether social contextual approaches would add essential ingredients to individualised packages (Haslam et al., 2018; Smail, 2018). Basically, the longer you follow people up, the worse some will do, unless they experience benevolent social change (Brown, Adler, & Bifulco, 1988). Therapies must therefore address behavioural and psychosocial issues. The newer therapies are a step forward, but not a giant one. Watkins and Newbold (2020) call for a greater focus on process research, of which they say:

To be clear, we distinguish between the active components of therapy, operationalized as the active elements or ingredients within a therapy that produce clinical benefit, which could be therapist-based, client activities, specific techniques, or related to therapy structure and delivery, versus the active mechanisms of the therapy, operationalized as the underlying change processes that causally underpin therapeutic benefit […] (p. 2)

Understanding the mechanisms or the active components of psychological treatments are important because either potentially enables the development of more direct, precise, potent, simpler, briefer, and effective treatments. Understanding the active components of a psychological therapy is necessary in order to parse and distil the therapy to focus on what is essential and most engaging to patients. (p. 2, italics added)

Norcross and Lambert (2019) also review considerable evidence on the active ingredients of psychotherapy. They are diverse but include the therapeutic relationship, therapist skill, client factors, external factors, spontaneous remission, social support, and fortuitous events (p. 11). Specific models account for only a small percentage of the variance. This is reminiscent of the community studies that show we can be triggered into depression with adverse life events and be lifted out of it with fresh starts and positive life events (Brown, Adler, & Bifulco, 1988). Whichever therapy individuals experience, it may be how it can help them make real changes in their lives such as moving away from toxic personal or community relationships, gaining confidence to find better jobs, forming supportive relationships, and becoming involved with meaningful activities such as charities and where people feel they make a contribution, that heals.

CFT has always been a process therapy seeking to understand process before moving to outcome randomised control trials. It is very clear now that packaged therapies, addressing narrow domains of functioning, will only take us so far. The obvious problem is that outcomes depends upon what processes are being focused on (Gilbert & Kirby, 2019). Freud recognised that we needed to link psychological processes with physiological ones (Ellenberger, 1970). However, his project, which sought to do that, became impossible, partly because there was not sufficient science to allow it. Today there is (Cozolino, 2017; Hood, 2011; Schore, 2019a,b; Siegel, 2020). The splitting off of mind from body and social context has been something of a disaster for mental health science. Writing in the British Journal of Psychiatry 35 years ago, Eisenberg (1986) referred to the problem as brainless versus mindless science. CFT strongly suggests therapists would benefit from having some overview understanding of the nature of the human brain to avoid getting lost in concepts such as having a real or authentic self, rather than understanding we are a set of distributed often competing processing systems; the self itself is an illusion (Hood, 2011).

Lacking an integrative biopsychosocial science (Gilbert, 1984, 1989, 1995) may well account for some of these disappointing findings noted by Watkins and Newbold (2020), (Gilbert & Kirby, 2019). Putting people into research trials on the basis of a set of symptoms labelled (say) depression, when it has been long recognised that depression is a highly heterogeneous disorder (Akiskal & McKinney, 1973; Fried & Nesse, 2015) and an end state of a multiple range of complex and different processes, is fraught with problems. For example, cognitive behaviour therapies can help people whose depression is indeed being generated or maintained by cognitive processes, but for some depressed people negative cognitions are symptoms rather than causes. Cognitive interventions may help us manage certain problems, but therapies need to address causes. For example, consider those individuals who have underlying health issues such as low testosterone, thyroid problems, vitamins B12 and D deficiencies, and anaemias to name the obvious (see Cowles, Pariante, & Nemeroff, 2009 for detailed discussion). Women undergoing menopause and perimenopause can have a wretched time of it. Viruses including our most recent little nasty Covid-19 can affect the brain, the immune system and trigger depression. Brain parasites like the one you can pick up from cats, Toxoplasma gondii, may play a role in some mental states. The diagnosis is also complicated now with the finding that many depressed people are suffering from problems of inflammation, which may be less responsive to any psychotherapy intervention alone (Bullmore, ...

Table of contents

• Cover
• Endorsements Page
• Half-Title Page
• Title Page
• Copyright Page
• Dedication
• Contents
• List of figures
• List of tables
• Directory
• Acknowledgements
• Preface and overview
• Section I Compassion focused therapy: An evolved biopsychosocial approach
• Section II CFT practices and settings
• Section III Specific applications
• Index