Chapter 6
Evolved minds and compassion in the therapeutic relationship
Paul Gilbert
The therapeutic relationship and working alliance emerge from what patients and therapist bring to the interaction. This co-constructed relationship impacts on outcomes (Freeman & McCloskey, 2003; Norcross, 2002). Part of the therapist’s role is to guide and support a patient into, and through, domains of experience that he/she may be fearful of or find distressing, or that he/she has erected a range of (disorder maintaining) safety strategies to cope with. Moreover, the prospect of change may involve risks (e.g., to a relationship), fears of change to a self-identity, fear of loss of control, and for some people, terrors. Indeed, for nearly all patient difficulties the therapist is confronted by the patient’s experience of threat (and lack of safeness) in specific domains (Gilbert, 1993). In this context of confronting threats, the therapist can be called on to enact a multitude of roles – as educator, mentor, coach, validator, boundary setter, soother–reassurer, morale-enhancer, inspirer, container, safe base, encourager – as well as being simply a fellow human being to share the painful with. The fact that all of these functions may be crucial for some patients points to a need to reflect on how and why these interpersonal domains exert the power they do; how is it that the mind of one person can have such a powerful impact on the mind of another?
Part of the answer becomes clear when we lift our eyes beyond the therapeutic relationship and contextualise humans in their evolutionary and social contexts. Humans are an exquisitely social species, who from the first moments of conception, and then throughout life, are physiologically influenced and regulated via social relationships. The exact patterns of genes we inherit depend on the choices our parents make with regard to whom they reproduce with and timing of conception. The environment of the womb, for example whether a mother is well fed or stressed, and her hormone levels, impacts on the maturation of the foetus and possibly on modes of inheritance (Harper, 2005). When we are born, social relationships influence the way our brain matures (Gerhardt, 2004; Schore, 1994, 2001; Siegel, 2001), the regulation of stress and immune functions throughout life (Cacioppo, Berston, Sheridan & McClintock, 2000), joy and happiness (Argyle, 1987), depression and anxiety (Gilbert 1992), our resilience to life stressors (Masten, 2001), self-evaluations (Baldwin & Dandeneau, 2005) and even the way we confront our own death (Aldridge, 2000). Briefly, when we experience the minds of others as loving, caring, forgiving, supportive and friendly (that is to say, compassionate), we are psychologically and physiologically regulated in different ways than when we experience the minds of others as condemning, rejecting, critical and withdrawing (Gilbert 2005a; Porges, 2001; Wang, 2005). It is not just that in the former case we are more likely to experience positive affect, and in the latter case to experience negative affect, but also that compassion from another creates internal conditions for feelings of safeness and soothing, can help deactivate threat and self-protective strategies, and facilitates internal conditions conducive to growth, maturation, change, healing and well-being (Gilbert, 2005a; Wang, 2005).
As we increasingly recognise the power of social relationships as psycho-physiological regulators we are able to move away from the idea that we are autonomous, self-centred beings, to a greater appreciation of our social nature and needs. So this chapter will contextualise the psychotherapy relationship in an evolutionary context that considers how our minds have evolved to co-regulate each other. We will also explore various components of compassion as therapeutic agents in their own right, and as processes that help patients engage with the various tasks of cognitive behavioural interventions.
The evolved mind
The basic infrastructures of our brains have emerged from millions of years of evolution. Over this time they have acquired capacities for a varied array of motivations, emotions and passions. More recently our hominid evolution has equipped us with abilities for language, symbolic reasoning and meta-cognitions – capabilities that can influence, dampen or inflame more basic affect systems (Wells, 2000). Cognitive therapists have been well aware that many of our problematic emotions and motives, especially those that lead to the seeking of psychotherapy, are routed in evolved systems and strategies (Beck, 1987, 1996, 1999). Gilbert (1984, 1989, 1992, 2005a, 2005b) focused on innate systems underpinning attachment, cooperation, and dispositions to form social ranks and hierarchies. In fact, various therapists have focused on evolved attachment and other interpersonal processes as central to the psychotherapy process (Holmes, 2001; Knox, 2003). In cognitive therapy Guidano & Liotti (1983) offered the first major integration of attachment theory into cognitive therapy, and Safran (1998) extended the interpersonal dimension in cognitive therapy following traditions from Cooley, Mead and Sullivan. More recently new approaches emphasise that our minds are organised around multiple and parallel processing systems, e.g., forms of attention, memory and emotions (Harvey, Watkins, Mansell & Shafran, 2004) that do not always work well together (Dalgleish, 2004). For example, our threat-systems, that evolved millions of years ago, can easily override more recently evolved competencies for rational thoughts; we can have powerful distressing intrusions at times when we wish to concentrate; we have memory lapses when we need to remember; our sensory and verbal memories may not cohere; we can experience negative emotional shifts when we want to be happy. There is much in evolutionary psychology that has focused on the fact that our minds are rather full of conflicting motives, thoughts and processing systems (Gilbert, 1989, 2000; MacLean, 1985).
Although concepts of schemas, core beliefs and assumptions are central to cognitive models, they can be problematic if they become tautological (Hammen, 1992) or if therapists are overly reliant on (only) consciously accessible thoughts (Baldwin, 2005; Hassin, Uleman & Bargh, 2005). We know, for example, that people’s verbal reports of reasons for their feelings and values may not be accurate (Haidt, 2001; Hassin et al., 2005). There is also evidence that we can process self-relevant and self-esteem information in non-conscious (implicit) and conscious (explicit) ways, and that these may not be congruent (Jordan, Spencer, Zanna, Hoshino-Browne & Correll, 2003). New work, using implicit self-esteem measures, suggests that depressed people may have positive implicit self-esteem (Raedt, Schacht, Franck & Houwer, 2006). Gilbert (1984, 2005a; Gilbert & Irons, 2005) suggested that some forms of low self-esteem and self-blame can reflect implicit, defensive strategies in the face of more powerful others where externalisation of blame is dangerous. The focus in therapy then may be on the fear of others and the patient’s own (avoided) retaliatory (aggressive) strategies. The therapeutic relationship will obviously differ according to whether therapists consider self-blame as a cognitive distortion or as a (functional) safety strategy.
Increasingly, cognitive therapists are developing therapies that target sub-components of our processing systems, such as types of memory, attention and rumination (Dalgleish, 2004; Harvey et al., 2004; Lee, 2005). Evolution-focused psychologists explore our innate relationship-building systems such as a kin-attachment, mating, or alliance formation (Buss, 2003), while others are beginning to explore the processing components (or modules) that enable complex social behaviours such as empathy (Decety & Jackson, 2004). The therapeutic relationship is clearly a form of relationship that involves helping and altruism and thus can be considered in the light of what we know about (innate and learned aspects of ) relationship building. Bailey (2002), for example, suggests that in order to feel safe some patients will try to build certain types of kinship relationship with their therapist. It is the accessing of these processing systems that enables the patient to be oriented to new learning within the relationship. My own efforts to link psychotherapeutic processes with evolved psychological systems, especially those associated with social behaviour, considers the evolved nature of four domains of functioning (Gilbert, 1984, 1989, 1993, 1995, 2005a):
- basic threat and safeness processing
- role-seeking and role-forming
- symbolic and meta-cognitive abilities
- identity-forming that depends on abilities for certain types of self awareness, and that gives rise to a sense of self “who is”, “who can”, and “who wants to be”.
Our “sense of self” emerges from the choreographies of the other aspects of our minds and is shaped via social relationships in which the self is embedded. Since each of these four domains impacts on the emergence of the therapeutic relationship, we can briefly explore them.
Threat and safeness
All living things must be able to make decisions in their domain of existence that pertain to whether stimuli impinging on them are threats or are safe (Gilbert, 1989; Porges, 2001). Very primitive defences might be to move away, take flight and avoid. Defences become more complex with evolution (Marks, 1987). Hence, over many millions of years there have evolved a range of specific behaviours (fight, flight, submission, camouflage, helpseeking), specific emotion-potentials (anger, anxiety, and disgust), and attentional-cognitive “better safe than sorry” processing heuristics for detecting and evaluating threats (Gilbert, 1993, 1998a, 2001; Marks, 1987). The defensive strategies are routed in earlier evolved brain structures (LeDoux, 1998), extended into the peripheral and autonomic nervous system (Porges, 2001), and can be triggered fast and directly by unconditioned stimuli, and by conditioned stimuli. As a result of learning, interacting with genetic sensitivity, these defensive processes can become easily triggered and frequent, with accentuated intensity and duration of negative emotional states (Gilbert, 2001; Rosen & Schulkin, 1998).
A key distinction here is between safety-seeking and safeness (Gilbert, 1989, 2005a). Safety-seeking pertains to defensive behaviours such as fight, flight, avoidance, immobilisation, submission and returns to a “safe base” that are triggered by specific stimuli or events. Planned safety behaviours may be carrying tranquillisers in one’s pocket or deliberate avoidance, and are associated with beliefs of the value of safety behaviours (Salkovskis, 1996). These directly regulate activity in threat systems in that if they are successfully enacted a person may feel relatively safe. However, any block to the safety strategies can reactivate the threat system. In contrast, when desensitised to fear/threat certain stimuli no longer trigger the same threat response because the person is processing the threat itself in a different way. Thus the network of safety strategies, such as remaining vigilant to the possible threat, and being ready with defensive safety behaviours, is deactivated. In this context one can feel relatively safe even in the presence of (what were) threatening stimuli. One may even come to enjoy them (e.g., an agoraphobic may come to enjoy going out). In childhood the transition from (natural) fear and safety behaviours to those of feeling “safe with”, and exploration and engaging, depend crucially on parental soothing and social referencing (Schore, 1994). The therapeutic relationship may play a similar key role in how a patient makes the journey from threat evaluations and safety behaviours to explorations, coping and coming to feel “safe with” (Gilbert, 1989; Holmes, 2001).
Leahy (2001, 2005) has pointed out that people can develop a range of negative threat reactions to their own internal stimuli of emotions/motives/ desires and fantasies – that is, these internal experiences constitute threats. These threats are linked to beliefs that certain emotions/desires/fantasies might be overwhelming, confusing, that they would be shamed by others, and by beliefs in thought–action fusion (if I think or feel it, it is as bad as doing it). Safety behaviours here can involve trying not to think about certain things, avoidance of situations that elicit certain feelings, hiding feelings from others, denial or dissociation. Leahy makes it clear that the therapist’s role here involves containment and psycho-education on the complexities of our evolved and socially shaped emotional lives; that we can have multiple and conflicting feelings/desires (because of parallel processing systems) to the same event (for example, we can be angry with someone we love), normalising (i.e., “it is understandable that you feel threatened by this because . . .”), exposure and validation. Therapist empathy and warmth is crucial here so as not to activate shame (“I am stupid to think like this; my therapist thinks I am immature with my emotions”). This requires the therapist to be empathically attuned with the patient, have an appropriate understanding of emotions and feared material (for example, a patient can have sadistic revenge fantasies that are feared), and feel safe enough with their own emotions and “shadow material” to act as a soothing agent. The therapist helps patients (re)code their inner world as safe to the extent that, while some emotions/fantasies are unpleasant or strange, they are normal to our humanity, and are manageable once we accept them, no longer fight to suppress or deny them, or label ourselves negatively as a consequence of having them. They can in fact be important sources of information that need to be addressed (Greenberg, Chapter 3, this volume). Carl Jung believed that “shadow material” could be a source of vitality and creativity if approached in certain ways and integrated in the mind.
We can look at these difficulties in another way based on conditioning. For some patients, therapists will be aware that some emotions/desires are under conditioned inhibitory control (Ferster, 1973; Gilbert, 1992). Ferster (1973) pointed out that if a child’s expression of anger or affection-seeking is constantly punished this will generate anxiety and fear of punishment. Thus the inner stimuli/feelings of anger or affection-seeking will be associated with fear, until the arousal of anger or affection-seeking automatically elicits a conditioned fear/anxiety response. In this context the child may gradually become unaware of feelings of anger or affection-seeking, in the context where these could be useful. Instead they are only aware of the secondary conditioned anxiety to stimuli, and not anger feelings or affection-seeking. This can have serious consequences for the child’s abilities to recognise certain emotions and mature them in helpful ways. Consider Jane, who saw her mother as powerful, critical but also “always right/clever”. Jane idealised her and relied on her for help. Jane felt that she herself was physically unattractive. Jane was able to recall how her mother would often tell that she had an awkward body, and that “everything you wear looks like a rag on you”. Although these “put downs” were clearly a source of shame (and she internalised these judgements), Jane was at first unaware and then very fearful of acknowledging anger to her mother for shaming her, or that her mother could be wrong. To begin to consider these alternative possibilities can be intensely threatening, especially if “the other” is more powerful and can inflict harm on us for rebellion or defiance (Gilbert & Irons, 2005). Her healing of shame emerged with seeing her mother as not always right, acknowledging and processing her anger at her mother, fear of the mother’s counter-attack or punishment (like a dominant on a subordinate), letting go of her dependency, and learning to cope with the changed dynamic of the daughter–mother bond. Healing shame often requires changes in our inner representation of others, processing feared and conditioned emotions, revisiting and working with shame–trauma memories, reducing submissive defences and becoming more able to defend/maintain a sense of self from external and internal (memory-linked) “attacks”. These may be key to alterations in self-evaluations.
Safeness
Some therapists work with threats via processes of desensitisation, reevaluation and negative arousal reduction. Compassionate mind work, however, suggests another important process. Over 30 years ago Bowlby (1969, 1973; Cassidy & Shaver, 1999) noted that a crucial element of parental care is that it provides a safe base for the infant. Not only does access to a parent offer protection, but parent–child interactions can soothe and calm an infant. For an infant to be calmed and feel secure, via interactions with others, implies the evolution of mental mechanisms that are sensitive and responsive to such care-providing behaviours (MacLean, 1985). Hence, what has evolved in mammals, and especially humans, is a social safeness system that is specifically attuned to certain social cues (e.g., touch, voice tone, facial expressions, access to care) from others (Gilbert, 1989, 1993, 2005a). There is now evidence that these signals impact on various and different aspects of mammalian physiological systems (Hofer, 1994). Such cues are not just signals of an absence of threat. We now know that the way the nervous system has evolved is hierarchical and the social safeness system, or what Porges (2001) calls a social engagement system, actually inhibits activity in threat systems, and deactivated fight/flight responses. Moreover, new research has shown that social safeness, which comes through certain types of relationships, is linked to a specific type of positive affect system.
Figure 6.1 Types of affect-regulating system (from Gilbert, 2005a).
This can be clarified by noting the growing evidence that, in addition to a range of threat/stress processing systems, there are at least two different types of positive affect systems, mediated by different physiological systems. Depue & Morrone-Strupinsky (2005) distinguish the appetitive/seeking aspects of motivation, related to dopaminergic systems, and consumatory contentment and soothing aspects related to oxytocin and opiate activity. Different drugs can affect these systems, with (for example) amphetamines tending to increase positive affect associated with drive, but opiate drugs producing a more calm, non-striving and “contented/laid-back” form of positive affect. By way of a simplification we can depict three types of affect-related system as shown in Figure 6.1.
Depue & Morrone-Strupinsky (2005) link the two positive affect systems to types of social behaviour. They distinguish affiliation from agency and sociability. Agency and sociability are linked to control, achievementseeking, social dominance and the (threat focused) avoidance of rejection and isolation. Affiliation and affiliative interactions, however, are linked to feelings of connectedness to others, and have a more calming effect on participants. They can alter pain thresholds, the immune and digestive systems, and they operate via an oxytocin-opiate system. A number of researchers suggest that the beneficial effects of affiliation are mediated via oxytocin (Carter, 1998; Depue & Morrone-Strupinsky, 2005; Uväns-Morberg, 1998). Thus, of special importance for psychotherapy is the safeness-affiliative positive affect system that appears to be linked to a pattern of neuro-hormones (e.g., oxytocin and endorphins) that mediates affiliative and affectionate behaviour and provides a neural basis for soothing, and feeling soothed and safe (Carter, 1998; Depue & Morrone- Strupinsky 2005; Uväns-Morberg, 1998; Wang, 2005). The powerful role of oxytocin in social behaviour and stress regulation evolved in part as the physiological substrate for attachment (Carter, 1998; Uväns-Morberg, 1998). Recent research has shown that oxytocin and social support interact, and both have inhibiting effects on the stress/threat system as measured by cortisol, especially in evaluative and stressful situations (Heinrichs, Baumgartner, Kirschbaum & Ehlert, 2003). So experiences of safeness are not simply via the absence of threat but are conferred and stimulated by others. Moreover, these systems actively inhibit threat based systems and open up new cognitive and emotional processing options that can be incorporated into schemas of self and other (Porges, 2001). New ongoing work in our department suggests that feeling safe and content may differ from feeling relaxed–calm.
For the young child the specific unconditioned signals/stimuli that stimulate the safeness, soothing system include: the care-giving signals of touching, stroking, and holding (Field, 2000), voice tone, the “musicality” of the way a mother speaks to her child, facial expressions, feeding and mutually rewarding interchanges that form the basis for the emergence of an attachment bond (Trevarthen & Aitken, 2001). Depressed mothers who may not directly threaten their infants can nevertheless have detrimental effects on their infant’s maturation because of the relative absence of (positive) forms of communication such as eye gaze, smiling, positive facial expressions, holding, talking to and stroking that stimulate positive affects in the infant, and create experiences of safeness and soothing and exploration/ engagement with the world (Murray & Cooper, 1997). Given the power of non-verbal signals, it is clear why the non-verbal behaviour of the therapist may be important in how safe a patient feels with their therapist. This is especially important as we now know that we monitor the non-verbal behaviour of others both consciously and non-consciously (Decety & Jackson, 2004).
Distinguishing safeness from threat systems is thus very important for psychotherapy because it implies that the warmth a patient may feel emanating from the therapist could stimulate the safeness–oxytocin–opiate system that regulates cortisol and stress experiences (Heinrichs et al., 2003). Under the influence of the safeness-oxytocin-opiate system (which probably also involves the frontal cortex (Schore, 1994, 2001)), stressors may be recoded as “safe”. If this is so then we are not simply lowering threat tone to a stressor (e.g., by repeated exposure) but also attempting to increase activity in the safeness systems. This has clear conditioning implications, especially with working on threatening imagery. For example, it is possible to stimulate compassionate images when having to confront threatening images/memories (Lee, 2005).
Interaction between safeness and threat
There is now general agreement that our threat systems are set up to be oriented to “better safe than sorry”, assume the worst and engage in protective actions (Baumeister, Bratslavsky, Finkenauer & Vohs, 2001; Gilbert, 1989, 1998a). What is required to regulate them is (among other things) development of the frontal and prefrontal cortex (Schore, 1994, 2001). These areas modulate the excitations in the threat systems and are important for coding stimuli as safe. The maturation of these areas is highly influenced by early care and empathic and affectionate interactions (Gerhardt, 2004). Abusive and neglectful parenting has a detrimental impact on the frontal cortex and can over-stimulate the threat system (Perry, Pollard, Blakley, Baker & Vigilante 1995; Rothschild, 2000; Teicher, 2002). These kinds of insights are important because they help us understand that some of what we are doing as psychotherapists is activating and deactivating key physiological systems (Cozolino, 2002; Lee, 2005; Schwarts & Begley, 2002). They are also important because many of the key social competencies that make us a highly sociable being, sensitive to the minds of others and empathic, depend on appropriate maturation and functioning of various structures of the frontal cortex (Decety & Jackson, 2004; Schore, 1994, 2001)
The emergence of the social self
The human mind has evolved a range of complex competencies to be emotionally regulated, cognitively oriented and perceptive to the minds of others. These competencies include abilities to emotionally resonate with, and simulate, the feelings of others, intersubjectivity, theory of mind, and perspective taking (Decety & Jackson, 2004). All these competencies play key roles in the therapeutic relationship.
Emotional resonance
A key component of empathy is to be able to represent the feelings of others in oneself (Decety & Jackson, 2004). Recent research has shown that we can understand the feelings of others because their emotion cues stimulate similar patterns of neuronal firing in ourselves – as if we were experiencing the emotion. One way this occurs has become clear with the discovery of mirror neurons (Borenstein & Ruppin 2005; Brass & Heyes, 2005; Decety & Jackson, 2004). Mirror neurons are neurons that fire when we observe emotional expressions or actions by others. For example, when we watch things happening to others, such as watching a sad or exciting film, we can feel sad or excited ourselves. The anterior insula is an important area of the brain for processing disgust. Wicker, Keysers, Plailly, Royet, Gallese & Rizzolatti (2003) found that observing others experiencing disgust (smelling noxious odours) stimulated the anterior insula in observers. Wicker et al. (2003) and Decety & Chaminade (2003) suggest that this empathic resonance (which mirror neurons facilitate) enables us to understand others by (automatically) simulating internal models of feelings and actions that others are feeling or doing. Based on these new findings of mirror neurons, Preston & de Waal (2002) present the perception action-model of empathic learning with a review of neurophysiological data that shows that signals expressed by one person can directly stimulate corresponding systems in recipients. Presumably empathic resonance can go both ways in therapy. It is the automatic simulation of affect in the mind of a therapist that enables the therapist to tune into and understand the feelings of his/her patients. Equally a patient’s attention to the emotion displays, expressions and voice tones of the therapist can influence the internal simulations of the patient.
Intersubjectivity
This direct capacity for mirroring affect states in others forms the basis for what has been called intersubjectivity. This forms the earliest basis for social communication (Trevarthen & Aitken, 2001). From the first days of life the mental state and motives of a mother (what is going on in her mind) are translated into a range of behaviours such as how she talks/sings; looks at, strokes and holds her infant; stimulates positive affect of affection/joy; and her ability to empathically reflect and resonate with her infant’s feelings and mental states. The infant is innately responsive to these communications (Trevarthen & Aitken, 2001). A mother’s smile may induce the motor programs for smiling in her infant (Decety & Chaminade, 2003). The process by which the mind of the mother is able to influence the mind (and physiological state) of the infant, through a process of empathic resonance, is called “intersubjectivity” (Trevarthen & Aitken, 2001) – that is, intersubjectivity is related to the moment-by-moment co-regulation of participants as they experience the feelings of others directed at them and emerging from the interaction (Gilbert, 2005a; Stern, 2004). These co-regulating “dances” of mother and infant have important effects on the infant’s mind/brain, helping to choreograph the infant’s brain maturation as it forms new neuronal connections at a rate of many thousand a day (Gerhardt, 2004; Schore, 1994; Siegel, 2001). Later, the way others, as socialising agents (especially the primary carer), understand and empathise with the child’s emotions and behaviours has major impacts on the child’s ability to understand and regulate their own emotions, behaviours and personal characteristics. In essence emotions can be coded as safe and manageable (the child has experienced soothing when distressed) or threatening (the child has experienced hostility or withdrawal of love when distressed) (see Ferster (1973) and Gilbert (1992) for a conditioning view). Over time these experiences form the basis for self-processing and self-defining systems (Leahy, 2005; Siegel, 2001). The key point is that social relationships regulate how (internal and external) stimuli are processed by a child and whether they become coded as manageable/safe (coded into the safeness systems) or as threats requiring safety strategies. Clearly, these issues are important in the therapeutic relationship especially for people who, as a result of abuse, may suffer difficulties with their affect regulation systems.
Social cognition
With maturation comes a host of evolved cognitive competencies which are specifically focused on understanding the mind of others and our relation to other minds. These include: theory of mind (Byrne, 1995; Suddendorf & Whitten, 2001); symbolic self–other representations (Sedikides & Skowronski, 1997); mentalisation (Bateman & Fonagy, 2004); metacognition (Bjorklund, 1997; Wells, 2000) and perspective taking (see Decety & Jackson (2004) for a review). These abilities play a crucial role in social interactions and self-regulation (Suddendorf & Whitten, 2001). With theory of mind abilities one can think about the mind of someone else; that is, we understand that minds give rise to agents with intentions, desires and knowledge. Thus we can think about what motivates their behaviour, what they might value, what they know and what they don’t know, whom they may like and why, and we can think how to manipulate them to like us or be wary of us. Whiten (1999) argues that: “Reading others’ minds makes minds deeply social in that those minds interpenetrate each other” (p. 177; emphasis in original).
If theory of mind relates to how we reason and think about the mental states of others, then clearly attributions are important for this ability. Holmes (2005) notes, for example, that some cognitive techniques of reattribution training may have a direct impact on theory of mind abilities. However, the way we make attributions when interacting with sentient beings is different from how we reason when interacting with non-sentient things. Not only can we attribute motives and intentions to sentient beings but we can also derive beliefs about how they judge and think about us. Suppose someone is angry with us. If we just respond to the external behaviour then we might feel attacked and attack back. However, with theory of mind we might think they are attacking us because they feel threatened or are depressed – we go beyond external appearances and may change our behaviour accordingly. The ability to think about and reflect on what is going on in the mind of the other is key to therapy, of course. Lacking this ability to “mentalise” other people’s states of mind may be part of the borderline problem (Bateman & Fonagy, 2004) and may inhibit compassion (Gilbert, 2005a).
However, how we use theory of mind (and how we reason about other people’s mental states and behaviours) can be influenced by our own mental state. Holmes (2005) notes that when we feel stressed or threatened our responses can be more automatic and defensive to the threat rather than reflective on the mind of the other. That is to say, when we are stressed we tend to revert to threat processing and self-defence. One implication of this is that the ability to develop complex reasoning about other people’s minds and not to be automatically on the defensive requires some modicum of feeling safe. Individuals who have had a secure attachment may find theory of mind easier than those who come from abusive backgrounds. Hence, once again we see the importance of threat and safeness interacting with other evolved competencies.
Another implication of this is that if therapists are working with threatening patients (for example, they may feel out of their depth, overwhelmed, burnt out or pressurised to get a quick result) or if (say) they are worried about external persecution if a patient kills themselves or makes sexual advances, this will impact on their therapeutic stance and abilities. Many implications flow from this, including the therapist having good insight into his or her own areas of threat. In addition therapists will need support from others who can convey safeness – a point well understood in dialectical behavior therapy’s (Linehan, 1993) recommendation that therapists need to work in supportive teams when working with complex cases. Thus the issue of threat and safeness impacts on our capacities to use our social cognitive competencies therapeutically. Furthermore, therapeutic relationships should not be decontextualised from the wider social arenas in which therapists operate.
The attracting/attractive self
Social threats either from patients or from external agencies who may judge our work, or our own negative self-evaluations of our abilities, are central to therapeutic safeness. In fact this is linked to a wider issue of why we have evolved some of these complex abilities, to read and be so in tune with the feelings of others. One reason is that we have evolved to be highly dependent on others for our survival and maturation. Over our evolution, unless one could court good relationships and reputations with others, survival, maturation and reproduction would be compromised. In fact there is a long history to the idea that humans are highly motivated to try to create positive feelings and impressions in the eyes of others (Buss, 2003; Gilbert, 1992, 1998b). We want to be cared for by our parents, desired by our lovers, liked by our friends, valued by our bosses and accepted in our groups. So humans have evolved social motivation systems to be valued and wanted by others with mental mechanisms for tracking and estimating the thoughts and feelings that we create in the mind of others, technically called social attention holding power (Gilbert, 1989, 1997, 2003). Experiencing our impact on the mind of the other as positive makes the world safe and increases the chances that we will be able to influence others in our favour. In contrast, experiencing the mind of the other as having hostile or contemptuous feelings and thoughts about us makes the world threatening and sets in motion various defensive strategies – with shame or humiliation being the most common (Gilbert, 1998b). The motive to create positive affects and thoughts in the mind of the other begins from the first days of life (Trevarthen & Aitken, 2001) and textures many subsequent relationships. Shame then is a major social threat because it is an indication that others are potentially rejecting or hostile (Gilbert, 2003).
Meta-representations
Emotional resonance is linked to the way emotion systems (especially those in the limbic system) are stimulated in interactions. The evolution of the frontal cortex in humans, however, has been key to many of our social cognitive competencies such as theory of mind and other aspects of empathy (Decety & Jackson, 2004). Psychopaths, for example, may have intact theory of mind abilities but lack empathic resonance due to disturbance in the limbic system – they are not emotionally affected by others’ distress (Decety & Jackson, 2004). Various aspects of the frontal cortical structures also support abilities to meta-represent self as an object for introspection (Wells, 2000). Symbolic self-awareness comes with language and the ability to symbolise “the self”, to “imagine” the self as an object and to judge and give value to the self; to have self-esteem, to think about the meaning of one’s appearance to others and other implications (Sedikides & Skowronski, 1997). This gives rise to a range of self-conscious emotions such as pride, shame and guilt. Self-identities and self-presentations emerge from both emotional experiences of how others treat the self in certain roles, and our introspective reasoning and thinking about such experiences.
Thus consider early experiences of how a child experiences the emotions of others in an interaction and how these become the foundations for self-beliefs. A positive belief of, “I am a lovable competent person” can be shorthand for, “in my memory systems are many emotionally textured experiences of having elicited positive emotions in others and being treated in a loving way; therefore I am lovable”. Suppose parents often express anger to a child. This child may develop beliefs that others do not see her positively, which is shorthand for, “in my memory systems are emotionally textured experiences of having elicited anger in others and being treated as inadequate - therefore I am vulnerable”. Consider the child who is sexually abused. This can become, “in my memory systems are emotionally textured experiences of fear and disgust ” therefore I am, disgusting and bad”. Tomkins (1987) argued that shame (and other self-conscious emotions) are laid down in memory as scenes and fragments of images of self in relationships. These encoded scenes can then become “mini coordinators” of attention, thinking, feeling and behaviour.
The importance of the internalised safe and soothing other
The importance and power of “how we experience and exist in the mind of the other” has been shown in a number of studies. Both conscious and nonconscious information processing can follow an “if-then” rule based on appraisals of how we exist in the mind of others (Baldwin & Dandeneau, 2005). For example, a rule can be: if others express disapproval then respond with withdrawal or shame/submissive defences. Such automatic rules and safety strategies have been explored in a research programme by Baldwin and colleagues (for reviews see Baldwin & Dandeneau, 2005). In one early study students were asked to generate research ideas and then subliminally primed (outside conscious awareness) with either the approving or the disapproving face of the department professor. Those primed with the disapproving face rated their ideas more unfavourably than those primed with the approval face. Self-evaluation was non-consciously linked to approval/disapproval from another (see Baldwin & Dandeneau, 2005). Once again we see that the reasons people may give for certain types of feelings are not necessarily accurate (Haidt, 2001), and that there is a possible role for mirror neurons in these evaluations.
Consciously priming people with feelings of being cared for also impacts on shame-related processes. For example, Baldwin & Holmes (1987) found that people who were primed with a highly evaluative relationship, and who then failed at a laboratory task, showed depressive and shame-like responses of blaming themselves for their failure and drawing broad negative conclusions about their personality. Conversely, individuals who were instead primed with a warm, supportive relationship were much less upset by the failure and attributed the negative outcome to situational factors rather than personal shortcomings. People can cope better with failures if they have access to a schema of others as warm and supportive.
Kumashiro & Sedikides (2005) gave students a difficult intellectual test. They were then asked to visualise a close-negative, close-neutral, or closepositive relationship. Those who visualised the close-positive relationship had the highest interest in obtaining feedback on the test even when feedback reflected unfavourably on them. Baldwin and his colleagues (see Baldwin & Dandeneau, 2005 for reviews) have demonstrated that a key variable determining self-evaluative styles in certain contexts is the cognitive accessibility of other-to-self (others as critical or reassuring) and self-to-self (self-critical and self-reassuring) schemas. Attachment theorists have also shown that the way people respond to various interpersonal threats (i.e., the degree of anxiety and anger they may feel) is related to internal working models of attachment security (see Baldwin & Dandeneau, 2005; Mikulincer & Shaver, 2005 for reviews). These studies suggest that the degree to which people are able to access warm and supportive (in contrast to condemning and critical) other-to-self and self-to-self-scripts and memories has a central bearing on emotional and social responses to negative, self-defining events, and abilities to cope with (shame-linked) failures. The implications for psychotherapy are clear from this research.
We can take a conditioning approach to threat and soothing systems in relationship to a sense of self. As noted, soothing is stimulated by natural cues (e.g., voice tone, facial expressions, holding), especially for the infant. If an infant is distressed and the parent soothes and calms the infant using these cues, then this affect system will be linked to that of distress and thus offer internal regulators for distress. Memories of being comforted and helped by others will be laid in emotion memory systems ready for use when distress arises. In contrast, if feelings of distress go unanswered or are punished then an internal distress cue can become a conditioned stimulus for fear or the return of feelings of “there is no one there to help or soothe me”. An unanswered question is the degree to which the empathic therapeutic relationship may also be a source for exploring and changing these conditioned responses.
Taking all the above together, we arrive at the view that humans are highly regulated by the minds of others, our abilities to create positive thoughts and feelings in the minds of others, our conscious and nonconscious appraisals of how others see us, and theory of mind. In fact psychotherapy would be a pointless task unless there were ways by which the mind of one person could impact on the mind of another. Although many animals are obviously oriented to social behaviour, and thus coordinate their behaviour for various functions (e.g., reproduction), it is only comparatively recently that we have begun to recognise the multiple, complex processes and mechanisms (for example, social motives to create positive affects in others about the self, empathic resonance, theory of mind, mentalising, meta-representations, non-conscious tracking of others’ feelings about us) that underlie human social behaviour and self-regulation. In the years to come this “science of mind” will have profound implications for psychotherapy, especially with complex cases (Bateman & Fonagy, 2004; Decety & Jackson, 2004).
Role forming: Biosocial goals and social mentalities
There is, of course, far more to human social behaviour than trying to create positive impressions in the minds of others. We do this partly because there are various roles and social tasks to pursue (for example, forming attachments, belonging to groups, mating and caring for offspring). Hence evolution has provided a set of motivating and processing systems, which guide us towards particular kinds of role and relationship. These have been referred to as biosocial goals (Gilbert, 1989, 1995, 2005a). Humans, like other animals, have to be motivated to care for their young, seek out sexual partners, form alliances with other members of the group, avoid being ejected from groups, compete for resources within groups, and so forth.
Social mentalities refer to the information-processing competencies that keep goal-focused behaviours on track (Gilbert 1989, 2005a, 2005b). For example, in the attachment role the young (of many species) need to be able to attend to and process information relevant to the accessibility and availability of the parent (Bowlby, 1969). Threat systems are triggered if information arrives that the parent is (for example) too distant. In a competitive role, however, a different set of information-processing abilities are required, such as social comparison. The same signal, e.g., eye gaze, can have quite different meanings, and automatic effects on threat and safeness systems, according to whether it occurs in the role of love/affection or competition.
As noted elsewhere (Gilbert, 1989) there is no commonly agreed classification of basic social roles, but a brief classification is given in Table 6.1.
The enactment of a social role depends on a number of different psychological processes. For example, there are attentional and motivating systems that direct attention and create interest in different types of stimuli. Thus, for example, care-eliciting and care-giving would not exist unless infants were “interested” in stimuli associated with mother (e.g., face and skin contact), were seeking care, would recognise care when it was available, and would be physiologically responsive to those inputs (Hofer, 1994; Knox, 2003). On the other side of the relationship, care-seeking would be useless unless there were individuals who were motivated to provide care, would have a sense of reward by doing so, and would have various psychological abilities to process the needs of others (Gilbert, 1989, 2005a). This is shown in Table 6.1. Care-giving and care-seeking roles emerge from motivating systems in each participant and information-processing that monitors the exchange of signals and from this constructs self in a specific relationship to another.
For co-operation, individuals must be motivated to be a member of a dyad or group and have a sense of belonging on the basis of similarity, sharing and collaboration. Hence humans are motivated to form alliance-type relationships and to have a sense of belonging and connectedness (Baumeister & Leary, 1995; Gilbert, 1992; Kohut, 1977). Of course, to feel accepted means we have to have a sense that we exist in the mind of the other(s) as acceptable, and thus we feel safe in the body of the group. Hence these experiences provide information on social support and mutuality and give us feelings of safeness with others (Gilbert, 1989, 2005a). For some patients a sense of belonging and connectedness may not have developed, leaving them feeling different from others – as an outsider, isolated and easily threatened. The focus on common humanity (Neff, 2003a, 2003b), and work on validating (Leahy, 2005) and de-shaming (Gilbert & Irons, 2005) can help some patients gain a sense of connection with (being just like) others. Indeed, this may be one of the key therapeutic aspects of group therapy (Bates, 2005).
Competitive behaviour can be used to enhance one’s own standing and position, taking pleasure in success, without necessarily deriving selfevaluative conclusions. However, we can compete to be seen as more likable or desirable than others and thus be chosen for various roles (for example, wanted as a friend or sexual partner). We can feel depressed or anxious when we feel that our competition is going badly; we are not creating sufficiently positive feelings in others about us, and people will not choose in our favour, want to associate with us, or help us (Gilbert, 1992, 2003).
Competition also gives rise to conflicts over resources or interests and individuals will try to defend themselves, advance their own interests, and avoid inferiority and being marginalised, rejected or powerless. Threats to our abilities to exert control in social and other domains can involve more aggressive ways of exerting control. In these contexts we may be less interested in stimulating positive affect in others about the self, and more in stimulating fear or submissive behaviour (Gilbert 1997, 2003). The bully, for example, exerts his/her control by creating wariness in others via aggression or “putting down” others. In psychotherapy, aggression is not an uncommon defence to the experience of threat, and it can be stimulated quickly (because our threat systems are ready to respond to threats) even against people’s conscious wishes. What also matters here is the post-event cognitions; while one person may feel guilt and remorse for having hurt somebody (able to switch to a care-focused mentality), the bully can be pleased they have hurt others, for it offers a sense of safety in their abilities to keep control and defend themselves (Gilbert, 2005c).
The activation of a mentality patterns motivations, emotions and cognitive processes. Hence, for example, in competitive behaviour, and especially if this is between enemies, the sub-components of the care-giving system, which focuses on distress, concern and helping others, are turned off. In care-giving, however, it is the desire to harm others that is turned off and we might feel guilt if we do cause harm. In other words, the activation of a mentality patterns components of our minds, turning on and off different motives, emotions and processing systems. Although this has some similarity to Beck’s (1996) concept of modes, it is also different because social mentality theory is based on innate dispositions for organising the mind in certain ways (Wang, 2005). This is crucial for psychotherapy because it means that we are not just working with modes or schemas but actually with psychobiological patterns and organising principles in the mind.
Another aspect of social mentality theory is that children’s abilities to understand themselves in relationship to others, to have feelings of empathy, concern for others, guilt and shame, to develop theory of mind, take an interest in peer relating and sexuality, are emergent through development; that is to say, they are part of our innate predispositions. Importantly, as the innate abilities for thinking about self and other unfold, motivational systems and social mentalities can blend together so that thoughts and feelings in one mentality (for example, caring) can come to influence those in another (for example, how one competes with others or treats one’s friends). Although sexual motivations are common to humans, one person may treat a sexual partner as an object, there only for their own enjoyment, while another cares for, cherishes and loves their sexual partner. As outlined by Liotti (Chapter 7, this volume) these role-forming processes can emerge within the psychotherapy relationship. The therapist can have an attentive ear to the kinds of relationship that are being co-created (and those avoided) via the awareness of the transference–counter-transference interactions. Some roles may be avoided or excessively engaged (for example, becoming dependent on, or competing with or challenging the therapists). How a therapist attends to, understands, supports, feels threatened by or withdraws from these manoeuvres will impact on the co-creation of roles between them and the mentalities activated in each (see Leahy, Chapter 11, this volume; Liotti, Chapter 7, this volume; Katzow & Safran, Chapter 5, this volume). Cognitive therapists recognise that core beliefs are often important windows on these role-regulating systems.
Some implications of role forming
Focusing on these role-forming systems touches on the social aspects of psychopathology and therapy, which have been prominent in psychodynamic writings (Holmes, 2001) and implied rather than specifically stated in cognitive behavioural therapy (though see Safran, 1998). However, contextualising role-forming in evolutionary and social contexts allows us to consider aspects of our therapeutic interactions, such as transference and counter-transference, within basic social processing models (Marcus & Buffington-Vollum, 2005; Miranda & Andersen, Chapter 4, this volume).
Our social evolution has given rise to biosocial goals and mentalities, bringing with them the fact that we use each other for advancing certain goals and creating states of mind; our survival and reproduction depend on how we engage with others and how others engage with us. If people do not communicate with us we cannot develop language and modes of communication, which will have a major impact on our brain maturation and thinking abilities; without early care we die; without a sexual partner we cannot reproduce; without friends (at least in the evolutionary past) we would not have survived long. The implication of having evolved to be social animals is that we use others to obtain support and as soothing inputs when we are not able to do this for ourselves. Indeed, studies of the neurophysiological mechanisms underpinning relationships show just how powerful relationships are in regulating our physiological states (Cacioppo et al., 2000). We need others to understand our emotions and develop a coherent sense of self (Bateman & Fonagy, 2004; Schore, 1994). Hence the story so far is that one cannot overstate the importance of the experience of the mind of another, in interaction with our own mind. This interaction is central to how our brain develops, and our abilities to understand and cope with our inner worlds of emotions, motivations, desires and fantasies. The mind of the other is key to the process of organising our inner potentials in becoming “a self”.
Compassion-focused therapy and the therapeutic relationships
The above offers some background for a focus on the nature and value of compassion. Compassion is the context for the therapy and self-compassion is one of the key therapeutic tasks for patients who are highly self-critical and shame-prone. Compassion-focused therapy was developed for people who have severe shame and self-attacking problems. These individuals typically come from abusive backgrounds, have disturbed attachment systems, have poorly developed self-soothing abilities and can pick up all sorts of labels, particularly personality disorder. Having worked with people who have these difficulties for some years, what struck me was that they had little ability to be self-soothing, partly because they had few emotional memories of being soothed and validated. Cognitive interventions did not always work for them because although they could learn to do such tasks, they rarely felt soothed or reassured by them. It was as if the positive soothing affect system had atrophied. Indeed, as I began to try to develop their self-soothing and “compassion for the self” when things go wrong, it turned out that many were frightened of such feelings. A feeling of warmth and care from the therapist was alarming, as it was associated with memories of abuse, or of the parent who could be kind one minute but aggressive and withholding the next. Self-compassion and warmth were seen as a weakness, letting oneself off the hook, not deserved, or dangerous because one was letting one’s guard down. Using a conditioning paradigm, I tended to see inner feelings of warmth as associated with affects of anxiety or disgust. The implication is that although we might be able to reduce negative emotions in traditional ways, one should not assume the positive affects will automatically come on line. Moreover, as I have stressed above, the soothing systems evolved as separate systems to regulate threat. Clearly, then, if the soothing systems are not available, this will have a major impact on the internal organisation of psychological processes. Yet if well-being is associated with abilities to access warmth, have emotional memories of others as warm, and turn to others for help (Baldwin, 2005; Masten, 2001) and be self-compassionate (Neff, 2003a, 2003b) then these affect systems need to be directly targeted. Thus, compassion-focused therapy was designed to try to stimulate the safeness–oyxtocin–opiate systems (Gilbert, 2000, 2005a). We are in the process of trying to develop studies to explore this.
In this section I am not going to focus on specific interventions that are designed to stimulate self-compassion (see Gilbert & Irons, 2005), but rather will focus on how the therapist can use an understanding of compassion to think about their own styles and forms of therapeutic engagement, and the co-construction of roles between them and their patient. If the arguments I have put forward so far have any value, then it may be in part via experiencing the mind of the therapist as compassionate (especially in nonverbal modes of communication), which can be internalised by the patient, which begins the road to self-compassion and healing.
What is compassion?
Compassion is a complex multi-faceted process and different therapies have slightly different views of it. There are a range of therapeutic models that articulate what are believed to be key healing ingredients in the therapeutic relationship, such as accurate empathy, positive regard, mirroring, and validation, which can form the basis for compassion (Gilbert, 1989; Kirschenbaum & Jourdan, 2005; Norcross, 2002; Gilbert & Leahy, Chapter 1, this volume). Some therapists, however, have specifically focused on compassion as a therapeutic process. For example, McKay & Fanning (1992), who develop a cognitive-based self-help programme for self-esteem, view compassion as involving understanding, acceptance and forgiveness. Neff (2003a, 2003b), from a social psychology and Buddhist tradition, sees self-focused compassion as consisting of bipolar constructs related to kindness, common humanity and mindfulness. Kindness involves understanding one’s difficulties and being kind and warm in the face of failure or setbacks rather than harshly judgemental and self-critical. Common humanity involves seeing one’s experiences as part of the human condition rather than as personal, isolating and shaming; mindful acceptance involves mindful awareness and acceptance of painful thoughts and feelings rather than over-identifying with them. Neff, Kirkpatrick & Rude (in press) have shown that self-compassion is different from self-esteem and is conducive to many indicators of well-being.
My approach to compassion is rooted in social mentality theory (Gilbert, 1989, 2000, 2005a, 2005b). The compassion model I use suggests that compassionate behaviour evolved out of the care-giving mentality. As such it utilises and patterns a variety of motivational, emotional and cognitive competencies that are care-focused. These are called the compassion circle, given in Figure 6.2.
Care and concern for the well-being of the patient
The evolved origins of compassion are to be found in the evolution of altruism and nurturance (Decety & Jackson, 2004; Gilbert, 1989, 2005a). Altruism makes possible a genuine desire to help others, alleviate suffering and engage with others to foster development and change conducive to their well-being. Fogel, Melson & Mistry (1986) define the core element of care–nurturance as: “the provision of guidance, protection and care for the purpose of fostering developmental change congruent with the expected potential for change of the object of nurturance” (p. 55).
They also suggest that nurturance involves awareness of the need to be nurturing, motivation to nurture, expression of nurturing feelings, understanding what is needed to nurture, and an ability to match nurturing with the feedback from the impact on the other of nurturing. Nurturing, then, needs to be skilfully enacted using various competencies that facilitate caring behaviour. Problems with any of these competencies can interfere with compassion in a (therapeutic) relationship. However, when a patient experiences these processes/motives occurring “in the mind of the therapist” – that is, that the mind of the therapist is oriented towards them in a compassionate way – this may activate the social safeness system. As this system begins to come on line this may create opportunities for new learning and conditioning. This is clearly a research question, but it is obviously important for a patient to “feel safe enough” to engage in painful therapeutic work. Keep in mind, though, that for some patients compassion is frightening and associated with negative beliefs (for example, it is weak, it can’t be trusted, or people are nice to you so they can exploit you).
Figure 6.2 Components of comparison (from Gilbert, 2005a).
Distress sensitivity
This requires micro-skills and refers to how a therapist notices, attends to and processes the patient’s verbal and nonverbal behaviour (Gilbert & Leahy, Chapter 1, this volume). Therapists trained in different schools of therapy will attend their “listening ear” in different ways. Being sensitive to what is going on inside the patient requires the therapist to be skilful in engaging with the patient so that they can tell their stories of their distress, as they understand them. Therapists may hear things that are deeply distressing and patients may be upset in the telling. Therapists can have ways of steering patients away from things that are upsetting (Leahy, Chapter 11, this volume), especially if the patient is upset with the therapist (Dalenberg, 2004). If I feel myself becoming defensive or autocratic, chances are I have stopped hearing the patient, and am less sensitive to their distress, and I have slipped into a competitive, defensive or controlling mentality and style. Therapists need to be internally attentive to this possibility (Bennett-Levy & Thwaites, Chapter 12, this volume). Unresolved or feared issues in the therapist can impact on distress sensitivity. The way the therapist is sensitive to distress (for example, with empathic resonance) while engaging with (say) Socratic questioning, formulation, exposure work or helping resistant patients can be crucial for some patients (Katzow & Safran, Chapter 5, this volume). Therapy with high shame-prone patients, who may “hide” their true feelings from the therapist, cannot be engaged with as a technical or mechanical operation (Leahy, 2005). Shame-prone therapists who easily become defensive may be problematic for shame-prone patients.
Table 6.2 Comparing sympathy and empathy (from Gilbert, 1989)
Sympathy
Sympathy and empathy relate to different processes as depicted in Table 6.2.
Eisenberg’s (1986, 2002) landmark work on the origins of prosocial behaviour drew attention to the fact that research has confounded different emotional constructs related to empathy, sympathy and personal distress. She articulates these as follows.
- The situation in which an individual feels the same emotion as another or understands what is in the mind of another: this is neither self-centred nor other-directed, but rather is true empathy or emotional contagion.
- The responses of one to the distress of the other, which need not match the other but are focused on the well-being of the other. This is labelled sympathy. Sympathy is closely associated with altruism. In social mentality theory it is a key emotion of the care-giving mentality and thus of compassion.
- A self-centred response related to anxiety, worry, shame or guilt rather than sympathy: this is labelled personal distress. Personal distress is related to self-focused threat processing. Therapists who are worried about “doing therapy right”, fearful of some external threat linked to failure (for example, persecution if a patient kills themselves), or who have unresolved feelings in themselves, may suffer personal distress that sets in motion their own self-protection strategies.
In sympathy we are emotionally drawn into the suffering of the other with feelings created in the self. As noted above, mirror neurons may be involved in this process. The accuracy of understanding may be loose, however. The feelings and emotions ignited by sympathy may not always match those of the patient because we bring our own reactions to distress. In extreme cases, the therapist may feel more upset than the patient; this can be especially true for patients who are somewhat dissociated from their emotions. Sympathy moves by the elicitation of feelings within oneself and can be elicited by projection, whereas projection reduces accurate empathy (Gilbert, 1989).
Distress sensitivity and sympathy are often conveyed by the therapist’s non-verbal communication of facial expressions, voice tone, postures, use of language and softness, and other micro-skills. The fact that the patient can experience a therapist as genuinely moved by their stories and distress helps the patient “know” they can have an emotional impact on the mind of the therapist. A non-sympathetic therapist is impassive and the patient may feel they are talking to a potato or a technocrat. This is complex, however. Suppose a patient tells of severe abuse and callousness by her father or husband. The therapist’s emotion might be anger. The patient might see the therapist getting angry (albeit on her behalf ), but stirring this emotion is alarming to the patient (especially if she has been abused) and the therapist is missing sympathy with the feelings of terror and powerlessness. Another patient may see anger on their behalf as a positive. Here the therapist may ponder how the patient ignites feelings in others, tells stories that make others angry on their behalf, and thus may avoid anger and assertion themselves. The point about distress sensitivity, and sympathy with it, is the way it conveys to the patient a feeling that “my therapist feels with me”. This advances feelings of attunement.
There are times in therapy where the emotion exchanged is one of sadness and extreme grief that can move a therapist to tears too. New research suggests that processing sad affect may be key to recovery for some depressions (Rottenberg, Joormann, Brozovich & Gotlib, 2005). Gilbert & Irons (2005) suggested that for some patients, when the soothing affect systems are toned down, people may have problems in processing grief for self. From the therapist’s point of view, however, he/she does not want to dissolve into tears but on the other hand does not want to sit impassively as if the shared moment has no emotional impact on him/her and he/she is indifferent or just technically focused on affect regulation. The way a therapist conveys how they are moved by the patient’s feelings (e.g., sadness) is important. Therapists who have strong beliefs that they must not show emotion to their patients, who feel they must rush in as rescuer, or who themselves struggle with feelings such as grief, may struggle with “allowing” grief as a normal process that they have to simply “be with” and share in a validating way. Grief can be a sign that a patient is beginning to make real inroads into they pain they have felt. Not all grief, however, is helpful, so again the therapist’s skill is to be sensitive to a grief process that is healing rather than one that is not. For example, repeatedly ruminating on one’s sadness may not be helpful.
Distress tolerance
Although compassion is focused on the alleviation of suffering, this does not mean that one rushes in as a rescuer at painful points in the therapy to try to alleviate that distress. This can compromise the other important function of compassion, which is to “foster developmental change in the patient conducive to their well-being”. Exposure of, working with, and learning to accept and tolerate painful emotions or memories and new appraisals and meaning may be crucial to developmental change (Greenberg, Chapter 3, this volume; Pierson & Hayes, Chapter 10, this volume; Swales & Heard, Chapter 9, this volume). Sometimes, in exposure work, the patient will feel worse for a while, and this can be openly discussed as the ability to tolerate discomfort in the service of growth and development (Leahy, 2001, 2005).
Therapists should be cautious of “filling the spaces” during silences because this can be intrusive and dominating and interferes with learning how to tolerate certain emotions and memories. In other words, therapy does require at times spaces and silences for reflection. However, with shame-prone people, who can simply close down, not filling the space can also be unhelpful. This is because the patient has become stuck in a shame-frozen state, feels highly scrutinised by the therapist, concerned with what is expected of them and their own frozen state. Attention has switched from working on a specific emotion or memory to a concern with what is in the mind of the therapist and their social presentation. To work collaboratively means to talk about silences: what they might mean, what is going through the mind of the patient when they occur, when they are useful because they offer space “to be with” and explore one’s feelings, and when they are not because the patient has switched to ruminating about what the therapist is thinking and expecting of them and feeling under shame-linked scrutiny.
The importance of trying to change feelings vs. learning to tolerate and accept them is part of new therapies in dialectical behaviour therapy; acceptance therapy; and mindfulness therapies (Hayes, Follette & Linehan, 2004; Pierson & Hayes, Chapter 10, this volume; Katzow & Safran, Chapter 5, this volume; Swales & Heard, Chapter 9, this volume). The great strength of behaviour therapy has been the importance placed on feelings via exposure and desensitisation. Few cognitive-behavioural therapists would try to treat common anxiety problems without helping people activate anxiety and working with that emotion, and the thoughts and safety behaviours associated with it. Anxiety, however, is only one of a range of emotions that patients may avoid, are fearful of, or are dominated by. Whatever the troublesome emotion might be (e.g., fear, disgust, rage, sexuality) the same issues apply: learning to tolerate and give new meanings to experiences, and reduce safety behaviours.
Empathy
Empathy has long been linked to compassion but has a chequered history in psychotherapy. This is partly because empathy has been used to refer to different things, i.e., a cognitive skill, a feeling state and a personality disposition (Decety & Jackson, 2004; Duan & Hill, 1996; Eisenberg, 1986, 2002; Preston & de Waal, 2002). As noted above, it can be confused with sympathy (see Table 6.2) and has been subject to increasing research in neuroscience. Empathy involves a particular capacity to be emotionally resonant with the other, which may depend on mirror neurons. We are then able to process and think about those feelings that have been stimulated within us. So empathy involves both this emotional communication and abilities to think about our emotions. Emotions that are stimulated in us that frighten us may lead to defensive reactions that are very non-empathic. Also key to empathy is the ability to recognise that what one feels is a simulation, and not to confuse self-feelings with those in others (Decety & Jackson, 2004).
There can also be confusion in the distinctions between genuineness, unconditional positive regard and empathy. Consider two examples from Book (1988, p. 422).
Example 1
A first-year resident, when verbally assaulted by a paranoid client, responded, ‘I’m glad to see you can get your anger out.’ The client hesitated, looked perplexed, and then angrily roared, ‘You bastard! To be so happy that I am this upset!’ When asked about his comment, the resident stated, ‘I was just trying to be empathic.’
In this example the therapist had confused a genuine desire to help and form an empathic bond to help the patient feel safe to express his anger, and empathy.
Example 2
A Holocaust survivor raged against the rudeness to which he felt subjected at work. His Jewish counsellor responded, ‘It really makes me angry when I hear that. What the hell’s the matter with them?’ The client responded, ‘That’s what I’m telling you. They’re all a bunch of butchers.’
In the second example the therapist was responding from his own frame of reference. Book (1988) gives many other examples, including hearing but not really believing that a client can mean what they say, or making subtle alterations in the client’s statement that actually change the meaning. As Decety & Jackson (2004) point out, keeping a distinction between “what self feels” and “what the other feels” is a skill, and leakage is common.
In empathy, one listens and attends to both what is actually said and expressed, and what is not. Therapist empathy is not just about attentive listening but is effortful because the therapist is trying to use his/her own mind to understand the mind of the patient. One may note possible hidden shame and resentment, the fear of loss or the disappointment that lies behind a self-attack (Gilbert & Irons, 2005). As Kohut (1977) points out, a client’s rage can often hide a deep sense of loss, a feeling of being devalued and marginalised. An empathic response helps the client make contact with those feelings behind the anger and their internal self-judgements.
Another misunderstanding of empathy is filling in the blanks or finishing a client’s sentence for him/her. This can be experienced as an intrusion. Instead, the therapist enables the patient to fill in his/her own blanks. Thus, as Book (1988) says, empathy may be understanding what the client is going to say, but being empathic is not saying it. A good measure of empathy is whether or not it enables clients to deepen their understanding and continue with their narrative and exploration.
Agenuine empathic response from the therapist is not necessarily perceived as such by the client, and therefore Miller (1989) refers to the “therapeutic empathic communication process”. This is a multi-stage model involving a therapist’s recognition of the client’s internal experience (via the client’s verbal and non-verbal cues); the sending of signals of recognition; and the client’s ability to recognise and internalise such signals (i.e., I understand, I show you I understand, and you understand that I have understood). Problems may occur at any stage. Empathy is a way of being with, or an “intuneness to”, the patient, not simply a skill to be “brought to bear”. As Margulies (1984) pointed out, empathy requires a “sense of wonder”, openness, and caring interest. Interest alone can appear detached. Caring alone can involve more sympathy and too vigorous an effort to “get the patient better”.
Another aspect of compassionate empathy is being able to view each other and ourselves as all part of a common humanity (Neff, 2003a, 2003b). As such we all inherit a set of genes (many of which we share with other species), we are born with a set of motives and needs that unfold with maturation (for example, for attachment and affection, group belonging, and to find sexual partners and reproduce). We can understand each other precisely because we are all the same. If children were not able to assume that others think and feel much as they do, if we could not make assumptions about how the minds of others work, then everyone would appear unfathomable aliens (Nickerson, 1999). Without commonalities we could never have a psychological or biological science because everyone would be so individually different as to make the project pointless. Individual differences and variation matter of course, but not so much as to make us total strangers to each other. Indeed, psychotherapy begins from this position, that we are all the same, with more or less the same needs, emotions and vulnerabilities to suffering, but by virtue of (small) genetic variations, and life histories that shape us, these become patterned and choreographed in different ways. As therapists, then, we seek to explore the patterning and choreographies of our common human nature that give rise to different patterns of suffering. A compassion-focused therapy begins with the notion of our common humanity that sets us on a journey to explore these commonalties and archetypal roots to our “being in the world”. Compassion-focused therapy is thus science-based, requiring knowledge of how the mind works, the processes underpinning altruistic motives, and competencies such as theory of mind and empathy. It is not just about being warm, kind or having positive regard – important as these are.
Non-judgement
This involves suspending one’s own immediate reactions to what a patient is saying or doing. This can be tricky for some cognitive therapists, who may believe that they have to help people spot cognitive distortions. Unfortunately, the term “distortion” itself implies a judgement that can easily be heard by a patient as “I have got my thinking wrong”. Shame-prone patients can be very black and white in their thinking and easily slip into such thoughts. Judgements can also interfere with “being-in-the-moment” and learning acceptance (Katzow & Safran, Chapter 5, this volume). For this reason, in compassion-focused therapy, we try to avoid the language of “cognitive distortion” or “maladaptive schemas” or even (more recently) “negative thoughts”, but focus on depressive thoughts, anxious thoughts, “understandable safety strategies” and “better safe than sorry thinking”. These more typically reflect actual processes in the brain. Moreover, patients find it easier to work with their thoughts and feelings once they construe them as threat-focused and the way our threat systems are just trying protect us, by accentuating warnings and worrying about catastrophes. As one recent patient noted, once I had helped construe his anxiety as an over-enthusiastic warning system that had been conditioned early in life (rather than as a distortion), he felt better able to be compassionate with the feelings of his own anxiety.
Salkovskis (1996) makes this point clear when he says that the aim of cognitive behavioural therapy:
is not to persuade persons that their current way of looking at the situation is wrong, irrational, or too negative; instead it is to allow them to identify where they have become stuck in their way of thinking and allow them to discover other ways of looking at their situation.
(p. 49; emphasis in original)
The therapeutic relationship is an important vehicle for this learning because the therapist pulls the patient into their own way of thinking; that is, the patient is pulled into how they exist in the mind of the therapist, the compassionate validating experiences that are occurring in the mind of the therapist and the beliefs of the therapist. Ideally the patient is able to begin to take the perspective of the therapist and see and judge himself or herself with the same compassion that the therapist has for him/her. These experiences make it more likely that the patient will move into those feared areas they have avoided, and openly consider alternatives because they believe that the therapist genuinely believes in those alternatives.
The importance of warmth
All these qualities of compassion are not segregated and isolated but flow and blend together in the mind of the therapist, and ideally they are infused with a quality that is often called warmth. Warmth is a difficult quality to define and is often associated with empathy, but is not empathy itself. For example, a sales person may appear “empathic” to a degree and know how to stimulate your interest and address your anxieties about a product (i.e., he/she is using theory of mind), but this is not necessarily with warmth and concern for you. The worst torturer to have is one who has some theory of mind abilities to the extent they can work out how best to hurt and frighten you. The non-theory of mind torturer puts the gun to your head; the theory of mind one puts the gun to the head of your child or spouse (Gilbert, 1989). So a patient may feel their therapist is understanding them and can see things from their point of view, but if this is not associated with warmth and a feeling of being cared for, it can also be experienced as deeply threatening. In work with a colleague (Sophie Mayhew) we have found that some paranoid patients may be frightened of being empathically understood if they believe that this could be used against them or they will reveal feared secrets. Warmth can be problematic because it implies closeness, and closeness can be experienced as a threat.
So warmth relates to a type of softness and gentleness that conveys caring concern, although not at the expense of avoiding the painful. It is related to affectionate relating, but is not affection as such. It is a quality that we intuitively sense when we encounter it, usually from a person’s non-verbal communication and manner. The key element of warmth in my view is that it provides stimuli that are coded as safe, and it activates, and is recognised by, the soothing system as safe. Lightness, gentleness, humour, containment, non-verbal cues (such as voice tone and facial expressions, pacing) and styles of using language in self-expression may be key to it. Bedics, Henry & Atkins (2005) found that therapist warmth had an impact on reducing hostility and submissive behaviour and increased patient affiliative behaviour. Warmth may activate a patient’s care-focused social mentality. Because a social mentality patterns and choreographs different elements of our minds, as this mentality is activated it may help reorganise various sub-components of our minds that can ripple through the whole psychological system (Gilbert & Irons, 2005; Wang, 2005).
Putting the elements together
Cognitive behavioural therapies have developed a range of ways of engaging in therapy that vary significantly from some psychoanalytic traditions. These include forms of exploration called Socratic questioning, inference changing and guided discovery; ways to directly educate and train patients in how they can attend and evaluate internal and external stimuli in new ways; progressive exposure and behavioural experiments. More recently, processes of imagery, affect tolerance, grieving, mindfulness and meditation have been incorporated into the therapy. Where possible, cognitive behavioural therapists act like personal trainers, collaborating with their patients to engage in certain tasks to achieve certain goals that are conducive to healing and well-being. Recently there have been efforts to design psychological therapies to target specific neurophysiological systems and functions (Cozolino, 2002; Gilbert & Irons, 2005, Schwartz & Begley, 2002). The more the patient understands and collaborates in designing the steps for change, the more involved (and less threatened) they are likely to be. However, these are not technologies to be brought to bear relatively regardless of the quality of the therapeutic relationship. A poor relationship may lead to drop-out, concealment, avoidance, poor collaboration or submissive compliance; we are not thought mechanics (Leahy, 2005).
For over two thousand years Buddhism has suggested that all beings seek to reduce suffering. Our patients are struggling the best way they can to survive or cope with great distress and we remain deeply respectful of that. We focus on the suffering of a person and their desire to find their way through the evolved and constructed complexities of mind, in their search for well-being, not just their diagnosis. Finally we can address the question that was posed earlier: how can the mind of one person have such an impact on the mind of another? There is one reason only – that we have evolved minds that are highly sensitive to the relationships in which they are embedded. This is shown in our needs for attachment, for protection and nurturance, to our need for other minds to help our own mind mature. So important is our social embeddness that evolution has given rise to a range of abilities to understand other minds and be significantly influenced by them. It is against this backdrop of evolved design that psychotherapists can work in the way they do – to use their mind to heal and help the minds of their patients. In this context the compassion in the mind of the therapist may be a key healing process.
Conclusion
This chapter has tried to contextualise the therapeutic relationship within an evolutionary and social context. Of special interest to the psychotherapist is how the mind of one person can have an impact on the mind of another. It turns out that there is an extraordinarily complex psychology underpinning these interactional processes. For example, there are a range of detection/response systems for threats (fast and slow) and these can be contrasted with affect-processing systems for cues, signalling and safeness. The safeness system seems to have evolved in complex ways with the evolution of attachment and social affiliation, exerting inhibitory control over threat and defence system processing. Our minds therefore are extraordinarily sensitive to the emotions and images we are creating in the minds of those around us, and mirror neurons play a key role in this.
Humans are also goal-seeking and relationship-creating. Within this context, caring and being cared for have played a major role in our evolution and may well underpin mechanisms for compassion. Understanding the processing systems involved in compassion, and the experience of receiving compassion, and developing self-compassion, may point to new ways of understanding the therapeutic relationship and its potential to operate as a healing process. Cognitive behavioural therapy, no less than any other therapy, is highly invested in trying to ensure that the processes that facilitate people’s ability to overcome their difficulties (for example, expose themselves to the feared and develop new ways of thinking) are adopted by patients. Teachers, coaches, mentors and therapists who engage in their crafts compassionately may be more likely to form collaborative relationships that increase the chances that patients will adopt healing practices and walk the sometimes difficult road of change.
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