This series is based on the model of Compassion Focused Therapy developed by Professor Paul Gilbert and others at the Compassionate Mind Foundation, including Dr Dennis Tirch et al.’s work integrating compassion with CBS. Thank you to them, and a grateful thank you to Professor Russell Kolts and Dr Tobyn Bell for their support and editorial guidance in putting this together. Thank you also to Jim Lucas and Dr Kate Lucre, from whom I’ve learned so much. I offer this, not as a definitive answer, but to contribute to the collective conversation, and hopefully as food for thought in your process of exploring what works for you.
Previous Post: Part 1. Start with Self-Compassion: self-care and cultivating our capacity and wisdom to work with our clients.
In this post, I invite us to explore a principle to guide all CFT (Compassion Focused Therapy) case conceptualisation and treatment planning, and integration with other therapies…
Compassion.
When we tune into this, the fundamental reason why we’re doing this work, it is like a compass. It orients us to the core of our clients’ problems and what would be helpful.
Building on the foundation of self-compassion we’ve established in Part 1, this is the meatiest post of this series, in which I share some of the most useful things I’ve learned about building a formulation-driven, process-oriented conceptualisation and treatment plan. This also offers a framework for integrating with other therapies, such as in CFACT (Compassion Focused-ACT) or CF-EMDR.
1. Case Conceptualisation
Experiential Practice
Before getting into the theory, I’d like to share with you an exercise that I find helpful to make sense of this. This is based on the Compassionate Self-to-Other exercise[1].
First, chose a client to bring to mind – one whom you like and find relatively easy to work with (you can try it again with a tricky case later). Take your time to practice as you read slowly.
Settle yourself into the position you might use for a meditation practice (‘sitting like a mountain’, feet grounded on the floor, hands in your lap, chest open, and head lifting up from your shoulders).
Take a moment to slow down… Notice your body being held by the chair… Draw your breath down to your belly… Breath out slowly… Find a smooth and soothing breathing rhythm… Give yourself a minute like this…
As you continue your soothing breathing rhythm, bring the client to mind.
Notice the way you can see them suffering… Really notice their face. What can you see behind their eyes? Fear? Shame? Anger?
What are they not saying?
Next, notice your reaction to their pain… How does your heart hurt for them? Are you picking up on their fear, shame, loneliness, anger?
Notice what they need… Do they need someone to see them and hold their suffering with them, so they can emotionally process? Do they need someone to give them guidance and some practical tools that actually help?
Notice your intention with them. Connect with the motivation to help them.
What actions could you take to help meet this need in them? Could you offer them a space, modelling compassion and acceptance with them? Could you offer your practical guidance?
Ok… Notice how a part of you can feel what is difficult for them, and has motivation and wisdom about what would be helpful.
Hold that in mind as you gently bring yourself out of the exercise. Take a stretch and a moment of reflection.
What do you notice?
What I notice in myself is that when I step back from all the mental spaghetti, there’s a knowing in my heart, from one human to another. There’s a sense of caring commitment, wisdom, and courage, with an intuitive sense of the hurt and what would be helpful. Sometimes it’s easy to connect with, and other times it’s a flicker beginning to illuminate the darkness. How about you?
This is compassion.
Theoretical Underpinning
Returning to the theory now, we can see that this maps onto the operational definition of compassion[2] that we use in CFT: an evolved, biological, motivational system, with 2 processes (sometimes called ‘psychologies’):
- Engagement: A sensitivity to suffering in self and others, and,
- Action: Motivation and helpful action to try to alleviate and prevent the suffering.
Holding this in mind, a really useful question that I’ve learned from Paul Gilbert[3] is: Are the client’s difficulties in Process 1 (i.e. awareness or capacity to engage with suffering) and/or Process 2 (motivation or skilfulness to respond helpfully)?
For example, Process 1 difficulties might include shame, unprocessed emotions including anxiety/grief/anger, trauma memories, or fused key fears/beliefs. Process 2 difficulties might include low motivation, feeling overwhelmed/phobic about their feelings, unhelpful coping strategies, or skills deficits.
Conceptualisation
The answer to this question points to the core of our client’s difficulties, and to what we need to work on in therapy. It is the essence of how we make sense of a case and our clinical choices.
Compassion thus serves as a guiding principle, like a compass, for case conceptualisation and treatment planning.
For me, and I think others in CFT and CFACT would generally agree, it holds everything together. It guides my clinical choices in treatment planning, and is what I find helpful to come back to when I’m finding a case tricky. Similarly, missing this point and diving into CMT (Compassionate Mind Training) without a clear, shared rationale is one of the key things I notice in new supervisees.
To flesh this out, we might now use or update one of the formulation frameworks we prefer. Would that be helpful for you? If it would, see the Footnotes[4] for some prompts.
For me, especially when feeling overwhelmed, there’s often something really useful in distilling it down into its essence like this. How can we see the wood for the trees, or park any threat-based drive to do everything and be a ‘good enough therapist’ – and, instead, state the problem and plan concisely, in as few words as possible without losing the richness? This creates something clear and precise, that we can manageably hold in mind within sessions.
Then, from this formulation-driven standpoint, we can start to ask ‘How can we cultivate these processes?’
Overlapping Processes
Often our answer might be ‘both’, because compassionate engagement and action are like 2 sides of a triangle. The capacity for one usually influences the other. Similarly, many interventions overlap both processes (e.g. in the imagery we just used).
In these cases, we can use the structure as a prompt to pay attention to both, and to consider what feels like the priority – or how we might hold both in mind and dance between them.
I find that, apart from in the simplest (unicorn-like) cases, this is usually a dance back and forth between them. We build up one a bit before building up the other some more, and so on.
For example, a self-critical client may have a fear that ‘if I’m not good enough then others will reject me’ stemming from experiences of conditional love from parents (Process 1), and also find their emotions/memories overwhelming and not know what to do with them (Process 2).
There are clearly some painful memories to address in Process 1, but first do we need to cultivate their capacity and sense of safeness to turn towards that in Process 2, with some psychoeducation, building safeness in the therapeutic relationship, and skills building? Or, do they resist Process 2, saying ‘these exercises are a load of sh*t’, revealing anger in Process 1 (which may link to early experiences of finding people unhelpful), that we need to acknowledge first?
2. Intervention Planning
Problems in Process 1: Engagement with Suffering
If there are problems are in Process 1, we need to support the development of that by modelling compassionate courage and acceptance, inviting our clients to turn towards what’s difficult, and creating a space for emotional processing.
‘Slow Down to Speed Up’: This takes time and that can feel hard, especially if we’re under service time pressures or our inner-critic tells us to ‘Be productive!’ I’d like to give you permission to slow down and be assertive about your client’s best interests. This is actually more efficient. If this is their first experience of receiving compassion in a relationship, we need to build their internal working model. When we engage meaningfully with the underlying processes and fears/blocks/resistances (FBRs), long-term change flows more easily.
Practical Tips
Assessment and Formulation: This process begins here. What I find most helpful is to look underneath what a client might be saying, to consider ‘Where does it really hurt?’ Here are some prompts that I use:
- Where’s the trauma or attachment wound?
- What are their key fears about themselves/the world?
- What emotions are they trying to control?
- What’s underneath a client’s goals? For example, if the goal is to ‘understand’ their thoughts, what’s it like to not understand their thoughts – scary/confusing/shameful? If they want to be more productive, how do they feel about themselves when not productive?
- What are the painful unintended consequences of their coping strategies?
Interventions: We can use anything that helps us engage with the suffering. This could be from the CFT toolkit[5] or integrating interventions from ACT[6], CBT[7], EMDR[8], or other modalities. This may include:
- Working relationally, modelling compassion, showing them by doing it ourselves[9],
- Formulation and Psychoeducation,
- Mindfulness and Acceptancem
- Emphasising compassionate engagement in CMT exercises,
- Identifying and working through FBRs to engagement,
- Emotional and trauma processing (inc. EMDR), including of the ‘big 3’: fear, anger, and grief,
- Multiple Selves and Chair Work[10],
- Body-based practices e.g. yoga[11],
- ACT functional analysis, creative hopelessness and willingness.
Problems in Process 2: Helpful Motivation and Action
For this, we need to help clients to find what motivates them, and teach them practical techniques to become more skilful in putting this into action to alleviate/prevent suffering. We also need to identify and work through any FBRs that might be getting in the way of a client’s motivation.
Practical Tips
Find the ‘Why’ before the ‘How’: The CMT (Compassionate Mind Training) toolkit is really appealing and, especially if we were trained in protocol-driven modalities like CBT, we can easily launch into using ‘techniques’ – only to find the client doesn’t really connect with it, they hit a load of blocks, or are subtly using it to try to control their experience without engaging meaningfully with it. If so, we need to go back into Process 1, and check whether our clients really understand their problems and the rationale for bringing compassion to them.
Interventions: Again, use anything that helps, such as:
- Emphasising compassionate action in CMT exercises,
- Identifying and addressing any FBRs,
- ACT and CBT techniques for values clarification and committed action or behaviour activation,
- Problem-specific interventions e.g. exposure,
- Skills learning e.g. assertiveness training, diffusion skills.
In Part 3, I’ll explore how to link this all together using a treatment planning framework. See you soon!
[1] Gilbert, P., 2010. ‘Compassion Flowing Out’, in Gilbert, P. Compassion focused therapy: Distinctive features. Routledge, pp. 177-180.
[2] Gilbert, P., 2017. ‘Compassion: definitions and controversies’, in Gilbert, P. (ed.) Compassion: Concepts, research and applications. Taylor & Francis, pp. 3-15.
[3] Gilbert, P. 2022. ‘Fears, Blocks & Resistances’ [Pre-Conference Workshop]. 11th International CFT Conference, 10th October, Edinburgh.
[4] In CFT, how big are the 3 circles? Or using the 4 columns formulation, what does this tell us about their key influences/fears/coping strategies/unintended consequences (see 1, above). In ACT, options include the Hexaflex or Matrix (see 4, above); what are they fused with, and what are their away/towards moves? In CFACT, check out the Compassion-Focused Hexaflex (see 3, above). In EMDR, what does this tell us about the past/present/future prongs on a timeline (see: Shapiro, F. and Maxfield, L., 2002. Eye movement desensitization and reprocessing (EMDR): Information processing in the treatment of trauma. Journal of clinical psychology, 58(8), pp.933-946.)? For CBT, how does this inform our longitudinal or 5 areas model (see: 11, below)?
[9] Kolts, R.L., 2016. ‘Compassionate Relating: Roles of the Therapist in CFT’, in Kolts, R.L. CFT made simple: a clinician’s guide to practicing compassion-focused therapy. New Harbinger Publications, pp. 33-48.
[11] Fay, D., 2021. Becoming safely embodied: A guide to organize your mind, body and heart to feel secure in the world. Morgan James Publishing.
