Question 1

What is compassion?

Paul Gilbert · Accepted Answer

Compassion is a motive that emerges out of the evolution of caring behaviour which is primarily a mammalian rooted motivational system. What turns caring into compassion is our new brain competence is for thinking, empathy and mindfulness. When we engage in caring behaviour with knowing intentionality that becomes compassion. I've written quite a bit on this.

Question 2

What is the difference between compassion and empathy?

Paul Gilbert · Accepted Answer

Compassion is a motive that organises the caregiving system whereas empathy is a competency. Competencies are used by motives but they're not primary motives themselves. So, for example we know that highly manipulative people and narcissists can be very good at empathy but the motivation behind their mind reading abilities it's not compassionate. So, do make a clear distinction between what a motivation is and what a competency is. Paul Bloom is also written quite a bit on this area.

Question 3

What's a common misconception you encounter around the idea of compassion?

Paul Gilbert · Accepted Answer

That compassion is the same as kindness, which it isn't for many reasons. Kindness is a way of being compassionate and it has a lot of wonderful impacts on oneself and others for sure --certainly in contrast to coldness or unkindness! Kindness is also essential in building quality affiliative relationships closeness, joyfulness and happiness

Gilbert, P., Basran, J., MacArthur, M., & Kirby, J. N. (2019). Differences in the semantics of prosocial words: an exploration of compassion and kindness. Mindfulness, 10(11), 2259-2271.

That your compassion is about love, which it isn't. The strongest compassion is for the people you don't love and the people you dislike. Also, if you make love central then people really struggle with compassion if they feel they can't love others. . For example, depressed mothers will really struggle if you focus on love. So, what you need to focus on is behaviours in the early days – the values of caring behaviours.

In the Buddhist tradition, the focus has always been on the freedom from suffering and the causes of suffering. The problem is the translation of words because loving in the Buddhist traditions does not mean the same as love in the western traditions, and people get these confused. So universal love in the Buddhist tradition is the universal wish that all sentient beings be free of suffering and the causes of suffering. That is the essential aspect of compassion.

So, it's very important to help people understand the definition, how and why its motivation, and how and why courage and wisdom are its central supports.

Question 4

Is Compassion Focused Therapy considered an evidence based intervention?

Paul Gilbert · Accepted Answer

Very much so, and in fact there are somewhere in the region of 50 studies now. We are lacking a good meta-analysis but that is underway, and there are several excellent studies that are also underway. Keep in mind that this is a relatively new therapy, getting money for a new therapy is very tricky and we certainly have tried. But the data is appearing all the time and it's really good not only in terms of effectiveness but dropout rates and so on. I would give it another three or four years and then the database I think will be very strong but it's wise to keep your eye on the database.

Question 5

Can you talk about compassion fatigue, especially in the context of health professionals?

Paul Gilbert · Accepted Answer

Personally, I think compassion fatigue is rare. We've done a few studies, and basically what we find is that it's mostly burnout. People get burnt out because frankly the system is overloading them with too many patients, too much bureaucracy, lack of managerial support and so forth. We find certainly clinically that most people would like to spend more time with their patients, not less. We're in a situation today with the Covid-19 which would look a lot like compassion fatigue but again be careful because a lot of our doctors and  nurses are simply exhausted and angry about lack of protective equipment, angry about the health service being run down so there's not enough beds and so on and so on. Compassion fatigue tends to focus on the individual and takes the attention off the system. Where you can get difficulties is individuals who come into the caring professions who are traumatised themselves and haven't really sorted that out and then they get triggered. But again, if whether you should see that as compassion fatigue or not is an open question.

Question 6

Any advice for defining compassion with clients? Especially if they are particularly self-critical and struggle with any sense of kindness or warmth towards themselves?

Paul Gilbert · Accepted Answer

It's usually best to elicit their understanding of compassion first and then see how they think about it. Ask them what worries them about it. Sometimes they'll say ‘it's weak’ ‘an indulgence’ or ‘I don't deserve it.’ So you elicit their resistances quite early.

You are then going to guide them towards the standard definition, which is sensitivity to suffering and self and others with a commitment to try to relieve and prevent it. It is very important you understand the root and the reason for this definition because there are many definitions floating about on the Internet which for clinical work are not always very helpful

From there, highlight the two key qualities of compassion which are courage and wisdom. Sometimes, we say dedication to wisdom. You want to avoid the client confusing compassion with the ways of being compassionate, such as being kind honest empathic and so forth. Those are ways of being compassionate, but the root of compassion is courage and wisdom

There are various ways you can do this. For example you could ask: what are the key emotions and skills of a firefighter rescuing somebody from a burning house, and guide them with Socratic dialogues to this recognition that such actions are obvious ones of compassion, to risk your life for another and then highlight  the importance of courage and wisdom. You need the courage to enter the burning house but also a lot of skill to know how to do it wisely -- so keep coming back to these to core qualities.

Another exercise we do is to invite somebody to think about how they would help a friend who needed to go to hospital for an urgent operation but was hospital phobic. Through discussions, you guide them to see that they would try to give their friend courage by say, talking with them supportively, maybe going with them to the hospital. They come to the recognition of the central role of courage and wisdom. So, do you make a big distinction between the core elements of compassion, it's based on a motivation to be sensitive to suffering, and this commitment to try to help and to do that, you will be building courage and wisdom. For example, empathy becomes part of wisdom, kindness becomes part of wisdom, because doing things unkindly wouldn't be compassionate. If clients confuse kindness with compassion, that's when you can run into trouble.

Question 7

What do you love about CFT?

Paul Gilbert · Accepted Answer

It’s a science-based model for understanding how the evolution of caring behaviour has such a fundamental impact on the nature of the brain and its organization. It's highly integrative and seeks to provide a science-based approach to understanding mental health problems in psychotherapy, and it is not really linked to any one school.

Gilbert, P. (2019). Psychotherapy for the 21st century: An integrative, evolutionary, contextual, biopsychosocial approach. Psychology and Psychotherapy: Theory, Research and Practice. 92, 164-189. DOI: 10.1111/papt.12226

Gilbert, P., & Kirby, J.N. (2019). Building an integrative science for psychotherapy for the 21st century: Preface and introduction. Psychology and Psychotherapy: Theory, Research and Practice, 92, 151–163. https://doi.org/10.1111/papt.12225

It also integrates not only a lot about what we know of caring behaviour attachment and so on and how to utilise these processes to help people who are struggling, it integrates quite a lot of work from contemplate traditions on compassion training . So, we utilise many of the Tibetan concepts too and that's another form of integration which I personally really like.

Question 8

What are some common un-compassionate behaviors that you notice people exhibiting in practice?

Paul Gilbert · Accepted Answer

There are a whole range of them out there that link into the defenses. So for example, denial, repression, dissociation etc are all ways of avoiding working with pain, difficulty or threat. Then, we have a whole range of ways of thinking about the fears, blocks and resistances to compassion, and, of course, narcissism can often be a source of lack of compassion for others.

Question 9

How specifically do you work with clients who believe that self-criticism works for them?

Paul Gilbert · Accepted Answer

A useful technique that I developed in CFT is a functional analysis of self-criticism. Here you invite the client to work through one of our guided discovery practices. Basically you invite people to think about what would be their greatest fear of losing or giving up self-criticism and you add in the idea of never beating up on yourself or being angry and putting yourself down again - that's a key element. This is because most self-criticism is shame-based and you want to tap that shame-based self-criticism.

Then they will tell you they might become lazy or arrogant or not want to improve. People typically see the positive functions of the critic. Then advise them that you're going to explore if that is true. You do this by inviting them to bring to mind something that they are critical of and then you go through the guided imagery practices of giving 20 seconds or so for each reflection:
1.	what would your critic look like if you could see it outside of yourself? 
2.	what would it say to you?
3.	what does it feel for you?
4.	what does it want to do to you?

Then, invite them to think about how they are now feeling which is usually bad. Have at least 20 seconds or so for the person to explore each of these domains and make sure that it's not overwhelming - it's designed to be a guided discovery, not overwhelming. Always advise clients they can pull out at any time if it's too difficult.   Then, invite them to reflect on the fact that actually, the critic is pretty harsh, and simply makes you feel bad, so it's not going to inspire you at all. Then, invite them to think about do they really want to be lazy or arrogant and usually they say no -  you can ask them why would they need to beat up on themselves to stop them being something they don't want to be anyway! Take them through the alternative which is of course the compassionate self-correction practice. Basically, invite them to step into the compassionate mind and go through the same things about how the compassion self can be visualised focused on helping you supporting you and so on. Take people through what this part would look like if you could see it outside of yourself what form would it take, and then you move them onto what would it say to you, what does it feel for you, and then, lastly of course what does it want to do to you or for you?

Another set of guided discoveries is with chairwork, where we invite clients to become the critic and they discover the critic is pretty hostile and not helpful. Then, we switch them into a compassion chair

Bell, T., Montague, J., Elander, J., & Gilbert, P. (2019). “A definite feel‐it moment”: Embodiment, externalisation and emotion during chair‐work in compassion‐focused therapy. Counselling and Psychotherapy Research.

Question 10

What is the evidence on using CFT for complex PTSD?

Paul Gilbert · Accepted Answer

Deborah Lee has written a book on the compassionate mind approach to trauma and is in the process of writing up quite an extensive set of studies on this.

Question 11

Do therapists use CFT as a stand-alone therapy or mostly combine it with other approaches? Which ones?

Paul Gilbert · Accepted Answer

It's very much a standalone therapy because it has a particular science-based model of the mind, rather than ones that are rooted in single processes like specific forms of cognition or behavior. You need to make a distinction between the model of understanding - how the mind works in contrast to specific interventions. CFT uses a lot of interventions such as guided discovery, Socratic dialogues, exposure, behavioral experiments, reappraisal, mindfulness, etc -- but we argue that if you can get the orientation through compassion then you will be activating the vagus and frontal cortex which will make all these interventions more effective.

Question 12

What should I do with clients who struggle to use imagery?

Paul Gilbert · Accepted Answer

Usually this is because they don't understand imagery. For example, you say to them: what's a bicycle? What is an elephant? What did you have for breakfast? And then you ask them: how do they know? Talk to them a little bit about sensory awareness not necessarily visual awareness. Or you might ask them to imagine somebody speaking to them describing a holiday, and then ask them to tell you what you heard in their mind when they imagined somebody speaking to them. This helps them see that imagination is simply about creating internal representations which can be visual but not necessarily.  Also, sometimes people who are very alexithymia don't do much in the terms of fantasy. You can also ask people, have you ever thought about what television program you're going to watch tonight? What happens in your mind when you do that; what comes into mind and so on.

Question 13

I feel as if my training lacked a model/intervention for emotion regulation and distress tolerance. How does compassion focused therapy conceptualise and target these?

Paul Gilbert · Accepted Answer

We start off with an evolutionary approach which highlights the fact that in mammals, and particularly in the higher primates and humans, emotion regulation is acquired in the context of a caring relationship. Also remember that we are hunter gatherers and socialised as soon as we could move really with other children and so on. So, emotion regulation is very much part of learning to be in the group and in the group, all of the individuals would take responsibility for childcare and would be helpful and caring.

For example, ADHD wouldn't exist because children would be out running around all the time and some of the context that cause children to have emotional difficulties are frankly abnormal to the way we evolved to live. So, crucial to emotion regulation is to utilise the evolved and physiological systems that support it such as the vagus nerve and frontal cortex and that's what compassion focused therapies go after. We suggest, as others do as well that we need the physiological infrastructures to help us with emotion regulation because otherwise a lot of emotion is driven by the limbic system rather than regulated through the frontal cortex and vagus.

Question 14

Does the attachment style of therapists using CFT matter? What about the attachment style of clients?

Paul Gilbert · Accepted Answer

I think the attachment style makes a difference in any kind of therapy you're doing. Ideally, you want securely attached people as your therapists rather than avoidant or overly anxious. There have been studies done on this particularly in the Journal psychology and psychotherapy.

Question 15

How does CFT work with grief, especially complex grief?

Paul Gilbert · Accepted Answer

We suggest that if you don't have some degree of compassion competence within you which gives you opportunities for grounding, secure base and so forth grief gets really tricky. Also, grief and the context of grief is so important. For example, grief that occurs where maybe the person will go back to living alone is linked to loneliness and the fear of loneliness. Sometimes grief can have both anger and fear in it as well. Sometimes, grief has guilt in it, so it's the complexions of grief that can be important. Sometimes, individuals were very dependent on their partner and when their partner dies they have all of their old anxieties coming back again and can see the world is a frightening place so the problem is that grief can be complex for many, many different reasons.

Question 16

Have you used the compassion approach with PTSD and developmental trauma?

Paul Gilbert · Accepted Answer

Yes, it's very important for developmental trauma partly because these individuals haven't really internalised the secure base or safe haven in the attachment model, so developing a compassionate mind is trying to stimulate these systems which provide for internal soothing grounding and security. Again, Deborah Lee has done a lot of work on trauma and compassion.

Question 17

Is there a CFT protocol for working with guilt?

Paul Gilbert · Accepted Answer

Not specifically guilt, but it is important to distinguish the evolutionary mechanisms and roots of shame and guilt because they are completely different. Guilt really is about the emotions of remorse and sorrow, whereas a shame is much more about social standing and self-attacking.

Question 18

What's the evidence on using CFT for anger?

Paul Gilbert · Accepted Answer

CFT is very useful for anger particularly when you help people recognise all the different types of anger such as frustrated, vengeful, envious and so on, but I don't know any data on it. Keep in mind the practice of multiple selves because then you always help a person contrast the thoughts intentions, impulses and so on, on the angry self and compare those to the compassion itself for the same situation.

Question 19

What's your view of self care? How does self care relate to compassion?

Paul Gilbert · Accepted Answer

It's important we distinguish between self-care and what sometimes passes as self-care which is basically narcissistic preoccupation.

So, remember that in CFT we have this model of courage and wisdom being at the centre of compassion. Self-care is how you bring courage and wisdom to the way you living your life -- living to be helpful not harmful to oneself.  What it means is that we focus on the areas where we are being helpful or harmful to ourselves.

This may be linked to psychological processes, like our tendency to engaging unhelpful rumination or criticism, but also to process is like not taking enough exercise or eating too much carbohydrates and sugars or drinking too much  etc. We might notice that if we are highly distrusting it stops us from having helpful relationships with others and so we need to do something about that.  So, we can see that maybe self-criticism is harmful, or that overworking, harmful or that our diets are harmful.

Then you focus on: what would help me on my life journey; what would support me; what would give me courage and what wisdom or skills do I need to develop, and so on.

Question 20

I'd love to hear about your thoughts on utilizing Compassion Focused Therapy in a palliative care context.

Paul Gilbert · Accepted Answer

Again, the key here is helping clients have an insight into what compassion is particularly the issue of courage and wisdom, because then that's something that you can explore with your client that would be helpful. Then you can use some of the body-based trainings, but also integrating many other schools and wisdom support palliative care with the focus that you're building a compassionate approach to the ending of ones life. This also takes one into spiritual questions and that can be facilitated through a compassion way of thinking.  How the person wants to start to think about the issue of the meaning of their life and the spiritual dimensions of their life can be quite important and while we can't direct them in anyway we can facilitate that as a compassionate journey.

Question 21

What's the best approach for working with young (5/6yo) children using Compassion Focused Therapy?

Paul Gilbert · Accepted Answer

There are various techniques you can use such as play paintings and so on. For example, you can talk about a helpful toy or a teddy bear and what would you like this teddy bear to do, how would you like it to talk to you, what kinds of things would you like to hear it say to you etc etc . If your teddy bear was unhappy how would you like to cheer it up?

Question 22

Would you categorize Compassion Focused Therapy as being an effective short term intervention?

Paul Gilbert · Accepted Answer

Dennis Tirch has introduced quite a lot CFT into ways of thinking into ACT, and now there's this concept of ACT with compassion. Once again, I think you have to distinguish between a model of therapy and the science of the mind – from the techniques. So, our science model is quite different tooACT but many of the CBT interventions they use we use too. For example, mind as context is very similar to mindfulness, the concepts of fusing we see differently because we take a classical conditioning model of fusing that is to do with physiological processes. The issue of flexibility nobody would disagree with because we have known for a long time that all systems, physiological and otherwise, work better if they are flexible and can change their behaviour according to the context. Freud said similar. Also, we know that experiential avoidance has been central to nearly all therapies. The whole point of Freudian defence mechanisms was rooted in experiential avoidance. So again, we can see that there is quite a lot more overlap in some areas than sometimes is recognised.

Question 23

What adaptations need to be made in CFT (if any) for autism/neurodiversity?

Paul Gilbert · Accepted Answer

This is tricky because we don't really know. We have colleagues working with this but there are all kinds of interventions being developed such as facial recognition training and so on. We do have a group of colleagues who are working in this area and developing it for these individuals, but I don't think they publish very much yet.

Question 24

How does Polyvagal Theory fit with CFT? Did this theory inform your work?

Paul Gilbert · Accepted Answer

A little bit for sure, but if you have a look at the book  Human Nature and Suffering which I wrote in the 80s and it came out in 1989, you will see quite a lot of overlap with Steve’s work. But we learn from other therapies and Sue and Steve have been very generous in helping.

Question 25

What is your view on the idea that rumination has an evolutionary function in motivating an individual to make necessary changes in their life?

Paul Gilbert · Accepted Answer

I think most people distinguish between helpful and unhelpful rumination. Helpful rumination is where you focus on a problem and try and work out how to solve it. For example, scientists might think over and over about a problem and then suddenly get an insight. Unhelpful rumination is usually focused on things like worry or anger where we overly stimulate the threat system for no real benefit. Some people have argued that rumination can even be helpful in depression but that's not my view. So, the ability to hold a problem in mind and go over and over it probably is useful and would have evolutionary advantage for individuals that could do that.

Question 26

Can you speak about doing assertiveness training within a CFT framework?

Paul Gilbert · Accepted Answer

Assertive training is very important within the compassionate mind training context because compassion is not submissive. So, helping people identify compassionate assertiveness can be quite important. For example, you might start off with what would compassionate assertiveness look like if you had to use it with your child who is wanting to eat far too many cakes! You can then begin to ratchet up the issue. What would compassion assertiveness look like if you had to take something back to a shop which was poorly made. Then, somebody was trying to make a sexual pass you didn't want, and you would discuss why it would be compassionate behaviour, and how it would be different from a simple aggressive or vengeful response or acting out of anger.

However, it's also important to help people recognise that assertiveness is about taking authority appropriately and presenting your views and opinions positively. Assertiveness is also about acknowledging if you have made an error and appropriately apologising. It's very important that we how people understand that assertiveness is multidimensional.

Question 27

How does CFT view alexithymia?

Paul Gilbert · Accepted Answer

We do a lot of emotional education practices with individuals who struggle to work with and identify their emotions. We use a range of acting techniques here. You have to distinguish between those individuals who have this problem for different reasons. For example, some are because they are traumatised and block down others because they are on the autistic spectrum etc.

Question 28

Has anyone utilised compassion focused therapy with sex offenders?

Paul Gilbert · Accepted Answer

Yes  - there is actually a special interest group now on CFT for forensic populations that you can sign up for if you've done a bit of training. It's all on our website. We've also just finished a big study in Portugal which is for forensic youth not specifically sex offenders though.

Question 29

Is there much literature to support the use of Compassion Focused Therapy in cases of paranoid schizophrenia and psychosis?

Paul Gilbert · Accepted Answer

There is a bit, yes.

Braehler, C., Gumley, A., Harper, J., Wallace, S., Norrie, J., & Gilbert, P. (2013). Exploring change processes in compassion focused therapy in psychosis: Results of a feasibility randomized controlled trial. British Journal of Clinical Psychology, 52, 199-214.

Heriot-Maitland C, McCarthy-Jones S, Longden E and Gilbert P (2019) Compassion
Focused Approaches to Working With Distressing Voices. Front. Psychol. 10:152. doi: 10.3389/fpsyg.2019.00152

White, R., Laithwait, H & Gilbert, P. (2013) Negative symptoms in Schizophrenia: The role of social defeat. In, A. Gumley, A. Gillham, .K. Taylor & M. Schwannauer (Eds). Psychosis and Emotion: The role of emotions in understanding psychosis, therapy and recovery. London Routledge

Question 30

Is there empirical support for using CFT with adolescents? What particular exercises would you recommend to use with teens?

Paul Gilbert · Accepted Answer

The data on CFT with teens is thin at the moment, but generally speaking those clinicians who are using it with adolescents find the adolescents really like it. You just have to introduce it in a way that is sensitive to their minds in this moment.

Question 31

Dear Paul, I work in health psychology and work with people who experience a lot of shame, disgust and guilt and grief about their health condition e.g., cancer, type 2 diabetes, STIs. How can CFT help them?

Paul Gilbert · Accepted Answer

Yes, that is very tricky. First, it's useful to have a very clear discussion about what shame is, the differences between internal and external shame, and humiliation and how it differs from guilt. In CFT, psycho education is always very important to help people have a framework for thinking.

The problem with some of this is trying to work out what are the complex emotions sitting underneath shame. For example, as you know we always go for the big three which are anger, anxiety/fear and sadness/grief. If people can grieve for what's happened are, they also able to work through rage or fear? So, next, decide - is this external shame or internal shame?

Then, to look at the benefits of staying in the shame state or not. Distinguishing between shame and guilt can be important. Guilt takes you into a grief process whereas shamed doesn’t. So, for example, knowing that you've got cancer cause you've been smoking --sometimes shame is also trying to over develop one sense of control when in reality there are so little things we control in life.

You always look at the fears of giving up shame like you do for self-criticism, and sometimes we look at the price of forgiveness. One of the tricky things is to see if shame is hiding other processes.

Question 32

Can CFT be used alongside DBT? I'm particularly interested in the idea of integrating chain analysis alongside CFT.

Paul Gilbert · Accepted Answer

Compassion focused therapy is about how you focus your therapy. As you will know there are many things in DBT which you will find in the old mindfulness texts and so on. So, we're all moving towards a better science of therapy and breaking out of our tribes. Also, sharing interventions that are helpful to people.

Question 33

What does Compassion Focused Therapy have in common with ACT?

Paul Gilbert · Accepted Answer

Dennis Tirch has introduced quite a lot CFT into ways of thinking into ACT, and now there's this concept of ACT with compassion. Once again, I think you have to distinguish between a model of therapy and the science of the mind – from the techniques. So, our science model is quite different too ACT but many of the CBT interventions they use we use too.

For example, mind as context is very similar to mindfulness, the concepts of fusing we see differently because we take a classical conditioning model of fusing that is to do with physiological processes. The issue of flexibility nobody would disagree with because we have known for a long time that all systems, physiological and otherwise, work better if they are flexible and can change their behaviour according to the context. Freud said similar.

Also, we know that experiential avoidance has been central to nearly all therapies. The whole point of Freudian defence mechanisms was rooted in experiential avoidance. So again, we can see that there is quite a lot more overlap in some areas than sometimes is recognised.

Question 34

How can compassion focused therapy be integrated with CBT?

Paul Gilbert · Accepted Answer

Again, like the other question on DBT, it's important to distinguish between a model of the mind and model of therapy from techniques of intervention. Tim Beck, who I was fortunate enough to do some training with in the late 1970s and early 80s  was always very clear that he was not that interested in developing complex models of the mind, but was very interested in developing heuristics and easy ways for clients to be helped. So CFT utilises a lot of the interventions that have come out from the last 40-50 years of these traditions, including things like guided discovery, inference chains, behavioral exposure, behavioral experiments and more recently mindfulness and so on.

However, we have never considered ourselves a third wave CBT therapy. In fact, I've always argued we don't need more waves of a particular therapy.  We need an integrated, science based - and here science means the science of physiology, psychology, sociology and so on to help us understand mental health problems.

For example, there's a lot of data now coming out that early life experiences have an impact on our epigenetic profiles, and we're now doing studies to see if intense compassion training can change epigenetic profiles. This is the future of psychotherapy -- how do we change the physiology. You are probably familiar with the fact that there's a lot of research now on how compassion changes the vagus nerve, and pathways in the frontal cortex and so on.

Question 35

Can CFT be combined with EMDR?

Paul Gilbert · Accepted Answer

Yes, people have done this.

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