Compassion Focused Therapy (CFT) is a form of psychological therapy developed by Paul Gilbert for people struggling with mental health problems characterized by shame, self-attack, and self-blame. It was developed for clients who might respond to CBT interventions with “I know it but I don’t feel it”, commonly termed ‘head-heart lag’ (Lee, 2004; Stott, 2007). Situated within the family of cognitive and behavioral psychotherapies, Compassion Focused Therapy has been described as one of the ‘third wave’ therapies, alongside Dialectical Behavior Therapy (DBT) and Acceptance and Commitment Therapy (ACT). Some of its philosophical roots differ from other CBT therapies. Like DBT and ACT, it incorporates ideas from Buddhist philosophy. CFT is also built upon foundations of evolutionary psychology, developmental psychology, attachment, and neuroscience.
CFT defines compassion as “a sensitivity to the suffering of self and others (and the causes of that suffering) with a deep commitment to relieve it, prevent it from returning, and promote wellbeing.” (Dale-Hewitt & Irons, 2015). There are two important components to this definition:
- Sensitivity to suffering. To respond compassionately, first you must be sensitive enough to detect suffering to which compassion is an appropriate response.
- A motivation to relieve it. Compassion can be thought of as a ‘mind set’ or an intention in which one is motivated to relieve suffering.
Within CFT, two methods are commonly used for understanding a client’s difficulties, described in detail in Dale-Hewitt & Irons (2015). One of the most common approaches is the ‘three systems’ conceptualization which illustrates an individual’s ‘threat’, ‘drive’, and ‘soothing-affiliative’ systems, and describes difficulties in terms of the function and relative balance of these systems. In some ways this can be considered a cross-sectional type formulation since it easily facilitates description of moment-by-moment shifts in an individual’s internal state. A historical discussion of the ‘training’ and sensitization of an individual’s three systems can bring a longitudinal understanding, but this formulation is often used in a here-and-now sense.
Another type of case conceptualization in CFT is a threat-focused formulation. This method takes a longitudinal approach, and links historical difficulties to current fears and safety strategies. This type of CFT formulation is designed to help clients to understand how their personal history has sensitized (or ‘trained’) their threat system (i.e. what they have learned to fear). It is also used to elaborate safety strategies used to manage these fears, and to explore unintended consequences of these strategies. A crucial final step is to explore the impact these unintended consequences have upon self-to-self relationships: CFT understands that particular types of relationships (e.g. self-critical, harsh, punishing) can create vicious cycle’s whereby current fears and threats are magnified. Published examples of this formulation can be seen in Gilbert & Procter (2006), Gilbert (2007: elaboration and instructions published on the Compassionate Mind website), Dale-Hewitt & Irons (2015: Formulation In Action) and Experiencing CFT From the Inside Out (2018).
This CFT Compassion Formulation worksheet is designed to help clients and therapists come to a compassion-informed and de-shaming understanding of their life and experiences. The language and prompts within this document have been chosen quite deliberately so that it is understandable by clients. Nevertheless, clinicians are advised to familiarize themselves thoroughly with CFT approach.
“One way of trying to understand what has happened to you, and how it has affected you, is to write them. I wonder if we could explore some of your experiences, fears, and coping strategies see what kind of pattern they follow?”
- Historical influences. Start by exploring key experiences and emotional memories. Dale-Hewitt & Irons (2015) note that “CFT conceptualizes emotion in terms of three basic systems [threat, drive, and affiliative-soothing], and thus, when assessing historical influences, we are keen to look out for the type of experiences that might have sensitized these, and try to understand how these systems have ‘learned’, developed, and express themselves”. As well as gathering information, discussion of historical influences is an opportunity for the therapist to bring a compassionate understanding to the client’s experiences. It can be helpful to review their experiences in the light of fundamental CFT concepts (e.g. tricky brains, flow of life, old brain new brain loops, three systems). The questions below are guides, but you can draw on information you have gathered during the assessment.
- Can you tell me about some of your most important experiences that have affected you or shaped your life?
- Growing up, what were your relationships like with your parents / siblings / wider family / friends?
- Have you had any experiences in your life of feeling like you didn’t matter (e.g. in your family, at work, intimate relationships)?
- Can you tell me about any experiences you had of feeling threatened, rejected, criticized, or blamed (e.g. bullying, not fitting in at school or work, being hurt)?
- Fears & threats. Our fears & threats are sensitized by our early experiences. CFT understands that many of our fears and threats “involve archetypal concerns linked to rejection, abandonment, isolation, shame, and harm” (Gilbert, 2010). An interesting component of the CFT formulation is that a distinction is drawn between external and internal threats. External threats are concerns about what other people might think of us, feel about us, or do to us (e.g. think we are bad, be disgusted by us, reject us, harm us). Internal threats are concerns about: how we think of ourselves (e.g. I’m unworthy), our emotions (e.g. I can’t cope, If I get angry I’ll lose control), memories (e.g. worry about what our unwanted memories mean), or concerns about feeling lonely or disconnected from others. Questions to explore fears and threats might include:
- What do you fear that others think of you?
- What do you fear that other people might do to you?
- Living in this world, what are you afraid of?
- What do you think other people would think of you if they really knew what had happened to you?
- What are your concerns about yourself?
- What are your fears about yourself? (e.g. I’m worthless, I’m not good enough)
- Are there any emotions, memories, or experiences you have that you struggle with?
- Safety strategies. We all actively try to cope with the world around us, and try to manage our own internal experiences. CFT understands that:
- These strategies are intended to regulate our threat system. They are attempts to ‘keep safe’. Strategies might differ according to whether we are trying to manage internal or external threats.
- We have evolved (pre-programmed) ways of responding to perceived threats (e.g. freeze, appease, fight or flight).
- We also have temperamental ways of responding (e.g. some people are more prone to approach, others to avoid).
- The strategies we use are shaped by our experiences and may have become habitual (e.g. learned helplessness – people who have experienced a lot of attack may have ‘learned’ not to speak up; appeasing – some people may have learned to appease in order to manage threats from others).
- Strategies might be learned during childhood or adolescence and become reinforced over time (e.g. “It’s understandable that you learned to behave that way – in the context that behavior developed it made a lot of sense. Now you’re not in that situation we can see whether it’s still a strategy that is helping you”).
Questions to explore safety strategies might include:
- What do you do to cope when your fears are triggered (e.g. avoid, seek reassurance, become defensive)?
- What do you do when you’re face to face with your fears?
- What do you do to protect yourself from the world, and other people?
- What do you do to protect yourself from your own thoughts, feelings, and memories?
- Unintended consequences. Safety strategies are an attempt to keep oneself safe. All actions have consequences, and this section of the formulation is designed to help clients reflect on the unintended consequences of their actions. The language of of ‘unintended consequences’ is intentionally de-shaming. It is helpful to encourage clients to reflect widely upon the effects of their safety strategies on their lives, relationships, confidence, and feelings. Clients can be helped to distinguish between external and internal effects. Helpful questions to explore unintended consequences include:
- The intended consequences of acting in that way are for you to feel safe, but are there any undesirable consequences?
- What happens you do that?
- What’s the impact of acting in that way on your relationships / how you feel / your life?
- What’s the downside of acting in that way?
- My relationship with myself. A critical concept in CFT is the ‘three circles’ model of emotional regulation systems. These are threat-protection, drive, and affiliative-soothing. If an individual’s affiliative-soothing system is underdeveloped for any reason they are likely to have a limited repertoire of strategies for managing their emotions: in the absence of a well-developed soothing system one’s relationship with oneself is more likely to be harsh or critical. In order to be able to feel different people need to be able to access different mindsets/systems. Therefore, an important goal of compassionate mind training is to build an individual’s capacity for affiliative thoughts, feelings, motivations, and behaviors. A key characteristic of the CFT compassion formulation is the focus on the self-to-self relationship. In the absence of a well-developed soothing system, unintended consequences of safety strategies are often met with harsh self-criticism which further exacerbates one’s key fears and threats. It is helpful to explore this in detail with clients.
- What kinds of things do you say to yourself?
- What tone of voice are these things said in?
- Does this tone remind you of anyone?
- What is your motivation of speaking to yourself in that way? Does it have that effect (e.g. to get things done, not be lazy)?
- Where did you learn to speak to yourself like that?
- Would you speak to someone else like that?
- How does it make you feel when you speak to yourself like that?
- Next steps. Clients are helped to develop a compassionate understanding of their history, fears, actions, and consequences. Next steps within CFT can include:
- Exploring what compassion is and why it is needed.
- Dispelling myths about compassion.
- Exploring fears and blocks to compassion.
- Compassionate mind training exercises.
- Dale-Hewitt, V., & Irons, C. (2015). Compassion Focused Therapy. In D. L. Dawson, N. G. Moghaddam (Eds) Formulation in Action, 161.
- Gilbert, P. (2009). The compassionate mind: a new approach to the challenges of life. London: Constable & Robinson.
- Gilbert, P., & Procter, S. (2006). Compassionate mind training for people with high shame and self‐criticism: Overview and pilot study of a group therapy approach. Clinical Psychology & Psychotherapy, 13(6), 353-379.
- Lee, D. A. (2004). The perfect nurturer. In Compassion: Conceptualisations, Research and Use in Psychotherapy, 326.
- Stott, R. (2007). When head and heart do not agree: a theoretical and clinical analysis of rational-emotional dissociation (RED) in cognitive therapy. Journal of Cognitive Psychotherapy, 21(1), 37-50.