Compassion-Focused Therapy (CFT) is a psychotherapeutic model that draws from evolutionary science and the science of compassion to alleviate suffering. CFT has been shown to be particularly useful in the alleviation of shame and self-criticism, and has been found to be effective with a range of populations struggling with various afflictions.
The following is a Q+A with Dr. Stan Steindl from the Compassionate Mind Research Group) at the University of Queensland.
What makes CFT unique as a model?
Professor Paul Gilbert, a researcher and therapist who is trained in many approaches, observed that patients with depression who were treated with cognitive behavior therapy (CBT) would often successfully challenge their irrational thoughts, but the challenges and the alternative thoughts would still often come with a hostile, critical or shaming voice.
This would mean that the effectiveness of CBT was limited by the tone used in thought challenging exercises. “You idiot, of course you have friends! ‘Nobody likes me.’ What a silly thing to say. You’re such a silly, whiny person!”
Compassion focused therapy was devised to get around this critical, shaming tone, and instead help people to approach themselves with a warm and friendly voice, and with kindness, wisdom, strength, and commitment.
The beauty of CFT is that it can be used to complement other types of therapy. So for instance, you may do CBT in a compassion focused way, or you may do acceptance and commitment therapy (ACT) in a compassion focused way.
In CFT for Eating Disorders (CFT-E), we are bringing the CFT model to established eating disorder treatment approaches. Thus, the cognitive behavioral theory and techniques of treating eating disorders are still used, but within this compassion-focused approach.
What was the rationale for using CFT for eating disorders?
Self-criticism, shame, stigma, and self-loathing are common in eating disorders, and so bringing CFT to eating disorder treatment is an attempt to help work with this. In CFT, we often speak of the “tricky brain,” that is the fact that our human brains have evolved over millions of years, and so many of the challenges we face today, such as difficult thoughts, feelings and urges, can be traced back to evolved adaptive functions.
In CFT-E, we also speak of our “tricky bodies,” and the fact that they too have evolved to aid our survival. And many of the challenges we face regarding our bodies, as well as a range of eating and weight concerns, are related to evolved adaptive functions—including aspects to our eating behaviors; urges, cravings, starvation, binging and so on.
The idea in CFT is to develop our compassionate self, the aspect of ourselves that can be kind, wise, strong and courageous. This compassionate self can be committed to what is best for our own well being, can soothe us in the face of the critical self, and can bring this wisdom and understanding of the tricky brain and the tricky body to assist us in making changes.
For the reasons that you’ve already mentioned, compassion work can be especially challenging with clients with eating disorders. Why is that?
In CFT-E, working with and through “fears, blocks and resistances” to compassion is some of the most challenging, yet important work we do. And it is often the first work we might need to do. People who are struggling with their weight or body image are often convinced that they need to be tougher on themselves, not the other way around, and they believe that their self-criticism helps motivate them to change.
Often, the early phases of CFT-E involves allowing people to fully explore their fears, blocks and resistances. Is it that they feel undeserving of self-compassion, is it that they think it is weak or self-indulgent, or is it that they think being kinder to themselves means they will actually become totally lax with themselves and make their situation worse?
People need a chance to fully explore these inhibitors to compassion and self-compassion, without someone trying to convince them otherwise, and so that they can understand themselves and their perspectives, and also feel heard, understood and validated by the therapist.
Once the person feels heard and understood about their fears, blocks and resistances to compassion and self-compassion, then they may be more open to explore the other side of the question. Deep down, most people feel two ways about compassion and self-compassion; their fear might inhibit more self-compassion in the first instance, but in the context of a safe therapeutic relationship, people are often willing and able to explore the facilitators of compassion and self-compassion.
Sometimes, they might talk about how compassion for others is okay, and this can be an avenue for inquiry, in terms of how, as a human being themselves, they might also be deserving of their own compassion. Sometimes, they might talk about what compassion is, and how, with wisdom, we are able to navigate concerns of falling into the trap of self-indulgence, and instead understand that self-compassion asks “what do I also really need right now?”
They might also start to explore the function of their self-criticism.
Do you have any tips on using compassion work with eating disorder clients?
One very useful strategy in CFT is the “functional analysis of self-criticism.” Developed by Gilbert, this involves an imagery exercise that invites people to imagine a conversation with the critical self, what it looks like, what it says, how it feels and importantly, how it makes them feel.
This can be a moment of insight, where the person feels the actual effects of self-criticism, which are often demotivating rather than the opposite. At this point, it can be really useful to introduce the concept of “compassionate support and encouragement.”
Compassion is still aspirational, still wants the best for you, still wants you to achieve and do well and live a values directed life. It is just coming with the different tone—one of kindness, wisdom, strength, courage and commitment.
What does the research say in support of this approach? What more do we need to know?
The research so far is very, very encouraging. For example, Drs. Ken Goss and Steve Allan and colleagues have found that CFT-E as part of a comprehensive inpatient treatment program can be effective for those with diagnosed eating disorders, such as anorexia and bulimia nervosa.
Also, in terms of people with concerns regarding overweight or obesity, a large scale project that is being conducted by Gilbert, Dr. Cristiana Duarte and others, seems to be showing that adding CFT components to a weight management program can offer added benefits. That said, the evidence is still largely at its infancy.
What we do know is the important roles played by self-criticism, shame, body shame and stigma in eating disorders, and eating and weight concerns generally. We also know that self compassion helps to mediate the relationship between self-criticism and shame on the one hand, and anxiety, depression, and other psychopathologies (including eating-related constructs) on the other.
Here in Australia, myself and Dr. Kiera Buchanan have developed a CFT-based program for people who are overweight or obese, and the pilot trials we have been conducting (which are not yet published, unfortunately) have shown a lot of promise, especially in terms of reducing self-criticism and increasing self-compassion. We are hoping to do more rigorous research sometime this year.
Fore more about Dr. Steindl’s work, check out the Compassionate Mind Research Group.