CoMPaSSionaTe MinD TRaining

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therapy healthcare Counselling and Psychotherapy Journal

July 2012

Being kinder to myself Compassionate Mind Training (CMT) can increase self-compassion in clients who have experienceda trauma. Elaine Beaumont outlines the results of a new study into its effectiveness when combined with CBT

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ndividuals who have been involved in a traumatic experience often feel significant levels of shame and/or guilt. Whilst cognitive behaviour therapy (CBT) may be effective in reducing other symptoms of post-traumatic stress disorder (PTSD), these individuals may also benefit from using self-soothing techniques, such as developing empathy, loving kindness and compassion for themselves, in a nonjudgmental way1. This might be described in everyday, non-technical language, as encouraging the client to consider ‘being kinder to myself’, as an aid to therapeutic recovery, following a traumatic incident. Compassionate Mind Training (CMT) research is relatively new and suggests that if individuals can develop their minds to be self-soothing, nurturing, kind and loving, they can alleviate self-criticism, guilt and shame2.

CBT and CMT are powerful therapies to contemplate combining. Research suggests that, through combining CBT and CMT, individuals can learn to challenge their own behaviour, thoughts and negative ‘self-talk’, by being more caring and sympathetic, rather than being critical and judgmental3.

Shame and guilt

CBT and CMT have certain similarities in that both use assessment, case formulation and work in collaboration with the client. In addition, both examine the role which behaviour, cognition and emotion play and how the body may respond to a perceived threat. However, Lee4 proposes that CMT can also act as an effective supplementary therapy to CBT, since it offers a way to work specifically with the crucial emotions of shame, guilt and self-blame. CMT accordingly aims to provide key skills in addition to CBT and therefore aims to aid relapse prevention. Table 1 lists some of the key differences between CBT and CMT. Beaumont, Galpin and Jenkins5 found that individuals who received CBT and CMT developed more self-compassion posttherapy than participants who received CBT-only treatment. Participants in the study were referred for a course of CBT to a treatment centre, by a range of agencies, following a trauma-related incident. Thirty two participants agreed to take part in the study and were randomly put into one of two groups, depending on the type of traumarelated incident experienced. For example, 12 individuals were referred because of a car accident and were randomly assigned so that there were six individuals in each group.

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Table 1: Some of the differences in approach and treatment techniques used in CBT and CMT Approach used

Cognitive Behavioural Therapy

Compassionate Mind Training

Reflective approach – client-based interventions

Writing about the trauma, learning to take charge of the memory.

Compassionate letter writing – focusing on being kind, supportive and nurturing.

Use of exposure therapy – revisiting the trauma scene, imaginal exposure.

Developing sensitivity, sympathy, acceptance and insight into one’s own difficulties through self-reflection.

Educational interventions

Anxiety management training, relaxation and distraction techniques.

Relaxation techniques. Mindfulness – learning to pay attention in the present moment without judging or criticising.

Learning to observe physical, emotional and cognitive reactions and think objectively.

Learning to observe self (similar to the CBT condition but including selfkindness, warmth). Learning to challenge the ‘bully within’.

Therapist based interventions including reflective tasks carried out by the client as homework tasks

Reliving work - exploring the worst memory and using coping strategies.

Examining positives, for example, focus on specific individual qualities.

Completion of thought records/charts/cost benefit analysis to explore emotions, thoughts, behaviour and bodily reactions.

Use of self-compassion journal.

Cognitive restructuring to examine core beliefs, dysfunctional assumptions and negative automatic thoughts.

Use of imagery - imagine the compassionate self dealing with this problem. Self-monitoring – paying attention to thoughts and feelings and monitoring them. Empty chair technique.

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being kinder to myself continued

Figure 1: Mean Scores pre-therapy and post-therapy for the CBT treatment group and the combined CBT and CMT treatment group 4

3.72

3.5

Mean Score

3

3.21

2.5 2 1.5

Pre-therapy scores Post-therapy scores

2.13

1.94

1 0.5 0 CBT only group pre and post-therapy

One group received CBT for up to 12 weeks and the second group received CBT, combined with CMT, for up to 12 weeks. All participants received CBT from a single, qualified, and BABCP-accredited cognitive behavioural psychotherapist (the author). All participants were informed that they would receive CBT in accordance with NICE Guidelines6. Participants in the CMT group were advised that, as part of therapy, they would explore and learn techniques which

CMT & CBT group pre and post-therapy

could help them develop empathy for themselves and acceptance of their distress. Data was collected using three questionnaires which measured anxiety, depression, self-compassion and trauma -related symptoms: Hospital Anxiety and Depression Scale (HADS); Impact of Events Scale – Revised (IES-R); Self Compassion Scale. A repeated measures design was used, with participants completing questionnaires pre therapy and post therapy. Ethical approval was given by the Research Governance and Ethics Committee at the University of Salford.

Whilst CBT may be effective in reducing other symptoms... these individuals may also benefit from using self-soothing techniques, such as developing empathy, loving kindness and compassion for themselves

Overview of therapy

In all cases, an assessment and case formulation was carried out, as this meant that the therapist and individual were able to focus on each problem together. Socratic dialogue was used in both conditions to help examine and explore goals, incorporate homework tasks and encourage the practice of therapeutic interventions outside of therapy. Individuals in both conditions explored a setback plan, which involved asking questions such as, what kind of situation could set you back? How would you deal with that if it did happen? And, how can you build on what you have learnt in the future? Individuals in the CMT group used imagery, for example, bringing to mind a loving, accepting and caring image (this could be a friend, teacher or family member). Graded tasks were examined in both conditions. Grounding work was explored with individuals, including using statements, such as, ‘that was then, this is now, then it was cold and dark and I was alone, but now it is cold but I am at home, safe’. Within the CMT group, grounding work included the use of a memory trigger, such as a precious stone, or smell that the individual could associate with relaxation, calm and safety.

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Self-compassion

The findings from this study supported the original hypothesis, that individuals receiving a course of combined CMT and CBT following a traumatic incident would have significantly higher scores on the Self-Compassion Scale than individuals in the CBT-only group.

developed more self-compassion post therapy than the participants in the CBT-only treatment group. However, the analysis indicates no statistically significant difference between both treatments in terms of reduction in symptoms of avoidance, intrusive thoughts, hyperarousal, anxiety and depression.

it is difficult to establish cause and effect. On the other hand, the results do suggest that individuals suffering with PTSD symptoms could benefit from developing loving kindness and self-compassion. Furthermore, the findings from the present study support the work of Brewin et al9 and Ehlers and Clark10, who found negative emotions, such as shame and worry about current threat, led to avoidant behaviours. This current research study suggests that individuals benefited from using techniques which helped develop self-compassion, as this, in turn, helped them reduce avoidant behaviours.

Compassion-based approaches have implications for the future of mental health practices and for our education system Figure 1 indicates that participants in both groups have low self-compassion scores pre-therapy, as the mean scores were lower than 2.5. However, there was a significant difference post therapy, as the mean scores for both groups increased. The mean score for the CBT-only group increased to 3.21 and in the combined group the mean score increased to 3.72. The main effect comparing the two types of intervention was significant, suggesting a difference in the overall levels of self-compassion post therapy between the two treatment groups [F (1, 30) = 4.657, p ≤ .05]. This suggests that participants in the combined treatment group developed more self-compassion than participants in the CBT-only group.

Reducing clients’ anxiety levels

Participants in the combined CBT and CMT condition did report fewer symptoms of anxiety and depression post therapy and reported higher scores on the HADS and IES-R pre therapy. The only exception to this was on the hyperarousal scale, where individuals in the CBT-only condition reported higher scores pre therapy than the combined CBT and CMT treatment group. This, incidentally, supports the findings of Gilbert and Proctor3 , who found a significant reduction in symptoms of anxiety, depression, self-criticism and an increase in feelings of self-warmth and self-care in clients in a group-setting (n:6), suggesting that CMT can be an effective therapeutic intervention.

Increasing self-esteem

The results are consistent with the findings of Neff, Kirkpatrick and Rude7, who found that CMT increased self-esteem and selfParticipants in both the CBT-only and compassion among a sample of college combined CBT and CMT treatment groups students (n:91). Furthermore, Thompson experienced highly significant reductions 8 in symptoms of anxiety, depression, avoidant and Waltz found a correlation between symptoms of avoidance, self-criticism and behaviours, intrusive thoughts and self-compassion. In their study, students who hyperarousal. Additionally, the results indicate that participants in both conditions scored higher on the Self Compassion Scale engaged less in avoidant behaviours, and experienced a statistically significant students who reported a traumatic event increase in self-compassion. Statistical were more self-critical and self-judgmental. analysis indicated that participants in the However, as this was a correlational study, combined CBT and CMT treatment group

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Limitations of the study

Although the results suggest an improvement in both conditions, there was no ‘no-treatment’ comparison group. Therefore, individuals may have improved because of external factors. Another limitation of the current study derives from the small sample size (n:32), potentially limiting generalisability to other populations. Initially it was thought that dropout rates would be a limitation of this study. This was proved not to be the case, as 32 out of the original 36 individuals completed therapy. Despite these limitations, the present study does, however, have relatively high ecological validity, because it examines the role trauma-related symptoms and self-compassion play in a real-life setting with individuals referred for a therapeutic intervention.

Implications for practice

Trauma and stress-related symptoms are becoming an increasingly integral part of life and can affect our home and work life. Compassion-based approaches can have implications for the future of mental health practices and for our education system. For example, if self-compassionate techniques could be taught in schools, colleges and universities, to students who are overly critical of themselves, they may go on to develop greater self-care and emotional resilience. This in turn could help individuals cope with the difficulties and pressures of life in a more psychologically healthy way.

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Summary

This research study has explored differences in treatment outcome measures, following a post-trauma course of either CBT on its own, or CBT combined with CMT. Thirty-two individuals took part in this study and a repeated measures design was used, as individuals completed questionnaires pre therapy and post therapy. There was a statistically significant improvement in both groups post therapy. The results show that individuals in the CMT group reported significantly higher scores (ie developed more self-compassion) post therapy on the Self Compassion Scale, than individuals in the CBT-only group. Furthermore, the mean scores suggest symptoms of avoidance, anxiety, depression, intrusion and hyperarousal reduced more in the combined CBT and CMT group, although the statistical analysis shows that there was no significant difference between the two treatment groups for these symptoms.

Self-kindness

A much-reported weakness of CBT is that individuals may say that they understand the logic of the approach, but report that they do not ‘feel any better’11. The results presented in this article suggest that, in order to feel differently, individuals could benefit from developing selfcompassion and by learning to access their own emotional regulation systems12 . Therefore, individuals may feel more benefit from therapy by learning to understand why they feel the way they do. This process can be assisted by clients learning to challenge self-criticism and their own ‘internal bully’ in a non-judgmental way by adopting the stance of ‘being kinder to myself’. Elaine Beaumont is a cognitive behavioural psychotherapist (BABCP accredited and UKCP registered) and provides therapy for Greater Manchester Fire and Rescue Service. Elaine is also a lecturer in counselling and psychotherapy at the University of Salford. Acknowledgements: Adam Galpin (University of Salford) and Peter Jenkins (University of Manchester) are thanked for their supervision of the original MSc research dissertation.

Research suggests that, through combining CBT and CMT, individuals can learn to challenge their own behaviour, thoughts and negative ‘self-talk’, by being more caring and sympathetic

References 1

ilbert P, Irons C. Focused therapies and compassionate G mind training for shame and self-attacking. In P Gilbert (ed). Compassion: conceptualisations, research and use in psychotherapy. London: Routledge; 2005.

2

ilbert P, Baldwin M, Irons C, Baccus J, Palmer M. G Self-criticism and self-warmth: an imagery study exploring their relation to depression. Journal of Cognitive Psychotherapy: An International Quarterly. 2006; 20:183-200.

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ilbert P, Proctor S. Compassionate mind training for G people with high shame and self criticism: overview and pilot study of a group therapy approach. Clinical Psychology and Psychotherapy. 2006; 13:353-379.

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Lee DA. Compassion focused cognitive therapy for shame-based trauma memories and flashbacks in PTSD. In N Grey N (ed). A casebook of cognitive therapy for traumatic stress reactions. London: Routledge; 2009.

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eaumont E, Galpin A, Jenkins P. ‘Being kinder to myself’: a B prospective comparative study, exploring post-trauma therapy outcome measures, for two groups of clients, receiving either cognitive behaviour therapy or cognitive behaviour therapy and compassionate mind training. 2012. Counselling Psychology Review. 2012: 27,(1):31-43.

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National Institute for Health and Clinical Excellence (NICE) Guidelines for post-traumatic stress disorder (PTSD): the management of PTSD in adults and children in primary and secondary care. NICE; 2005.

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Neff KD, Kirkpatrick K L, Rude S. Accepting the human condition. Self-compassion and its links to adaptive psychological functioning. Journal of Personality. 2007; 41:139.154.

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Thompson B, Waltz J. Self compassion and PTSD symptom severity. Journal of Traumatic Stress. 2008; 21(6):556-558.

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rewin CR, Andrews B, Rose S. (2000). Fear, helplessness B and horror in posttraumatic stress disorder: Investigating DSM-IV criterion 2A in victims of violent crime. Journal of Traumatic Stress. 2000; 13:499–509.

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Ehlers A, Clark DMA cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy. 2000: 38:319-345.

11

rant A, Townend M, Mulhern R, Short N. G Cognitive behavioural therapy in mental health care. London: Sage; 2010.

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ilbert P. Compassion focused therapy. London: G Routledge; 2010.

Reader response

The author welcomes feedback on this article. To contact Elaine, please email: [email protected]. To contact the journal, email [email protected]