The acceptability of compassion-focused therapy in clinical populations: a metasynthesis of the qualitative literature

Background

Compassion-focused therapy (CFT) is a psychological intervention that is increasingly used in UK NHS services, either in an individual or a group format, with individuals experiencing psychological difficulties. Reviews of the quantitative evidence suggest that CFT effectively improves psychological well-being in various clinical groups. Participant experiences of group CFT in those with psychological difficulties have also been explored in several published qualitative and mixed-methods studies. Thus, the aim of this review was to further our understanding of the acceptability of group CFT, in relation to both the content of the intervention and its delivery, in order to help inform the future design and delivery of CFT in clinical services.

Method

Following the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines, eight relevant databases were searched for terms associated with CFT and qualitative research. The methodological quality of included studies was appraised using the Critical Appraisal Skills Programme (CASP) screening tool. Findings were synthesised using thematic synthesis.

Results

Twelve studies involving 106 participants with psychological difficulties met inclusion criteria. Five main themes were developed from the extracted data: 1) participants' experiences prior to the intervention, 2) initial response to the idea of participation, 3) participants' experiences of the intervention: aspects valued or considered beneficial, 4) valued outcomes of the intervention, and 5) the end of the intervention and moving forward.

Conclusions

Findings indicated a high level of acceptability of group CFT and commonality of experiences across participants despite different clinical presentations. The crucial role played by facilitators and other group members to participant engagement and outcomes was highlighted, among other factors. Clinical and research implications of these findings are discussed.

A preliminary investigation into self-compassion and compassion-based intervention for mental health in the performing arts

Objectives

Very little is known about the role of self-compassion on performing artists' mental health. This project had two primary aims. First, was to examine the relationship between self-compassion and mental health among performing artists in dance, music, and acting. Second, was to test a brief compassion-based intervention to establish proof of concept for future work.

Method

Two sequential studies recruiting Australian performing artists were conducted. In Study 1, a cross-sectional online survey of performing artists explored patterns of association between self-compassion and mental health. In Study 2, participants engaged with a brief compassion-based intervention including an online workshop and daily meditation over 3 weeks. Descriptive pre-post data combined with thematic analysis of semi-structured interview transcripts identified performer perspectives of the compassion-based intervention.

Results

In Study 1, 211 participants were included in the final cross-sectional analysis, which showed that the intention to be self-compassionate was associated with lower symptoms of depression and anxiety, and higher wellbeing, even while controlling for several key demographic and risk factors (stress, alcohol use, and body appreciation). In Study 2, ten participants completed the intervention with medium-large improvements in self-compassion and small improvements in wellbeing and body appreciation. Qualitative data demonstrated that participants experienced self-compassion to be helpful, however fears of lowering standards existed. Participants feedback from this study can now directly inform future compassion-based interventions among performers.

Conclusion

While acknowledging the small sample size, these findings suggest that self-compassion may help performing artists manage various forms of internal, interpersonal, and environmental distress. These findings warrant progression to controlled evaluation of compassion-based interventions within larger samples of performing artists.

A call to action: Re-activating the latent human factor for achieving the UN SDGs-cultivating courageous partnerships and compassionate human systems

The raison d'être for psychotherapy1 is to address individual suffering and distress. The sustainable development goals address suffering and distress on a global scale in the context of threats to the survival of our communities and planet.

OBJECTIVE

We propose scaling up therapeutic principles for collective impact and nurturing therapist commitment beyond the therapy room, to activate and sustain compassion-in-action at the community system level.

DESIGN

The SDGs represent the strength of collective human concern and action coming together. At the half-way point, we are falling dangerously short of our targets, requiring an urgent response. The tenet of this paper is that the weakest link in our journey is not technical capability or finances, or even the impact of multiple intersecting crises, but our ability to collaborate for sustained action-it is the human factor-hence, we need a psychologically informed response.

METHOD

Notably, least 'visible' is SDG17, the umbrella goal designated means of implementation, through partnership. Partnership has been treated as a transactional element of SDG projects, rather than the vital heartbeat connecting daily actions to the 2030 vision. Partnership is about investing in relationships and a commitment to working together with a common purpose-the bailiwick of psychological therapists.

RESULTS

We propose an architecture to support the development of courageous partnerships and compassionate systems.

CONCLUSION

Compassion uniquely potentiates global action on wicked problems.

Threat, safety, safeness and social safeness 30 years on: Fundamental dimensions and distinctions for mental health and well-being

In 1993, the British Journal of Clinical Psychology published my paper titled 'Defence and safety: Their function in social behaviour and psychopathology'. The paper highlights that to understand people's sensitivity to threat, we also need to understand their ability to identify what is safe. This paper offers an update on these concepts, highlighting distinctions that were implicit but not clearly defined at the time. Hence, the paper seeks to clarify distinctions between: (i) threat detection and response, (ii) safety and safety seeking, (iii) safeness and (iv) their social and non-social functions and forms. Threat detection and response are to prevent or minimize harm (e.g., run from a predator or fire). Safety checking relates to monitoring for the absence and avoidance of threat, while safety seeking links to the destination of the defensive behaviour (e.g., running home). Safety seeking also relates to maintaining vigilance to the appearance of potential harms and doing things believed to avoid harm. Threat-defending and safety checking and seeking are regulated primarily through evolved threat processing systems that monitor the nature, presence, controllability and/or absence of threat (e.g., amygdala and sympathetic nervous system). Safeness uses different monitoring systems via different psychophysiological systems (e.g., prefrontal cortex, parasympathetic system) for the presence of internal and external resources that support threat-coping, risk-taking, resource exploration. Creating brain states that recruit safeness processing can impact how standard evidence-based therapies (e.g., exposure, distress tolerance and reappraisal) are experienced and produce long-term change.

Differentiating mindfulness-integrated cognitive behavior therapy and mindfulness-based cognitive therapy clinically: the why, how, and what of evidence-based practice

It is important to be able to differentiate mindfulness-based programs in terms of their model, therapeutic elements, and supporting evidence. This article compares mindfulness-based cognitive therapy (MBCT), developed for relapse prevention in depression, and mindfulness-integrated cognitive behavior therapy (MiCBT), developed for transdiagnostic applications, on: (1) origins, context and theoretical rationale (why), (2) program structure, practice and, professional training (how), and (3) evidence (what). While both approaches incorporate behavior change methods, MBCT encourages behavioral activation, whereas MiCBT includes various exposure procedures to reduce avoidance, including a protocol to practice equanimity during problematic interpersonal interactions, and a compassion training to prevent relapse. MBCT has a substantial research base, including multiple systematic reviews and meta-analyses. It is an endorsed preventative treatment for depressive relapse in several clinical guidelines, but its single disorder approach might be regarded as a limitation in many health service settings. MiCBT has a promising evidence base and potential to make a valuable contribution to psychological treatment through its transdiagnostic applicability but has not yet been considered in clinical guidelines. While greater attention to later stage dissemination and implementation research is recommended for MBCT, more high quality RCTs and systematic reviews are needed to develop the evidence base for MiCBT.

Never underestimate fears, blocks, and resistances: The interplay between experiential practices, self-conscious emotions, and the therapeutic relationship in compassion focused therapy

Experiential practices are a core component of compassion focused therapy (CFT). Throughout the treatment process, the client's engagement with these practices may become blocked, resulting in a rupture in the therapeutic relationship. In these instances, the interplay between these experiential practices and the therapeutic relationship becomes an essential focus of therapy to repair the rupture, re-engage the client in the therapeutic process, and proceed with the CFT treatment plan. This paper presents the case of a man diagnosed with social anxiety disorder, with the presence of shame-based self-criticism, treated via 12 sessions of CFT. CFT was proceeding well until certain embodiment practices and chair work were introduced, at which point the client refused to continue and became disengaged in the session. The process of repair and re-engagement will be discussed from the perspective of this interplay between experiential exercises and therapeutic relationships. Implications for CFT practice and clinical recommendations will be provided.

Feasibility and Acceptability of Group Compassion-Focused Therapy to Treat the Consequences of Childhood Maltreatment in People With Psychiatric Disorders in France

ABSTRACT

Childhood maltreatment contributes to the development of psychiatric disorders. Shame appears to be an important mediating factor. Compassion-focused therapy (CFT) targets shame and seems relevant for adults with hard-to-treat psychiatric disorders associated with childhood maltreatment. Nevertheless, few studies have examined the feasibility and relevance of group CFT for this population and none in a French routine care setting. The aim of our study was to evaluate the feasibility and acceptability of group CFT for psychiatric disorders associated with childhood maltreatment. Eight adult patients with a history of childhood maltreatment participated in the 12-session group CFT. Feasibility and acceptability were assessed via a standardized satisfaction questionnaire, dropout rates, and attendance. Clinical benefits were assessed via changes in scores on scales of self-compassion, shame, and psychopathological dimensions. Adherence to therapy (75%) and attendance (88.3%) were high, and all participants reported high satisfaction. Posttreatment, self-compassion significantly increased (p = 0.016), and depression, anxiety, and posttraumatic scores decreased. Our study is the first to show that transdiagnostic group CFT (difficult-to-treat psychiatric disorders associated with a history of child maltreatment) is feasible in a French routine care setting. Changes in clinical scale scores after the intervention suggest the clinical value of the intervention and encourage further research of its effectiveness.

Defining compassion: A Delphi study of compassion therapists' experiences when introducing patients to the term 'compassion'

OBJECTIVES

Compassion-focused therapy (CFT) is shown to be an effective psychological intervention; however, patients can experience resistance to CFT due to preconceptions regarding the term 'compassion'. This study aims to obtain guidance from therapists in how to overcome these resistances DESIGN: This is the first study using the Delphi methodology to ask CFT therapists about how their patients understanding of the term compassion might act as a barrier to engaging with an otherwise beneficial therapy.

METHODS

Two rounds of interview questions were posed to 15 expert CFT therapists.

RESULTS

The results provide verification that there is resistance to CFT due to preconceptions around 'compassion', specifically its association with 'pity', 'weakness' and low-rank social positions. Further, this appears to be pronounced in patients who value competitiveness.

CONCLUSIONS

The results have practical implications such as the need for therapists to acknowledge the potential for resistance and the need for experiential strategies and illustrative examples of compassion to facilitate successful engagement with CFT.

Compassion Focused Group Therapy for People With a Diagnosis of Bipolar Affective Disorder: A Feasibility Study

Background

Compassion focused therapy (CFT) is an evolutionary informed, biopsychosocial approach to mental health problems and therapy. It suggests that evolved motives (e.g., for caring, cooperating, competing) are major sources for the organisation of psychophysiological processes which underpin mental health problems. Hence, evolved motives can be targets for psychotherapy. People with certain types of depression are psychophysiologically orientated towards social competition and concerned with social status and social rank. These can give rise to down rank-focused forms of social comparison, sense of inferiority, worthlessness, lowered confidence, submissive behaviour, shame proneness and self-criticism. People with bipolar disorders also experience elevated aspects of competitiveness and up rank status evaluation. These shift processing to a sense of superiority, elevated confidence, energised behaviour, positive affect and social dominance. This is the first study to explore the feasibility of a 12 module CFT group, tailored to helping people with a diagnosis of bipolar disorder understand the impact of evolved competitive, status-regulating motivation on their mental states and the value of cultivating caring and compassion motives and their psychophysiological regulators.

Methods

Six participants with a history of bipolar disorder took part in a CFT group consisting of 12 modules (over 25 sessions) as co-collaborators to explore their personal experiences of CFT and potential processes of change. Assessment of change was measured via self-report, heart rate variability (HRV) and focus groups over three time points.

Results

Although changes in self-report scales between participants and across time were uneven, four of the six participants consistently showed improvements across the majority of self-report measures. Heart rate variability measures revealed significant improvement over the course of the therapy. Qualitative data from three focus groups revealed participants found CFT gave them helpful insight into: how evolution has given rise to a number of difficult problems for emotion regulation (called tricky brain) which is not one's fault; an evolutionary understanding of the nature of bipolar disorders; development of a compassionate mind and practices of compassion focused visualisations, styles of thinking and behaviours; addressing issues of self-criticism; and building a sense of a compassionate identity as a means of coping with life difficulties. These impacted their emotional regulation and social relationships.

Conclusion

Although small, the study provides evidence of feasibility, acceptability and engagement with CFT. Focus group analysis revealed that participants were able to switch from competitive focused to compassion focused processing with consequent improvements in mental states and social behaviour. Participants indicated a journey over time from 'intellectually' understanding the process of building a compassionate mind to experiencing a more embodied sense of compassion that had significant impacts on their orientation to (and working with) the psychophysiological processes of bipolar disorder.