What is recovery? Recovery in mental illnesses can mean living a meaningful and productive life despite a disability. It can also refer to a reduction or complete remission of symptoms and a healing transformation of the self. For most people, it refers to the power of hope in healing disorders that were once thought to be hopeless. As Henry Ford once said, "Whether you think you can, or you think you can't, you're right."

Tuesday, December 29, 2015

Compassion Focused Therapy (CFT)

        I've personally found compassion-focused therapy quite helpful in my own quest to be my own therapist (in addition to any other therapist I may have at the time). Visit http://compassionatemind.co.uk and click "resources" to access a ton of free resources on this topic which are helpful in self-help work and in working with others. Below is a summary of CFT I wrote for graduate school in a paper entitled Mindfulness and Compassion for Psychosis. The lesson? Love yourself! You may not feel that you deserve it, but your brain needs that self-love to be healthy. 

Compassion-focused therapy was developed with and for people who have chronic and complex mental health problems linked to shame and self-criticism and who come from difficult backgrounds (Gumley, et al., 2010). It addresses emotional aspects often missed by cognitive therapies when clients understand their issues logically but don’t feel better (Gilbert & Procter, 2006). In CFT, clients are first introduced to the compassion-promoting ideas that evolution has not given us brains that are easy to manage and that “we all just find ourselves here.” The three neurological affect regulation systems are then explained. 
The threat and self-protection system (“fight or flight”) operates within the amygdala and the hypothalmic-pituitary-adrenal (HPA) axis and produces feelings of anger, anxiety, and disgust (Gilbert, 2010). Problems with the system include the types of triggers that activate it, the type, frequency, rapidity, duration, and intensity of the threat-protection response, and unhelpful coping responses to its activation (Gilbert, 2010). Nearly all therapies focus to a greater or lesser degree on difficulties within the threat and self-protection system (Gilbert, 2010). According to Gumley, et al. (2010), the unbearable affect in psychosis is linked to the threat protection system and is accompanied by a hypersensitivity to threat.
The incentive and resource-seeking, drive-excitement system is a dopaminergic system that motivates us to seek out resources for ourselves and our loved ones, such as food, sex, comfort, friendship, or recognition (Gilbert, 2010). People with mood disorders have problems with this system: it is over-activated in mania and under-activated in depression (Gilbert, 2010). 
The soothing, contentment and safeness system uses endorphins and oxytocin to calm us when there are no threats to face and no goals to pursue in the present moment (Gilbert, 2010). It is this system that promotes and is promoted by mindfulness and compassion (Gilbert, 2010). It can be left underdeveloped by early attachment difficulties, trauma, and neglect — all problems which are are extremely prevalent in persons with psychotic disorders (Gumley, et al., 2010).
A secure attachment allows children to learn to turn to others for support and soothing, and also enables them to activate their own soothing, contentment, and safeness system to soothe themselves and others when needed (Gumley, et al., 2010). Psychosis, in contrast, is associated with insecure avoidant attachment (Gumley, et al., 2010). Physical and sexual abuse, homelessness, assault, and other trauma are also linked to the development of psychosis, after controlling for other factors (Gumley, et al., 2010; Read, et al., 2008). The threat protection system, already over-activated and under-soothed after these and other experiences, can be exacerbated by the external threats of forced treatment and stigma and the internal threats of fear of relapse and shame (Gumley, et al., 2010). This is worsened by unhelpful safety strategies and the subsequent unintended consequences of those safety strategies (Gumley, et al., 2010). In a compassion focused formulation, all of these challenges are addressed by activating the soothing, contentment, and safeness system with compassion, as shown in Figure 1. 

Interpersonal Environment and Experiences 

Compassion, love, and support 
Breakdown of family relationships
Service responses to seeking help
External Threats

Others untrustworthy
External shame/stigma
Psychiatric interventions

Internal Threats

Internal shame
Fear of recurrence
Cognitive/perceptual change
Emotional distress
Safety Strategies

Cognitive, emotional and interpersonal avoidance
Withdrawal and disengagement
Preoccupation and worry
Subordination and submission
Unintended Consequences 

Loss of affect
Impaired reflexivity and theory of mind
Social isolation
Increased emotional distress
Criticism/Emotional Overinvolvement 
Coercive service responses

Compassionate responding

Sensitivity, sympathy, distress tolerance, forgiveness, empathy, non-judgment, acceptance, warmth, care for well-being, balance/proportion, ease with imperfections 

 Figure 1. A compassion focused formulation. Gumley, A., Braehler, C., Laithwaite, H., MacBeth, A., & Gilbert, P.. (2010). A compassion focused model of recovery after psychosis. International Journal of Cognitive Therapy, 3(2): pp. 186-201.
In compassion focused therapy, clients are taught to deliberately focus attention on compassionate thoughts and images, to use reason to bring about a balanced perspective, and to learn compassionate ways of alleviating distress to replace unhelpful safety strategies (Gilbert, 2010). Clients learn to use compassionate self-correction rather than shame-based attacking (Gilbert, 2010). A compassionate body scan and a soothing breathing rhythm are used to encourage mindfulness (Gilbert, 2010). Imagery work develops the inner compassionate self, compassion flowing out to others and in from others, and self-compassion (Gilbert, 2010). Clients learn to write compassionate letters to themselves and to deal with blocks to compassion (Gilbert, 2010). 
A study found that participants in a Compassionate Mind Training (CMT) group exhibited significant reductions in depression, anxiety, self-criticism, shame, inferiority, and submissive behavior (Gilbert & Procter, 2006). (Gilbert has not clarified the difference between the earlier term Compassionate Mind Training and his later use of the term Compassion Focused Therapy, but if there is one it seems to be a difference of group versus individual therapy. The theory and techniques appear generally the same.) There was also a significant increase in the participants' ability to self-soothe and focus on feelings of warmth and reassurance. 
Mayhew and Gilbert (2008) used CMT with three cases of persons hearing malevolent voices. Participants showed decreases in depression, psychoticism, anxiety, paranoia, obsessive-compulsive disorder, and interpersonal sensitivity. The hallucinations of the participants became less malevolent, less persecuting, and more reassuring. Two of the participants showed a remarkable increase in functioning, although the third did not allow himself to fully embrace self-compassion due to a shameful sexual secret.

Heather Laithwaite (2010) adapted Compassionate Mind Training for use in a high security forensic setting and named the resulting program Recovery After Psychosis (RAP). Fifteen men with schizophrenia and three men with bipolar disorder participated. Eight of these participants had also been diagnosed with anti-social personality disorder. The subjects demonstrated a large magnitude of change for depression and self-esteem, a moderate magnitude of change for social comparison and general psychopathology, and a small magnitude of change for shame. Participants continued to show these changes six weeks later.
Gilbert, P. & Procter, S. (2006). Compassionate Mind Training for people with high shame and self-criticism: Overview and pilot study of a group therapy approach. Clinical Psychology and Psychotherapy, 13: pp. 353-379.  
Gilbert, P. (2010). Compassion Focused Therapy: Distinctive features. New York: Rutledge. 

Gumley, A., Braehler, C., Laithwaite, H., MacBeth, A., & Gilbert, P. (2010). A compassion focused model of recovery after psychosis. International Journal of Cognitive Therapy, 3(2): pp. 186-201. 
Laithwaite, H. (2010). Recovery After Psychosis: A compassion focused recovery approach to psychosis in a forensic mental health setting. (Doctoral Dissertation, University of Glasgow). Retrieved from http://theses.gla.ac.uk/1759/1/ PhD_thesis_Final_April_2010.pdf
Mayhew, S.L., & Gilbert, P. (2008). Compassionate Mind Training with people who hear malevolent voices: A case series report. Clinical Psychology and Psychotherapy, 15: pp. 113-138. 
Read, J.,  Fink, P.J., Rudegeair, T., Felitti, V., & Whitfield, C.L. (October 2008). Child maltreatment and psychosis: A return to a genuinely integrated bio-psycho-social model. Clinical Schizophrenia and Related Psychoses, pp. 235-254. Retrieved from http://www.integration.samhsa.gov/pbhci-learning-community/child_maltreatment_and_psychosis.pdf

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