K. Boersma (&) A. Håkanson E. Salomonsson. I. Johansson. Introduction

Transcription

1 J Contemp Psychother (5) 5:89 98 DOI.7/s ORIGINAL PAPER Compassion Focused Therapy to Counteract Shame, Self-Criticism and Isolation. A Replicated Single Case Experimental Study for Individuals With Social Anxiety K. Boersma A. Håkanson E. Salomonsson I. Johansson Published online: 6 November Ó Springer Science+Business Media New York Abstract Most forms of psychological distress encompass both the relation to the self in the form of shame and self-criticism, as well as the relation to others in the form of distance and isolation. These are often longstanding and pervasive problems that permeate a wide range of psychological disorders and are difficult to treat. This paper focuses on how problems with shame and self-criticism can be addressed using compassion focused therapy (CFT). In a pilot study we tested the effectiveness of CFT with a single case experimental design in six individuals suffering from social anxiety. The aim was to establish whether CFT lead to increases in self-compassion, and reductions in shame, self-criticism and social anxiety. Moreover, the aim was to investigate to what extent participants were satisfied and experienced CFT as helpful in coping with social anxiety and in increasing self-compassion. Taken together the preliminary results show that CFT is a promising approach. CFT was effective for of 6 participants, probably effective for of 6 and more questionably effective for of 6 participants. These results add to the empirical evidence that CFT is a promising approach to address problems with self-compassion. This research body is as of yet small, and more studies are needed. Keywords Compassion focused therapy Self-criticism Shame Social anxiety K. Boersma (&) A. Håkanson E. Salomonsson I. Johansson Department of Law, Psychology and Social Work, Örebro University, Örebro, Sweden katja.boersma@oru.se Introduction Most forms of psychological distress encompass both the relation to the self in the form of shame and self-criticism, as well as the relation to others in the form of distance and isolation. Shame is a painful self-conscious affect associated with the perception of having a personal attribute, characteristic or behavior that others find unattractive or undesirable and that may result in rejection or being put down (Gilbert 998). Included in a shameful experience are oftentimes self-critical and self-attacking cognitions (Gilbert and Miles ). These cognitions are an important target for intervention as they trigger, perpetuate and intensify emotional reactivity. For example, Longe et al. () compared the neuronal correlates of self-criticism and self-reassurance using fmri and showed that selfcritical thinking engaged brain regions signaling greater error processing and behavioral inhibition. Self-reassurance on the other hand, engaged brain regions similar to expressing compassion and empathy towards others. Indeed, compassion and empathy towards the self could be seen as the antidote of self-criticism and shame and it appears that highly self-critical individuals have a very hard time mobilizing self-compassion. For example, there are indications that highly self-critical individuals have difficulties attenuating their physiological reactivity through compassionate self-soothing (Rockliff et al. 8). In this study, practicing self-soothing imagery was generally related to increased heart rate variability and decreased cortisol levels, but this was not the case for those with high levels of self-criticism and low levels of social safeness. Moreover, several treatment studies show that high pretreatment levels of self-criticism in general predict worse treatment outcome (Cox et al. ; Marshall et al. 8). These results indicate that self-criticism is hard to change

2 9 J Contemp Psychother (5) 5:89 98 and that the mere (self) instruction to be more self-reassuring and empathetic may not suffice for those who are chronically self-critical. Over and above the direct pathogenic effect that self-criticism has in firing up the threat system, it seems that self-critical individuals may be unable to access and generate self-directed warmth and soothing. This means that psychological interventions should not only focus on decreasing self-criticism but also on helping self-critical individuals access and build positive emotional experiences in the form of warmth, soothing and selfreassurance. The concept of self-compassion has received increasing clinical and scientific interest. While there are several definitions, one of the most commonly cited is Neff s definition (Neff ), describing self-compassion as being kind and understanding towards oneself in instances of pain or failure rather than being harshly self-critical; perceiving one s experience as part of the larger human experience rather than seeing them as shameful and isolating failures and holding painful thoughts and feelings in mindful awareness rather than over identifying with them. These concepts draw largely on Buddhism, but are, in many ways, also related to humanistic psychology themes stressing the importance of self-acceptance and self-kindness (Barnard & Curry, ). However, the concept of self-compassion can be said to stretch beyond just self-acceptance and selfkindness to incorporate a sense of inter-connectedness to humanity at large, equanimity, as well as hope and meaning in the face of life s difficulties (Neff et al. 7). Several-related-treatment approaches have been developed recently, as a means to specifically and directly target compassion (see Singer and Botz ). These therapies share in many ways the strengths of mindfulness oriented therapies such as Acceptance and Commitment Therapy, Dialectical Behavior Therapy and Mindfulness Based Stress Reduction (Barnard and Curry ), but stand out in their explicit focus on increasing compassion. One of these, Compassion Focused Therapy (CFT; also referred to as Compassionate Mind Training (CMT)) focuses on developing a warm, compassionate and accepting attitude towards the self and others in order to specifically counteract shame, self-criticism and isolation (Gilbert ). While originally designed and tested for pervasive problems with self-criticism in chronically depressed patients (Gilbert and Procter 6), CFT has been extended to conceptualize problems with shame and self-criticism in populations with for example eating disorder, psychosis and social anxiety disorder (e.g. Gale et al. ; Gumley et al. ; Werner et al. ). CFT integrates influences from cognitive behavioral theories, affective neuroscience, Buddhism, attachment theory and evolution theory (Gilbert ). It combines thorough psycho education on human (emotional) functioning and the brain from an evolutionary perspective with specific cognitive, behavioral, mindfulness and compassion focused imagery exercises that foster self-care in the form of compassion for self and for others. The aim of CFT is to, through these efforts, increase empathy and sympathy for one s own distress, increase mindful awareness without judgment or blame, increase the ability to refocus and activate safety-signaling processing systems, generate compassionate feeling (warmth and affiliation) and increase compassionate attention, thinking and behavior. While CFT has been extensively described only a few, small, empirical studies have been published (e.g. Gilbert and Procter 6; Laithwaite et al. 9; Judge et al. ; Lucre and Corten ; Gale et al. ). The results of these studies are promising but there is a need to replicate and extend these results to other populations and settings. For example, no empirical data has yet been published on the effectiveness of CFT on social anxiety disorder, although reports and accounts have been made of it being used clinically (Henderson ). Yet, CFT might be an especially suited treatment for social anxiety disorder given its large shame and self-criticism component. For example, Cox et al. () showed that self-criticism was robustly associated with social phobia in a large general population mental health survey. Moreover, Gilbert () points out the great overlap between social anxiety and shame problems in that both can be viewed as submissive strategies in contexts where people feel vulnerable to loss of social standing, attractiveness, rejection and/or criticism. Indeed, this study showed that there is a strong association between social anxiety and shame. In addition, there is evidence that people with social anxiety have problems with self-compassion. For example, Werner et al. () studied selfcompassion in a clinical sample of individuals diagnosed with social anxiety disorder. The results showed that individuals with social anxiety disorder had significantly lower levels of self-compassion than healthy controls and that low self-compassion was associated with greater fear for both negative and positive evaluation. Thus, the large self-criticism component and the low level of self-compassion suggest that targeting self-compassion may be particularly important in individuals with disorders that include problems with social anxiety. Therefore, as a pilot study, we aimed to investigate the effect of CFT on self-compassion, shame and self-criticism in individuals with social anxiety. As the application of this treatment in this population is a largely unexplored area, we make use of a replicated single case experimental design (Kazdin ). While this design provides the opportunity to draw valid inferences of treatment effectiveness, the requirement to collect data on large and homogeneous groups is circumvented. Thus, this type of design is well suited to test initial feasibility and get a

3 J Contemp Psychother (5) 5: preliminary indication on effectiveness. Specifically, this pilot study aims to answer the following questions: Does CFT lead to an increase in self-compassion, and reductions in shame, self-criticism and social anxiety? To what extent are participants satisfied and experience the treatment as helpful? Methods Design and Analyses A replicated single case experimental design was used with weekly repeated measurement during a three-week baseline period and an eight-to-nine week treatment period. Using the baseline as a benchmark, 6 participants function as their own control and the primary analysis is a comparison of daily diary data during the baseline and subsequent treatment phase. This analysis is complemented with analysis of change of scores on standardized measures from baseline to post treatment, and a short term ( week) follow up. Participants and Procedure Participants were recruited through advertisements posted on bulletin boards throughout campus as well as on a student internet forum. Inclusion criteria were experiencing social anxiety (operationalized as fulfilling the DSM-IV criteria for social phobia according to the Social Phobia Screening Questionnaire (SPSQ; Furmark et al. 999) and being a university student. To prevent inclusion of individuals in need of specialist psychological care, persons with serious depressive symptoms (operationalized as [7 points and/or [ on question on suicidal ideation of the Montgomery Asberg Depression Rating Scale (MADRS-S; Svanborg and Åsberg 99), substance abuse and serious mental disorder were excluded from participation. Furthermore, participants could not be in currently ongoing psychological treatment or recently (last months) having initiated psychopharmacological treatment. After screening and assessment six persons could be offered participation in the project. The 6 participants (5 females and male; age range ) had studied 5 semesters (median =.5). All reported that they experienced social anxiety and shyness more or less throughout their whole life, and all fulfilled the DSM-IV criteria for social phobia according to the SPSQ. One participant (P6) completed three of the eight sessions (8 %) and then chose to discontinue. The reported cause was lack of motivation and time. However, this participant consented to remain in data analysis and fill out post measurement. Intervention The intervention consisted of eight, weekly, individual sessions of h. The content of the intervention was inspired by the book Compassionate-Mind Guide to Building Social Confidence (Henderson ) and similar self-help books (Tirch ; Goss ) that are based on compassion-focused therapy as described by Paul Gilbert (see Gilbert and Procter 6; Gilbert, ). A main adaptation consisted of transforming self-help format of Henderson () to a face-to-face therapy format. Furthermore, somewhat more explicit focus was put on addressing safety behaviors and avoidance (using valuing and guiding principles of self-validation, acceptance, valued direction and compassion from respectively ACT and DBT). Details of the content of the protocol are presented in Appendix. Each session contained psycho education and Socratic dialogue around a theme, in session training relating this theme to the participant s own situation, and in-session experiential mindfulness and imagery exercises focused on compassion. Participants were given a written psycho education, information about common obstacles that may arise during homework assignments, a training dairy and instructions for homework assignments after each session. In the training diary, participants were asked to fill in how much they practiced each of the exercises during the week in between sessions. If participants encountered problems related to training during the week, they were able to contact their therapist by or read the document on Common barriers that they brought with them from the sessions. Therapists were two psychology students who were in their final part of their professional clinical training program. They received weekly supervision of a licensed psychotherapist and followed a manual. Audio files with meditation and imagery exercises were included in the training program and were sent to participants by in concurrence with each session. Measures The Social Phobia Screening Questionnaire (SPSQ; Furmark et al. 999) was used to screen for social anxiety. The SPSQ can be used to get an indication of social phobia against the criteria in DSM-IV. While formal diagnosis was not part of this study, the SPSQ was used to benchmark the level of difficulties that participants experience and whether they could be judged to belong to a clinical population or not from pre to post measurement. The SPSQ is reported to have high concurrent validity (r =.79 with SIAS) as well as internal consistency (a =.9) (Furmark et al. 999). The Self-Compassion Scale (SCS; Neff ) was used to measure self-compassion. The measure contains 6

4 9 J Contemp Psychother (5) 5:89 98 items that are scored on a five-point Likert scale ( = almost never to 5 = almost always ; range 6 6). While the scale can be divided into 5 subscales, this study uses the total score on the scale. In accordance with the original article, mean scores on each of the subscales were added to form a total score. SCS has been shown to have good psychometric properties (Neff ). The Social Interaction Anxiety Scale (Mattick and Clarke 998) was used to measure the degree of anxiety experiences in social interactions. SIAS contains items that are scored on a five-point Likert scale ( = strongly disagree to = agree ; range 8). The internal consistency of the SIAS (a =.9) and comparisons between SIAS and several other instruments that measure social anxiety have shown medium to high correlations and good validity (Mattick and Clarke 998). The Mongomery Asberg Depression Rating Scale (MADRS-S; Svanborg and Åsberg 99) was used to screen for the degree of depressive symptoms where potential participants with severe depression and/or suicidal ideation were excluded (see participants and procedure ). Depression scores of the 6 participants ranged from to 9 (signifying slight to mild depression). The MADR-S was not used for further assessment of treatment effect. A treatment evaluation at the end of treatment period was used to assess treatment satisfaction. Three questions were asked: How satisfied are you with treatment? (scoring alternatives: very dissatisfied, quite dissatisfied, neither satisfied, nor dissatisfied, quite satisfied, very satisfied ); To what degree do you consider you have improved your ability to cope with discomfort in social situations? and To what degree do you consider you have improved your ability to be self-compassionate? (scoring alternatives for both questions: not at all, a little, somewhat, a lot, very much ). A weekly diary was used to establish a baseline and to track the process of participants change in shame (a composite of How often have you felt ashamed of something you thought, said or did? and How discomforting have these feelings of shame been? ), self-criticism (a composite of How often have you felt you failed or thought you failed? ; How often did you become angry frustrated/disappointed with yourself when you felt you failed or felt you did not meet the standard you set for yourself? and How discomforting has it been to get angry/frustrated/disappointed with yourself and have selfcritical thoughts and feelings? ) and self-compassion (a composite of As I experienced difficulties, I have tried to show myself warmth and comfort myself and How often have you managed to feel warmth and compassion towards yourself? ) across treatment. The items were scored on a five-point Likert scale ( with end points depending on the question; all referring to the past week). Participants filled out the diary at home and brought it completed to each training session. If the participant forgot the diary was filled out on the spot before the session started. Therapists did not have access to dairy scores during treatment. Statistical Analyses Weekly dairy ratings on shame, self-criticism and selfcompassion were graphically displayed and the percentage of data points exceeding the median of baseline phase (PEM) approach was used to complement visual inspection of changes in level and trend between baseline and treatment (Ma 6; Kazdin ). In the PEM approach, the baseline median is used as a benchmark to judge change during the treatment phase against. The percentage of treatment phase data points above the baseline median (if increase is expected such as with self-compassion) or below the baseline median (if decrease is expected such as with shame and self-criticism) is calculated. As criteria for interpretation, 9 % of treatment phase data points below the median signified a strong effect, 7 9 % a moderate effect and \7 % a questionable or no effect (Scruggs et al. 986). As this study uses a relatively short baseline, the mean baseline score was used as a benchmark, instead of the median. To investigate whether there was a reliable pre to post difference between the scores on standardized measures for self-compassion and social anxiety, the Reliable Change index (RC, Jacobson and Truax 99) was calculated. For this calculation, the standard deviation and test retest reliability of the SCS and the SIAS were obtained from previous research (Mattick and Clarke 998; Neff ). Furthermore, clinically significant improvement on social anxiety (SPSQ) was determined for each individual using a post-test score within two standard deviations (SDs) of the mean of the normal population as a benchmark, in accordance with Jacobson and Truax (99). Swedish normative data (Furmark et al. ) were used (SPSQ M = 9., SD = 7.). Results Figure graphically displays participants weekly dairy ratings on shame, self-criticism and self-compassion. Table shows pre to post changes on standardized measures of self-compassion and social anxiety. Participant showed consistent improvements of moderate size in diary scores from baseline to treatment on all three variables as well as reliable and clinical improvements on all pre to post measures. In the treatment evaluation, this participant rated a high treatment satisfaction ( very satisfied ) and a high

5 J Contemp Psychother (5) 5: Fig. Graphical display of weekly diary ratings of selfcriticism, shame and selfcompassion. PEM = Percentage of treatment phase data points above (if increase is expected as with self-compassion) or below the baseline mean (if decrease is expected as with shame and self-criticism) shame P (PEM 89%) shame P (PEM %) self-cri cism P (PEM 89%) self-cri cism P (PEM %) self-compassion P (PEM 89%) self-compassion P (PEM 56%) shame P (PEM %) shame P (PEM %) self-cri cism P (PEM 75%) self-cri cism P (%) self-compassion P (PEM 5%) self-compassion P (%) shame P5 (PEM 9%) shame P6 (PEM 67%) self-cri cism P5 (PEM 5%) self-cri cism P6 (PEM 67%) self-compassion P5 (PEM %) self-compassion P6 (PEM %) degree of perceived improvement ( improved a lot ) in ability to cope with social anxiety and in self-compassion. Participant showed some possible but questionable changes in dairy scores on self-compassion but reliable change on this variable and an additional reliable change on social anxiety on pre to post measures. This participant rated a high treatment satisfaction ( very satisfied ) and a high degree of perceived improvement in ability to cope with social anxiety and in self-compassion ( improved a lot ). Participant showed changes of strong to moderate size in diary scores on two out of three variables but no reliable improvements on any of the pre to post measures. This participant rated being quite satisfied with treatment and being somewhat improved in ability to cope with social anxiety and in self-compassion. Participant showed no clear changes in diary scores but clinically significant improvements on pre to post measures for social anxiety, as well as reliable changes on self-compassion. This participant rated being quite satisfied with treatment and being somewhat improved in ability to cope with social anxiety and in self-compassion. Participant 5 showed consistent changes of moderate and strong size in diary scores on two out of three variables as well as reliable improvements on two out of three pre to post measures. This participant rated a high treatment satisfaction ( very satisfied ) and a somewhat respectively high degree ( improved a lot ) of

6 9 J Contemp Psychother (5) 5:89 98 Table Pre post raw scores, reliable change index and clinically significant change Participant 5 6 Self-compassion (SCS) Pre Post Post RC.*.7*.5.78* 5.5*.7* Social anxiety (SIAS) Pre Post Post RC -5.9* * -.7 Social anxiety (SPSQ) Pre Post Post 9 CSI Y Y N Y N N Pre = pretest, Post = post measurement directly after intervention, Post = post measurement, weeks after intervention. RC = reliable change index relating to change between Pre and Post. CSI = clinically significant improvement. SCS = self-compassion scale; SIAS = social interaction anxiety scale; SPSQ = social phobia screening questionnaire. *p\.5 perceived improvement in ability to cope with social anxiety and in self-compassion. Participant 6 showed a change of strong size in diary scores on self-compassion as well as reliable change on self-compassion on pre to post measures. This participant rated being quite satisfied with treatment and being somewhat improved in ability to cope with social anxiety and in self-compassion. Discussion This pilot study tested the effectiveness of compassion focused therapy (CFT) using a single case experimental design with six individuals suffering from social anxiety. The aim was to establish whether CFT lead to increases in self-compassion, and reductions in shame, self-criticism and social anxiety. Moreover, the aim was to investigate to what extent participants were satisfied and experienced CFT as helpful in coping with social anxiety and in increasing self-compassion. In summary, the results indicate that CFT was effective for of 6 participants (P, P and P5), probably effective for of 6 (P) and more questionably effective for of 6 participants (P and P6). Taken together, these results add to the growing body of empirical evidence that CFT may be seen as a promising approach to address problems with self-compassion. This research body consists as of yet of relatively small, pilot studies, and more studies are clearly needed. Discussion of Results Not all participants improved on all variables. For example, improvement on self-criticism was not as consistent or convincing as on self-compassion. This could reflect the established difficulty of changing self-critical thinking (e.g. Cox et al. ). It could also reflect that the measure used was not sensitive enough to pick up true changes. Indeed, a clinical observation was that the psycho education and selfmonitoring elements related to self-criticism did lead to participants shifting their perspective. Several participants commented on that they were surprised to find out that they were at many times unduly harsh and critical towards themselves. However, it could be that the treatment dose was not enough to effectively change self-critical thinking. Indeed, as self-critical thinking often is chronic and long standing, more extended treatment may be necessary to influence it. Not in the least it may be important to address hindrances and blocks to feeling positive affiliative emotions and letting go of self-criticism. For some individuals feelings of warmth and affiliation can be hard and even be frightening. These fears have been shown to be highly correlated to self-criticism (Gilbert et al. ). The treatment in this study did include some focus on exploring possible blocks and fears but could have been more explicit and extensive in addressing this. Future studies could also include measurement of fears of compassion, and thereby study its possible moderating role in treatment effect. Most systematic improvements were seen on self-compassion where 5 of 6 participants showed reliable improvements on the pre to post measure. This could be an indication of the sensitivity of the measure, picking up on subtle changes, but could also reflect that this variable was most systematically addressed in treatment. Indeed, CFT includes a clear focus on psycho education with the aim to deshame and increase empathic understanding of oneself and ones problems. A clinical observation is that the psycho educational elements that focus on how our evolved hard wiring sets us up for difficult emotions helped participants to gain a new perspective on that their responses are not their fault. This helped to bring about a clear motivational shift towards empathetic understanding of ones difficulties and trying to help and support oneself. Results on improvements in social anxiety were more mixed. Two participants showed reliable improvements on socials anxiety as measured with SIAS and three showed clinically reliable improvement on social anxiety as measured with SPSQ. This may indicate that the SIAS and SPSQ pick up on different aspects of social anxiety, but could also signal that the participants included in this study

7 J Contemp Psychother (5) 5: were heterogeneous when it comes to the severity of their problems. There was some indication that participants with more severe problems had larger treatment effects. This could be due to floor effects on the measures but also to the face validity of this approach for those with obvious selfcompassion and self-criticism difficulties. Future studies could include measurement of treatment credibility to pick up on these variations. As in many psychotherapies that have a cognitive and behavioral and/or a mindfulness orientation, emphasis in CFT is put on active engagement and training on the part of the patient. In general, all participants showed active engagement in both the daily mindfulness and compassionate imagery training as well as in the other CBT oriented exercises such as such observing and writing down critical thoughts and letting go of safety behaviors. However, an interesting observation was that the degree of homework compliance appeared to covary with variation in treatment effect. Specifically, participants training frequency of mindfulness and compassion focused imagery respectively other CBT exercises showed that the participants with the best results (P,, and 5) adhered to 8 95 % respectively % of these homework exercises while the participants with more questionable results adhered to 6 % respectively 67 % (P) and 8 % respectively 5 % (P6) of the exercises. While, of course, caution should be taken in interpreting the direction of these relations, it does point to the potential importance of addressing obstacles for homework compliance. Limitations It should be kept in mind that this is a pilot study and it has some obvious shortcomings. Due to time constraints the baseline measurements were relatively short and a longer baseline measurement would have been preferable. Moreover, all measurement was conducted with self-report, increasing the risk for common method variance. Also, no follow up data beyond weeks after treatment was available and it is therefore not sure whether results are maintained over time. This is important, not only because treatment effects may be lost to follow up, but also because the opposite may be the case and treatment effects may be delayed. For example, changing perspective on one s constant self-attacking cognitions and starting to genuinely support oneself and seek out others for comfort and support may require time. It could be that changes on scores of selfcritical thinking improve gradually over time, rather than abruptly during treatment. Another point to be kept in mind while drawing conclusions is that, while the data give indications of reliable improvements with some clinical significance, group studies on the effectiveness of CFT need to establish the magnitude of the effect and relate this to the effect of other treatments. For example, the percentage of treatment phase data points above the mean approach that was used as a complement to visual analysis is insensitive to magnitude of data points above the mean. Also, this method does not consider trend and variability in data points of treatment phase. Another shortcoming is that, while all participants had sufficient levels of social anxiety to meet DSM-IV criteria for social phobia according to the SPSQ, some of the participants scored low on the weekly ratings, possibly leading to floor effects and difficulty in detecting change. This could in part be due to that the diary was constructed for the purpose of the study, and therefore not formally tested on its sensitivity to pick up on change, but it could also be due to recruitment from a non-clinical population with more variable problem levels. In addition, while the threats to internal validity are relatively well addressed within a single case experimental design, a shortcoming of this design is that the generalizability of the results remains unclear. Due to the non-clinical population and the restrictions of the design in this pilot study, external validity remains to be established. This being said, the results show that CFT may be a promising approach for individuals with problems with social anxiety and further studying is justified to replicate and extend these results to other, preferably clinical, populations and settings. Eventually, this approach needs testing in RCTs and further investigation of processes of change. The next step may be to test CFT in a randomized controlled trial, preferably including individuals formally diagnosed with social anxiety disorder. Lastly, it should be kept in mind that the treatments were performed by two different and not so experienced clinicians. While they had extensive support in a manualized protocol and patient materials as well as clinical supervision, this could also be linked to the different pattern of improvements in patients. Theoretical Discussion The main hypothesis of CFT is that emotional suffering is exacerbated and perpetuated by constant self-attacking and shame and stands in the way of people being able to genuinely sooth and support themselves as well as receive and seek support from others. It is theorized that self-criticism activates the threat emotion regulation system and that there may be two separate but interactive positive affect regulating systems (Gilbert et al. 8). One is focused on doing/achieving and anticipating rewards, while the other focuses on social signals of affiliation and care. Development of these systems takes place during the developmental periods of the individual through stimulation by caretakers providing warmth, reassurance and soothing and thus

8 96 J Contemp Psychother (5) 5:89 98 creating experiences and memories of safeness for the individual. This enables the individual to understand and feel safe with their own emotions and be able to respond with self-soothing in response to stress. It is hypothesized that soothing and affiliation systems are underdeveloped for self-critical individuals. Indeed, evidence suggests that lack of self-compassion is linked to insecure attachment and childhood maltreatment, and may mediate the effect of insecure attachment on emotional dysregulation (Tanaka et al. ). Also, evidence shows that in self-critical individuals, high levels of negative affect are accompanied by low levels of safe and content positive affect (Gilbert et al. 8). Therefore, in CFT the ability to treat oneself and others with compassion is seen as a key regulator of emotion, not only pivotal to down regulate negative emotion but also to increase the experience of positive emotions and well-being. Where cognitive behavioral psychotherapies traditionally mainly focus on decrease of symptoms and direct change of maladaptive cognitions and behaviors, CFT adds an explicit focus on compassion and integrates and utilizes a variety of psychotherapeutic methods that aim to directly increase ability to experience self-soothing, warmth and communion. The methods used in CFT are not necessarily new, but rather integrated within a new theoretical framework of emotion theory and put in a uniting humanistic context of compassion for self and others as a point of departure and as a basis for developing adaptation and well-being. In CFT compassion for self and others has an extended meaning that incorporates a sense of interconnectedness to humanity at large, equanimity, as well as hope and meaning in the face of life s difficulties. It is therewith, like other psychotherapies such as ACT and DBT, based a Buddhist life philosophy that departs from common western conceptualizations of mental health problems as pathologies, and normalizes them as part of the human experience. While effectiveness of CFT is one main question that needs to be further addressed, another question is what mechanisms may be underlying the effect. It is hypothesized that CFT deactivates the self-perpetuated activation of the threat system in a direct way by decreasing selfcritical thinking and shame. But it is also hypothesized that an ability to feel safe and secure can be trained and become a buffer, an increased resilience, through activation of selfsoothing and warmth. Thus, compassion may be hypothesized to regulate emotion through its effect on rumination (brooding) as well as through its effect on positive emotion. Future studies could include process measures on rumination and positive affect to investigate mechanisms of effect. In conclusion, this study adds to the as of yet small body of evidence indicating the effectiveness of compassion focused therapy for increasing self-compassion, and decreasing shame and self-criticism. These problems are not specific to social anxiety disorder and this approach may therefore be used and tested as a transdiagnostic treatment approach to address shame and self-criticism in a wide range of psychological disorders. Appendix Session content description Session Psycho education on shyness, how the brain evolved through evolution and sets us up with sensitivity to social threat, how emotions are regulated in different systems (threat, soothing and achievement), compassion and mindfulness. In session, collaborative, case-conceptualization to connect emotion regulation systems to the participants own lives. In session mindfulness soothing breathing exercise. Homework: daily practice in soothing breathing. Session Psycho education on shame, self-criticism and barriers to feeling compassion. Further conceptualization of the participant s problems focusing on the threat system, coping strategies to regulate anxiety symptoms and compassionate understanding of oneself. Homework: daily monitoring with focus on identifying self-criticism, daily practice in soothing breathing. Session Psycho education on the function of critical thoughts and on imagery. In session experiential exercise on how imagery can help to create warm, helpful and compassionate feelings while negative thoughts create negative feelings. Homework: daily monitoring and mindfulness of self-critical automatic thoughts, daily practice of imagery exercise Safe Place, daily practice in soothing breathing. Session Psycho education on self-validation. In session training in generating more compassionate thoughts as an alternative to self-critical thoughts. In session imagery exercise on feeling compassion from others. Homework: daily training in generating compassionate thoughts as alternative to self-critical thoughts, daily practice of imagery exercise Receiving compassion from others, daily practice in soothing breathing. Session 5 Psycho education on safety behaviors. In session training on identification of safety behaviors in relation to own shyness and social anxiety. Homework: daily monitoring and challenging of safety behaviors, daily practice of imagery exercise Feeling compassion for others, daily practice in soothing breathing. Session 6 Psycho education on how life values can motivate and help people to cope with difficult emotions in order to reach a long term goals. In session training on mapping important values using a life compass. Introduction of guiding principles validation, acceptance, direction and compassion as an aid in facing difficult situations in

9 J Contemp Psychother (5) 5: daily life. Homework: exposure to a difficult situation using guiding principles, daily practice of imagery exercise Feeling compassion for oneself and others, daily practice in soothing breathing. Session 7 In session work on how to integrate compassion in one s life and action and how to use compassion to meet difficult situations. Homework: exposure to a difficult situation using guiding principles, assignment on writing a compassionate letter to self, daily practice in soothing breathing. Session 8 Collaborative summary of the intervention. In session work on making a plan in order to continue to evolve and meet difficulties with compassion for self and others. References Barnard, L. K., & Curry, J. F. (). Self-compassion: conceptualizations, correlates & interventions. Review of General Psychology, 5(), 89. Cox, B. J., Fleet, C., & Stein, M. B. (). Self-criticism and social phobia in the US national comorbidity survey. 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