Using a compassionate mind to work with treatment resistant

shame and self-attack: Weaving into cognitive

therapy

Dr Deborah LeeConsultant Clinical Psychologist

Berkshire Traumatic Stress ServiceHonorary Senior Lecturer UCL

www.compassionatemind.co.uk

Thanks to

o Paul Gilberto Compassionate mind foundation

Compassion Focused Therapy

o CFT is a therapy focus rather than a new school.

o Evolutionary model of social mentality theory (Gilbert, 1989,1999, 2005, 2007)

o Symptoms of psychopathology relate to social threats

o Focus on self soothing, self support and self nurturanceo As an emotional felt sense

o Contextualise mind in it’s environmento Evolutionary function

o The therapy is not technique driven but process driven. o A way of being with yourself and your patients

What does compassion offer CBT

o A way to work with Shame and Self attacko transdiagnostic

o Why? Can we think our why out of shame? o Shame is a socially constructed emotion- how we live in others

minds.

o We need to feel our way out by accessing emotional memories of safeness and self-soothing

From the care giving mentalityo Attachment relationshipo Theory of mind

Why is shame and self criticism

difficult to work with in CBT?1.Shame is not a core belief

It’s a threat focused mind set

2. Self attack is a particular form of negative automatic thought Does not respond well to evaluation and evidenceSelf critics do less well with CBT ( Rector 1991)

3. Based on inter and intra relational experiencesHow we live in the mind of others?Which we struggle to access or influence using self focused CBT techniques

Can we understand then……

1. How we naturally develop an ability to feel soothed and safe.

2. The functional origin of shame and self criticism

3. How ‘symptoms’ or diagnosis can be seen as a set of strategies used to manage threat and manage feelings of shame.

And then….

Does it make sense … to focus on the developing skills to deal with shame so that the symptoms are no longer functional?

Engage in processes that help help our clientso 1. Develop self soothing abilitieso 2. Develop supportive and soothing self talk.

Basic Philosophy and Model

o To derive models of psychopathology based on the science of mind

o To derive models of psychotherapy based on the science of mind

o To derive models of both that integrate all the relevant sciences e.g., genetic neuroscience, development, cognitive psychology through to social and political psychology and beyond

Contextualise mind in it’s environment

Flight or Fight in everyday life-

a brain that is designed for self protection

Neural Bases of Threat Processing Neural Bases of Threat Processing (LeDoux, 1994)(LeDoux, 1994)

Safe or not safe?

What’s the other major threat to human beings?

Social threat

ExerciseExercise

Let’s take a hypothetical situation: Imagine that as part of this workshop you will be asked to describe something you feel ashamed about, and would rather keep hidden, to the person sitting next to you. We would like you to explore this is a series of steps. Rest assured this is hypothetical, but try to imagine it as if it were to be the case.

Strategies for Gaining and Strategies for Gaining and Maintaining Rank and StatusMaintaining Rank and Status

StrategyStrategy AggressionAggression AttractivenessAttractiveness

Tactics usedTactics used CoerciveCoercive Show TalentShow TalentThreateningThreatening Show competenceShow competenceAuthoritarianAuthoritarian AffiliativeAffiliative

Outcome desiredOutcome desired To be obeyedTo be obeyed To be valuedTo be valuedTo be reckoned withTo be reckoned with To be chosenTo be chosenTo be submitted toTo be submitted to To be freely given toTo be freely given to

Purpose of strategyPurpose of strategy To inhibit othersTo inhibit others To inspire, attract To inspire, attract othersothers

To stimulate fearTo stimulate fear To stimulate positive To stimulate positive affectaffect

From Gilbert & McGuire 1998From Gilbert & McGuire 1998

Not part of the gang?

Self Criticso Significant number clinical caseso Chronic difficulties characterised by shame

and depressiono Early abusive histories (emotional, physical)o Drip drip underminingo Highly critical internal dialogueso Ability to self soothe may be

underdeveloped/under-elaborated??

Self attacking thoughts and shame

o Self-critical dialogues manifest shame (Gilbert, 2005)

o “Constant threat of attack from selfo Manifest on going threato Amygdala: – left- vocal; right- facial

o Self-criticso Often present with the heart-head lag dilemmao Poorly developed capacity to self soothe

The Clinical Picture

Overwhelmed, Out of control, terrified

Living in a threat focused mind

A sense of current threat

Self criticalDialogues

Shame

A sense of current threatLimbic system activated

Maintains

Working with current threat

Self criticalDialogues

Shame

A sense of current threatLimbic system activated

Maintains

Working with current threat

Ends aversive affectby engagementin various strategies

Behavioural

Emotional

Cognitive

?

External shamePeople stare at me and flinch when they see my scars. My mother thinks I’m disgusting.

Internal shameI am disgustingand unacceptableI loathe myself

StigmatisationPeople think I am a freak

Layers of shame

Safeness: A missing Component?

Feeling safe from physical, psychological and self- attack is essential for well-being

Safeness and the minds of Safeness and the minds of othersothers

Creating positive feelings and thoughts in the minds of

others, about oneself, makes the world safe

External shame is experiencing negative feelings (contempt, anger, ridicule) in the minds of others lead to attack, rejection or ‘un-included’

major threat --- major threat --- generating defensive behaviours such

as,fight/flight/submit

Self criticalDialogues

Shame Compassion/Safeness

Self soothingDialogues/

Compassionate imagery

A sense of current threat

Maintains Ends

Turning off the threat system From the care giving mentality

From the competitive mentality

Types of Affect SystemsTypes of Affect Systems

o.Incentive/resource

focused

Seeking and behaviour activating

Dopamine (?)

Affiliative focused

Soothing/safeness

Opiates (?)

Threat-focused safety seeking

Activating/inhibitingSerotonin (?)

Safeness

How we live in the minds of others

Overview of an EvolutionaryJourney

Attachment

ThreatThreat Safeness Compassion

Mutual support

o Self -Regulation

Care seeking mentalityo Human brain requires nurturing, caring and

kindness

Helps and affects brain maturationExperience of safeness and pro-social behaviour

Physiological regulatingHealth and well-being

o Become safe by eliciting positive affect in the mind of others o from parent to peers

The Carer-Provider offers……

oProtectionoDistress responsive

oPhysical needs provision oAffection and affiliation

oEducation and Validationo Social Interaction

Building an inner sense of safeness

o Emotional memories of self as safe, loved, valued, wanted and held positively in the mind of another PAMO

o PAMO - a gold coin for the emotional piggy bank self esteem/ psychological safeness

Meaningful thoughtso Congruent affect in order for our thoughts to be meaningful

to us. I am safe, and I know what it feels like to be safe

o To be reassured by a thought ‘I am lovable’ or ‘I am worthy’ this thought needs to link with the emotional experience of ‘being loved’ or feeling valued

o To be able to take a compliment

o Heart-head lag

Messageo CFT targets the activation of the soothing system so that it

can be more readily accessed and used to help regulate threat based emotions of anger, fear, and disgust and shame.

Developing and living in a compassionate mind is a life long process

Learning to deal with life struggles with compassion – life will always be hard

Meal

SexualBully

Limbic system

Stomach acid

Saliva Arousal Fearful

Depressed

Stimulus-ResponseStimulus-Response

Kind, warm and caring

SoothedSafe

Meal SexBully

Compassion

Care giving mentality

Compassion

Components of compassionfrom the care giving mentality

o

CompassionCompassion

SympathySympathy

EmpathyEmpathyNon-judgementNon-judgement

Care for well Care for well being being

Distress sensitiveDistress sensitive

Distress tolerantDistress tolerant

Create opportunities for growth and change Create opportunities for growth and change With Warmth With Warmth

Contrast self-compassion to Contrast self-compassion to self-esteemself-esteem

Self-Esteem

Access when things going well

Individuality/difference

Achievement/doing/drive

Competitive mentality

Self-Compassion

Access when not going well

Common humanity

Acceptance/being/content

Caring mentality

Soothing and Shame

oSocial threat THE major threat to humans – oShame is becoming the undesired and undesirable self -

how we exist in the minds of others’ – and our ability to imagine a self and a self as thought about by others

oSelf-criticism originates – abuse, neglect bullying, competitive relationships, trying to win approval - is usually linked to feeling ‘socially unsafe’ – thus with external threat

oVelco-like trauma like memories – ‘threat first’ processing

oBecome safe by eliciting positive affect in the mind of others – ‘care’ cues are soothing ( from parent to peers)

Its not your faultIts not your fault

Compassionate focus on self, Compassionate focus on self, goals and futuregoals and future

Development of compassionDevelopment of compassion

for selffor self

Explanation of modelExplanation of model

Shared formulationShared formulation

Non judgementNon judgement

Distress Distress toleranttolerant

Care for well beingCare for well being

Distress sensitiveDistress sensitive

EmpathicEmpathicSympathySympathy

Stages of CFTo Explanation of modeloShared formulationo Validation of fearo Makes sense of safety behaviourso Identify critic or inner bully as safety strategyoIt’s not your faulto Promotion of grief reaction to sufferingoDevelopment of compassion for selfo Through relationshipo Imageryo Attention, behaviour, thought, mindfulnessoVisualise, practice, rehearse compassionate focus on self, goals and future

In order to use my compassioante mind I have to give up….

o My self blame…..o My critical bullying voice…….o Self destructive behaviours ……..

o If I don’t change these things I will remain in a life where I am…. Isolated, powerless, tortured

o The unintended consequences are……..

Working with self blame

The compassionate story of your life and your struggles

Not Your Fault

oDeep empathy for non intentionality

o Kindness activates grief

oShifts shame to guilt and responsibility

Working with Self criticismoExplore the relational and dialogic nature of self- cognitions (e.g., two chairs) bully-bullied

oOrigins of bullying voice – their credentials

oWhy submissive acceptance response to self-attack?o(linked to history of submission to authority)

oSubmission as safety behaviour; self blame as safety cognition –acknowledge desire for safeness

oFunctional analysis of critic (improve, ridicule, Functional analysis of critic (improve, ridicule, destroy)destroy)

Historical perspective of internal critical voice

o Mother thought physical perfection was paramounto Disappointment to mothero My mother made my feel my body was disgustingo Put on diet at 11 yearso Bought clothes that covered my scarso Would not accept permanence of scarso Teased at school and made to feel like a freako 1st boyfriend was abusive and cruel about my scarsI WAS MADE TO BELIEVE THAT I WAS

UNACCEPTABLE PHYSICALLY

Compassionate Mind Training (worksheet 1)

Credentials of my critics

©CMT Worksheet, Deborah Lee & Paul Gilbert, 2002 (adapted from CMT, Gilbert, 1997)

Positive aspects

Negativeaspects

Positive aspects

Name: Name:Mother Father

Negativeaspects

Blond, skinny, underfed,

highly strung, highly critical,

disorganised perfectionist, cruel,

devious, manipulative, careless,

self-centred, dangerous driver,

domestic fascist, rude, opportunist,

selfish, incapable of love,

humourless, indescribable

LovingPhysicallyaffectionate

Disinterested

Self obsessed,vain, reluctant to take on any responsibility that isn’t immediately self serving,incapable of self doubt,Like my mother he ispainfully egocentric

A good man but a bad father

Unlike my Mother he iscapable of loving but onlyon his own terms

Decentring from the critico Th: “What exactly do you say to yourself in your head?”o J: “You deserve to suffer. You are disgusting. No one wants you. I am a worthless

piece of nothing. I am bad. You are toxic”. o Th: “Whose voice do you hear? Has anyone ever said those things to you?”o J: “Well it’s a mixture of my uncle, my mum and the boys who bullied me at school”o Th: “What do you make of that?”o J: “That’s interesting as I never realised that before but I can see my uncle saying

things to me in my head now”.o Th: “What do you think is the function of your critical voice? Is it trying to protect

you, motivate you, or destroy you?” o J: “It’s definitely trying to bring me down and make me feel bad, like it’s my fault?”o Th: “Is it your fault?”o F: “Well I feel like it is because I feel it in my memories”.o Th: “What makes you believe what it says without question?”o J: “I don’t know, I just always have thought it was who I am”.o Th: “What qualities and personal attributes does your critic have?”

Contdo J: “My uncle was creepy. He always made me feel bad and uncomfortable. Those

boys at school were just plain mean”.o Th: “Are their qualities ones you admire in people?”o J: “No, not at all” o Th: “Is their opinion worth accepting unchallenged?”o J: “No I suppose not but I hadn’t really realised that it was them that was making me

think these things about myself. I just always thought it was me”.o Th: “Can you imagine the critical part of yourself if you close your eyes”. [Prompt:

“What does it look like, facial expression, tone of voice, size, characteristics and qualities?”]

o J: “Oh I can see him winking at me and telling me I deserve this. His eyes freak me out. It’s definitely my uncle”.

o Th: “OK what does that tell you?”o J: “I speak to myself like my uncle used to speak to me, but the problem is that I feel it

is true”.o Th: “Yes I can see that and are you able to hold onto the fact that you were made to

believe these things about yourself?”o J: “Yes I can”.o  [

Multi-Modal Compassionate Mind Multi-Modal Compassionate Mind TrainingTraining

Imagery

Attention Reasoning

Feeling Behaviour

Sensory

Care for well-being

Sensitivity Sympathy

Distress tolerance

EmpathyNon-Judgement

CompassionCompassion

ATTRIBUTES

SKILLS -TRAININGWarmthWarmth

WarmthWarmth

WarmthWarmth

WarmthWarmth

A compassionate mentalityWhen I am compassionate to

myself o I talk to myself like this……..o I remind myself of my struggles…..o I focus on…………o I use my imagery to…….o I behave like this……..o I interact with people like this……o I am motivated to do…….o I feel warmth and kindness for myself…..o The things I have in my life are……o My relationships are…..

Compassion

oDiscuss the components of compassion and that each one might take practice ( maybe in stages)

oEmphasise the importance of empathy for distress including self-attacking. Acceptance and compassion grow from genuine understanding - especially of safety behaviours –Recognise when patient tries to minimise distress with rationalisation

oEmpathy for distress often grows naturally from the work you have done on safety behaviours

Compassionate Focus

o When generating alternatives one is trying to work with different processing systems –stimulating a care-focused mentality

Empathy for distress – standing back

* What would compassionate motives look like?

* What would compassionate ‘attention’ attend to or

focus on?

* What would compassionate ‘thinking’ ‘think/reflect?

* How could you take compassion into behaviour?

* Reflecting on these ideas and actions; how could you

bring warmth into the experience of them?

Compassionate Focus

oDesigned to stimulate different (care-based) affects, thoughts and role relationships with self

oWhat would help you feel supported?oWhat would you say/do to someone you care for?oWhat would like some who cared for you to say/do?

oUse examples and education to build insight and desire to use rational compassionate approach –can see the point

Rescripting shame memories

o Therapist: How do you want to feel?o Gemma: Powerful, disdainful and control.o Therapist: What needs to happen for you to feel like

that? o Gemma: I need to see him shrinking, being

exterminated, looking very terrified and alone, begging – looking pathetic as I beat him.

o Therapist: Can you hold that in your mind’s eye?o Gemma: Yes, he’s gone – the pathetic, disgusting

little man. o Therapist: And knowing that, how do you feel? o Gemma: Good, I feel strong and powerful.

What would be a compassionate rescript?

oWhat is potentially unhelpful about this?

Compassionate rescripto Therapist: How do you want to feel?o Gemma: Safe, that it’s not my fault, that I am not dirty. o Therapist: What needs to happen for you to feel like

that? o Gemma: I need to focus of the feelings of warmth, care

and kindness I have for myself, I need to focus on the sadness of this memory and to understand how hard this was for me to endure.

o Therapist: Can you hold that feeling in your mind and body?

o Gemma: Yes, I am feeling stronger, he is going and he cant harm me now.

o Therapist: And knowing that, how do you feel? o Gemma: Good, I feel strong and soothed.

Compassion Imagery

Using imagery to access and work with soothing systems and the interactions between threat and

soothing systems

Point of Imagery o Powerful way to access affect systems

Connectedness

Provides new sensory based experiences to work with other, threat-based, ones

Uses a form of theory of mind – another mind ‘with you’

Re-focuses attention (work on sensory qualities)

A different way of ‘thinking’ of alternatives as co-A different way of ‘thinking’ of alternatives as co-constructed and affect/compassion focusedconstructed and affect/compassion focused

The Perfect Nurturer/ The Compassionate Ideal

o Not prescriptive – variety of wayso Qualities to nurture the emotional needs in an

unquestioning way- meeting their needs perfectlyo Does not suffer human failingso Although self soothing emotions can be created

without imageryo PN- distinctive memory, may be readily triggered

Imagery Practice ExperienceoFocusing on your image

ocan you feel warmth for you – what does that feel like?

ocan you feel empathic understanding for you – what does that feel like?

ocan you feel acceptance for you – what does that feel like?

ocan you feel strength for you – what does that feel like?

oReally focus on image generating and staying with affect

Compassionate ReframeoFocus on your breathingoNow bring compassionate image to mindoFocus on sensory qualities (trying to access care-focused mentality)

oWhat would your compassion part/image say?oHow do they see this situation?

oWhat opportunities for growth and change might be here?

oWhat is a compassionate thing to do now?What is a compassionate thing to do now?

Self attackingthought

Compassionate mind thought diary (worksheet 3)

Identity of judger

Compassionate reframe (image)

Extent to which I endorse Reframe (0-100)

Mood Rating(1-100)

© CMT worksheet ,Deborah Lee , 2002

Went out not wearing my neck scarf. My scars are repulsive to others and should be hidden from sight

My mother whowas obsessed withphysical perfection. SHE could not accept my scars. SHE thought they were disgusting and tried to hide my body with ridiculous clothes

True beauty is everywhere just let yourself see it Your scars are a sign of your strength and courage in a battle fought and won. Let people stare at you and know that it does not matter. What matters is that you live your life for you. Not others

100% Peacefuland calm

100%

Re-EvaluatingoThird chair practising

oCompassionate thinking

oCompassionate attention

oCompassionate behaviour

oCompassionate letter writing

Play video clip

o Expresses concern and genuine caring,o Sensitive to the person’s distress and needso Sympathetic and is emotionally moved by, in tune with their

distresso Helps them to become more mindful and tolerant of their feelings o Helps them become more understanding and reflective of their

feelings, behaviours, difficulties and dilemmaso It is non-judgment/condemning o A genuine sense of warmth understanding and caring permeate

the whole lettero Generates genuinely compassionate helpful encouraging attention

memories thinking and feelings – what do they feel like? Are the “experienced as helpful”

o Helps them think about the behaviour they may need to attempt in order to move forward

The point of these letters is not just to focus on difficult feelings but to help people stand back and reflect empathically on, be open with feelings and thoughts, and develop a compassionate and balanced ways of working with them. They will not offer advice or should etc.

Working with shame memories I

(key self-defining memories)

o Identify a shame ’triggering’ memoryo Ask client to talk about it and focus on key

threats and affecto Discuss what they would need in the

memory to help them feel soothed and safe o What would they like their perfect nurturer to say

and or doo How would they like to feel in the memory

Working with shame memories II

o Use smell as trigger for affecto Ask client to recount shame memory using a

reliving paradigm o See OCTC online presentation on reliving

o Bring in image and affect via smell and develop the new memory and emotional experience by focusing on the rehearsed compassionate reframe

From threat to safeness - how?

o What do you need right now? (worked out before)

o What do you need to know? (worked out before)

o What do you need to do right now?o Bring in imagery ( practised, rehearsed,

available)

How does that feel??

Play video clip

Its not your faultIts not your fault

Compassionate focus on self, Compassionate focus on self, goals and futuregoals and future

Development of compassionDevelopment of compassion

for selffor self

Explanation of modelExplanation of model

Shared formulationShared formulation

Non judgementNon judgement

Distress Distress toleranttolerant

Care for well beingCare for well being

Distress sensitiveDistress sensitive

EmpathicEmpathicSympathySympathy

The end

Key referenceso Arntz, A., & Weertman, A. (1999). Treatment of childhood memories: Theory and Practice.

Behaviour Research and Therapy, 37, 715-740o Brewin, C. (2001). A cognitive neuroscience account of PTSD and it’s treatment.

Behaviour Research and Therapy. 39, 373-393.o Brewin, C.R. (2006). Understanding cognitive behaviour therapy: A retrieval competition.

Behaviour Research and Therapy, 44, 765-784o Gilbert, P. (1989). Human Nature and suffering. Hove. Lawrence Erlbaum.o Gilbert, P. (1998). What is shame? Some core issues and controversies. In B. Andrews

(Ed.), Shame: interpersonal behaviour, psychopathology and culture (pp. 3–38). New York: Oxford University Press.

o Gilbert, P. (2000). Social mentalities. Internal social conflicts and the role of inner warmth and compassion in therapy. In P.Gilbert and K.G. Bailey (eds) Genes on the couch. Explorations in Evolutionary Psychotherapy, pp118-150. Hove: Psychology Press

o Gilbert, P. (2007). Psychotherapy and Counselling for Depression (3rd Edition). Counselling in Practice, Sage Publications Ltd, London

o Gilbert, P., Baldwin. M.,, Irons, C., Baccus, J. & Palmer, M. (2006). Self-criticism and self-warmth: An imagery study exploring their relation to depression. Journal of Cognitive Psychotherapy: An International Quarterly, 20, 183-200

o Gilbert and Irons (2005). Focused therapies and compassionate mind training for shame and self attacking. In Compassion and psychotherapy: Theory, Research and Practice. Routledge, London

References contd.o Gilbert, Lee and Wleford (2006) Working with relentless shame and self attack using

a compassionate mind www.compassioantemind.co.uko Grey, N., Young, K., Holmes, E. (2002) Cognitive Restructuring within Reliving: A

treatment for peritraumatic emotional “hotspots” in post-traumatic stress disorder. Behavioural and Cognitive Psychotherapy, 30, 37-56

o Lee, D.A., Scragg, P. & Turner, S.W. (2001). The role of shame and guilt in traumatic events: A clinical model of shame based and guilt-based PTSD. British Journal of Medical Psychology, 74, 451-466.

o Lee, D.A. (2005) The perfect nurturer: A model to develop compassion within cognitive therapy. Compassion and psychotherapy: Theory, Research and Practice. Routledge, London.

o Lee, D.A (2009). Compassion Focused Cognitive Therapy For Shame-based Trauma Memories and Flashbacks in PTSD. In Grey, N. (Eds.) A Casebook of Cognitive Therapy for Traumatic Stress Reactions. Chapter 15. London: Brunner-Routledge.

o Lee, D.A. (2009): Compassion focused therapy to overcome shame and relentless self attack: in Sookman, D., and Leahy, R. (eds). Treatment Resistant Anxiety Disorders. Routledge, New York

o Wheatley,J et al (2007). Imagery rescripting of intrusive sensory memories in depression. Behaviour therapy and experimental psychiatry, 38 (2007) 371-385