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A Compassion Focused Approach to Anxiety Disorders

Article  in  International Journal of Cognitive Therapy · June 2010

DOI: 10.1521/ijct.2010.3.2.124

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International Journal of Cognitive Therapy, 3(2), 124–140, 2010
© 2010 International Association for Cognitive Psychotherapy
WELFORD
AN APPROACH TO ANXIETY DISORDERS

A Compassion Focused Approach

to Anxiety Disorders
Mary Welford
Greater Manchester West Mental Health NHS Foundation Trust

All animals need processing systems that enable them to detect danger and then
rapidly take defensive actions to cope and/or avoid them. Anxiety is an evolved
mechanism that facilitates such protective and defensive strategies and thus is part
of a normal, highly evolved system for threat detection and defence.
Problematic forms of anxiety can occur when evolved mechanisms are triggered
inappropriately, too intensively, or last too long. The reasons for anxiety becom-
ing “problematic” have been attributed to a complex interaction between genetics,
environmental factors, and personal appraisals. This article will explore anxiety dif-
ficulties from the compassion-focused theoretical position which argues that the
regulation of anxiety occurs both within and outside of the threat system. In par-
ticular the system that evolved for attachment processes can be a major regulator
of threat processing. Thus anxiety disorders may represent problems in different
systems other than the threat system (e.g., soothing system), and attention to those
systems is required for recovery. This article outlines the rationale and key compo-
nents of a Compassion Focused Therapy (CFT) approach for the understanding
and amelioration of anxiety conditions. A case example highlighting key points is
provided.

The DSM-IV (APA, 1994) outlines 12 different anxiety disorders, ranging from sim-
ple phobias to obsessive compulsive and generalized anxiety disorders. With collective
lifetime prevalence rates of approximately 30% and 12-month rates of approximately
18% (Kessler, Chiu, Demler, & Walters, 2005) anxiety disorders are one of the most
prevalent of all psychiatric conditions in the general population.
The CBT view of anxiety disorders, was first described in full in 1985 by Beck,
Emery, & Greenberg. They proposed that life experiences and the development of
core beliefs and schemas sensitize an individual’s attention and interpretive competen-
cies to certain types of threat, thus triggering evolved and innate threat systems (e.g.,
fight, flight, freeze, and faint). Experiences of anxiety and fear can sensitize attention
systems, create core beliefs (e.g., “I am vulnerable,” “other people are rejecting”) and
lead to the development of a range of safety behaviors for coping and avoiding threats.
These safety behaviors typically increase the sense of threat or prevent the learning of
adaptive coping or engagement and desensitization (Thwaites & Freeston, 2005).

Correspondence concerning this article should be addressed to Psychology Services, Greater Manchester
West Mental Health NHS Foundation Trust, Bury New Road, Prestwich, Manchester M25 3BL. E-mail:
mary.welford@gmw.nhs.uk.

124
AN APPROACH TO ANXIETY DISORDERS 125

Over the last three decades however much has changed and advanced in our un-
derstanding of the mechanisms that underpin and regulate anxiety (LeDoux, 1998;
Panksepp, 1998). A menu of model-specific protocols looking at the re-evaluation of
specific thoughts and/or catastrophic misinterpretations via verbal reattribution and
behavioral experiments have performed very well across a range of groups such as
those suffering with social anxiety (Fedoroff & Taylor, 2001), Posttraumatic Stress
Disorder (Ehlers et al., 2003, Ehlers, Clark, Hackmann, McManus, & Fennel, 2005)
and Panic Disorder with or without agoraphobia (Clark et al., 1994, 1999). Cog-
nitive-Behavioral Therapies (CBT) for anxiety related disorders have been found to
perform well but with a recognition of a need for further research and improvement
(NICE, 2004). More recently classic CBT models have been supplemented by inter-
ventions that, instead of looking at the content of thoughts, focus on the individual’s
relationship with his or her thoughts and feelings. Mindfulness Based Stress Reduc-
tion (Kabat-Zinn, 1990), Mindfulness Based Cognitive Therapy (Segal, Williams, &
Teasdale, 2002), Acceptance and Commitment Therapy (Hayes, Strosahl, & Wilson,
1999), and Meta-Cognitive Therapy (Wells, 1995) have performed well with this cli-
ent group (see Baer, 2006; Cullen, 2008; Wells, 2008 for reviews).
Research and clinical practice indicates that one area, in which we may need to
look at improving anxiety-focused approaches, are for those individuals who are high-
ly self-critical and experience shame. Such psychological phenomena have been found
to be highly associated with each other (Andrews, 1998; Gilbert, 1998; Gilbert &
Miles, 2000; Tangney & Dearing, 2002) and highly prevalent in those suffering with
such difficulties as social anxiety (Cox et al., 2000) and Posttraumatic Stress Disorder
(Brewin, 2003; Lee, 2005). There is evidence that individuals with high levels of self-
criticism and shame may do less well with standard therapies (Rector, Bagby, Segal,
Joffe, & Levitt, 2000). Hence there maybe a need to look at developments to tradi-
tional and specifically focused therapies to address this.
A second group of individuals who appear to do less well with standard CBT
approaches are those who agree in principle to an alternative way of thinking about
things but report not feeling any different. In sessions they may say such things as “I
know it is highly unlikely that something will happen to my son but I don’t feel it, I
am not reassured by the evidence,” “I know I won’t lose control but it still feels like
it,” or “I know I am not bad but I still feel it.”
Beck, Rush, Shaw, and Emery (1979, p. 302) suggest “the therapist can tell the
patient that a person cannot believe anything ‘emotionally.’ . . . When the patient says he
believes or does not believe something emotionally, he is talking about degree of belief.” Gilbert
(1989, 1993) argued that beliefs could be driven and textured by core innate systems
regulating threat and safeness evaluations, and that cognitive processing and emotion-
al processing interact but should not be conflated. Neurophysiological evidence shows
also that mechanisms underpinning emotion and those underpinning cognitions are
separate and have complex interactions (Panksepp, 2007). To compound this prob-
lem, cognitive therapist sometimes use the concept of information processing and cog-
nition interchangeably as if they are equivalent, which they are not. “Cognition” is not
just information processing. One’s computer and DNA are information processors but
do not have cognitions (Gilbert, 2009a). Indeed within the cognitive traditions the
complexity of the interaction between emotional and cognitive processing has been
addressed. For example, Teasdale and Barnard (1993) proposed two levels of mean-
ing, that account for an intellectual and emotional belief, or “knowing in the head”
versus “knowing in the heart.” As Teasdale (1997, p. 146) notes, at the propositional
126 WELFORD

level thoughts such as, “I am worthless,” are simply statements of belief—propositions

about properties of self as an object. At the implicational level, however, such a state-
ment represents a rich activation of affect and memories associated with experiences
of being frightened, rejected, or shamed. Stott (2007) also addresses this important
question, of what he calls “the dissociation between emotion and cognition” in impor-
tant and helpful ways. Behavioralists using classical conditioning models have always
argued on the importance of new learning in the context of affect. What Compassion
Focused Therapy adds is that this affect sometimes needs to be positive, especially that
associated with affiliation and reassuring. Moreover CFT argues that some individu-
als are fearful of certain types of positive affect especially those linked to compassion,
helpfulness, encouragement, and forgiveness. The inability to experience certain types
of positive affect leaves the threat system poorly regulated.
Gilbert’s (2000, 2005, 2009b) Compassion Focused Therapy (CFT) and Com-
passionate Mind Training (CMT) has its scientific and theoretical roots in neurosci-
ence models of emotion, and evolutionary psychology models of human motivation—
especially research in attachment (Gilbert, 1989, 2009b) and belonging (Baumeister
& Leary, 1995). The basic propositions of this model, with details of the three affect
regulation systems that are important to CFT, are outlined by Gilbert (this issue).
The specifics of the therapy were originally developed as an antidote to shame
and self-attacking. The theory not only attributes problematic levels of anxiety to an
overactive or oversensitive threat system and subsequent appraisals, but, in many cases
to underdeveloped regulation of the threat system by other systems, in particular that of
endorphin-oxytocin linked soothing system. It proposes that if the soothing system
isn’t working particularly well or accessibly then methods such as exposure and cogni-
tive interventions may struggle because the person doesn’t possess the emotional sys-
tem necessary to experience alternatives, especially those of a verbal nature, as calming,
soothing, and reassuring.
In terms of the formulation, the therapist first develops a shared understanding
of the origins of a person’s difficulties and distress, as understandable anxiety regula-
tion efforts, utilizing education about how our threat systems work. For individuals
experiencing high levels of shame in particular, this is designed to be normalizing,
depathologizing, destigmatizing and deshaming. Second, therapists provide a clear ra-
tionale and method aimed at “toning up” the affiliative and soothing affect regulation
system so that it can then be recruited to help regulate the threat and drive systems.
This latter component is clearly distinct from many other forms of therapy for anxiety
in which the emphasis lies in only “toning down” problematic emotions associated
with activation of the threat system such as anxiety, anger, fear, and sadness, via verbal
and behavioral challenging of thoughts, beliefs, etc.

BACKGROUND TO THE CFT APPROACH TO ANXIETY

CFT locates many of our emotional difficulties to the way in which our brains have
evolved, and now interact with very different environments from which they originally
evolved. Rather than thinking of conditions as pathologies, CFT sees many of them
as understandable glitches and difficulties associated with our tricky brain. It notes
that all of us just find ourselves here with a brain we didn’t design and life experiences,
that have shaped us, that we did not choose. This is the philosophical basis for the
therapeutic stance, that not only impacts on the client’s psychological well-being but
AN APPROACH TO ANXIETY DISORDERS 127

also the therapist’s. Such a stance differentiates fault, blaming, and shaming (we did not
choose our brains or our early experiences that gave rise to our safety behaviors and
emotional difficulties) and responsibility (only through our own actions and efforts will
change occur), is accepting, validating, and encouraging.
More specifically, terminology that emphazises “common humanity” and a shared
evolutionary perspective serves to unite rather than differentiate therapist and client
and can have a significant and profound effect on the message conveyed in therapy at
many levels. Statements such as “we have a complex brain, it’s not our fault we . . . or
it is understandable/makes sense to feel . . . in this situation” are commonly heard and
offered repeatedly by the therapist. This is done in a soothing manner throughout the
journey together. Helping the individual to connect with this message emotionally is
part of the therapeutic work.
In order to engage emotionally the therapist teaches the individual to engage with
a “compassionate mind” via the practice of various imagery and behavior exercises.
Just as we can activate anxiety so the therapist can also help the individual activate wise
compassion—such as engaging in soothing breathing rhythm and imagining oneself
to be a compassionate person; imagining oneself at one’s best and as one would re-
ally like to be. That then becomes the position to slowly reflect on the process in the
therapy. The therapist is trying to create a brain state which brings online, capacities
for empathy and reflection (see Tirch, this issue) before engaging in complex work.
Creating these brain states first can facilitate the therapy to work.
CTF also focuses on the therapeutic relationship and the microskills of that re-
lationship—such as pacing, voice tone, emotional attunement, playfulness, support,
encouragement, boundary setting and so forth.

THE THREAT SYSTEM

Anxiety, of course, is about threat processing. The kinds of anxiety disorders that CFT
is especially concerned with are those associated with shame, self-criticism, and fear of
engagement. Such individuals can struggle with standard CBT. In CFT great emphasis
is placed on conveying to the individual the incredibly important role of the threat sys-
tem. Understanding the emotional, cognitive, behavioral, and physiological responses
of the threat system is key. More specifically it evolved as a self-protection system, is not
their enemy, nor something to be got rid of but something to be worked with and
brought into balance with other systems.
So the therapist explains that the threat system exists because without it living
things (including us) wouldn’t survive. Its role is to detect and warn us about poten-
tial threat and enable us to respond quickly. We experience automatic physiological
reactions, a rapid activation of emotions (e.g., anxiety, anger), behaviors (e.g., freeze,
fight, flight, submit), and cognitive processes (e.g., selective attention, black/white
reasoning. jumping to conclusions). These are called “better safe than sorry” process-
ing (Gilbert, 1998).
The therapist normalizes the tendencies for these reactions. For example, if an
animal calmly eating in a field hears a sound behind it, it will become alert and pos-
sibly run away. Nine times out of ten there was no need to run and they have lost good
feeding time in the process. However, they are safe. The tenth time there may well be
a predator. So their overcautious, “better safe than sorry” thinking was incorrect nine
times out of ten but they survived. The animal that decided to go for a more laid-back
128 WELFORD

approach to life and ignore the sound would have been okay nine times out of ten
but the tenth time is dead. Discussing with individuals that their system is designed
to catastrophize, and learning to identify “better safe than sorry thinking” helps to
normalize their experiences. In addition the therapist points out, for example, that
threat emotions are designed to turn off positive emotions—to enable the focus on the
threat; this can be helpful for people who struggle with comorbid depression.
For many individuals, the threat system can be extremely sensitive. We can de-
tect this sensitivity using various physiological measures (e.g., fMRI) and can detect
changes in (for example) amygdala activity (LeDoux, 1998). This may be attributable
to independent or interrelated factors. First, the individual may have grown up and
experienced an environment in which physical, social, and or psychological threat was
common. As such the need to detect and react to threat is heightened. Alternatively
they may have grown up in an anxious environment whereby significant others mod-
elled and reinforced high levels of threat processing therefore transferring this to the
child via learning and genetics. Anxious parents, for example, may try to prevent their
children from feeling anxious by encouraging avoidance. This may be partially because
an anxious and stressed child is aversive to many parents and they may, for example,
believe that preventing their children from experiencing anxiety is a kind thing to do.
So, if the child becomes anxious about going to a party, for example, and the parent
says “that’s okay you can stay with me,” the child never learns how to tolerate anxi-
ety nor the social skills of meeting new people in that kind of social situation. Hence
the parent models and teaches the child “better safe than sorry” and a range of safety
behaviors that have unintended consequences—lack of learning how to tolerate and
cope with anxiety, lack of the opportunities to learn that parties can be fun not just
threatening; lack of opportunities to develop skills for social relating, making friends,
and sharing in such contexts. Clearly, it is important for therapists to distinguish be-
tween threat sensitivities that have come from a traumatic or frightening environment
(trauma related) verses those that have come from a lack of opportunity to learn how
to tolerate and deal with anxiety.
So CFT spends a lot of time in helping people recognize that their brains are set
up to be able to generate high levels of anxiety, and at times to make mistakes—which
of course is not their fault.

UNDERSTANDING SAFETY STRATEGIES

CFT places the development of safety strategies, in a whole range of contexts, as key
to understanding the origins of what may be traditionally described as “psychopa-
thology.” For example, children who are fearful of their hostile parents may develop
safety strategies linked to monitoring their own behavior, trying to ensure they don’t
activate anger in the parents, and self-blame if they do. Thus self-monitoring, submis-
sive behavior and self-blaming in the context of powerful threatening others can be
seen as very understandable safety strategies (Gilbert, 2007, 2009b). Although such
thinking and behaving, when carried on into adult life, could be seen as a distortion, in
CFT the emphasis is placed on understanding their better-safe-than-sorry function and
protective value rather than the degree to which it is a reflection of reality. Of course,
as with all safety behaviors there can be unforeseen and unintended consequences
which themselves become the source of further difficulties. As such, individuals who
AN APPROACH TO ANXIETY DISORDERS 129

are anxious and self-blame might not learn how to be assertive or sort out conflicts
with other people.

REGULATION OF THE THREAT SYSTEM VIA

THE SOOTHING SYSTEM

With the evolution of mammals, the attachment system has enabled parents and key
individuals to act as threat regulators and soothers for their offspring’s arousal and
distress (Bowlby, 1969). This means that the brain has evolved special mechanisms to
be sensitive to the care and kindness of others and to respond by calming down and
reducing threat sensitivity (Gilbert, 2009b). A parent who is regularly able to sooth a
distressed infant is stimulating pathways in the infant’s brain which will be available to
be activated by self-soothing in later in life. More specifically the connections between
the limbic system (home to fast-track, automatic, and nonconscious threat process-
ing) and the prefrontal cortex are strengthened. A child from a secure and affectionate
background will still become sensitive to certain threats, and quick to notice and react,
but this will also quickly be followed by recruitment of the prefrontal cortex, as well
as other areas of the brain, to appraise and regulate this reaction in light of a broader
range of information. Even in the absence of others, an individual who has benefited
from good early attachment can self-sooth and self-regulate—and this is linked to
resilience. Individuals who have had fewer opportunities for the development of a
soothing/safeness affect system may not have learnt and may not be able to regulate or
“calm down” the natural propensity for high threat reactions.
So a key message is that human beings have evolved a very complex brain, and it
is important to recognize just how tricky it is. This is especially true of the threat sys-
tem (Gilbert, 2009b). People working with more complex anxiety disorders should be
familiar with these complexities; for example, within the threat system emotions can
conflict (e.g., people might become anxious at being angry or angry at been anxious),
there are different memory systems that code for trauma (e.g., amygdala body-based
memory and event memory); anxieties can arise from approach avoidance conflicts
(e.g., wanting to leave an abusive marriage but being frightened and uncertain of
doing so—or frightened of acknowledging anger toward a particular parent). CFT
points out that different brain states (e.g., the state of depression) alter information
processing routines making threat processing much more prominent. CFT emphasises
the development of safety strategies as ways of self-protection whose function must
be clearly understood and delineated in all their complexity—not seen as pathologies.
Reviewing this information helps us be more understanding of what it is to be hu-
man, more accepting of the difficult situations people often find ourselves in, and also
understand why we often (over)react the way we do. Subsequently, we may experience
less self-criticism and shame enabling the individual to begin to focus on management
and responsibility as opposed to working on a disorder, maladaption, distortion, or
pathology.
First described in 1892 by Santiago Ramón y Cajal, but largely forgotten for the
next century, the theory of neuroplasticity describes the ability for all areas of the brain,
and not just areas such as the hippocampus and dentate gyrus, to constantly evolve
and change. Although it is certainly true that such development is more efficient dur-
ing early childhood and puberty, there is a growing and clear body of evidence that
the brain can develop at any part in our lives, even in old age. As such the question is
130 WELFORD

where we wish to concentrate our efforts and develop new potentials. Certainly with
many individuals we would propose that work on developing the soothing system is
highly important. Analogies with physiotherapy are helpful here—the systems model
gives the rationale for why we need to concentrate on “toning up” the soothing system
while the concept of neuroplasticity allows us to demonstrate that concentrating our
efforts on this is worthwhile, brains do change (Begley, 2007).

COMPASSION AND ANXIETY

Compassion means different things to different people, individually and culturally, so

it is important that both therapist and client develop a shared understanding of the
term. This article cannot go into the different definitions of compassion but a good
starting point is the Dalai Lama’s view that states that compassion is associated with a
sensitivity to distress in self and others with a motivation to relieve it—so sensitivity and
motivation become key. Gilbert (1989, 2000 2005a, 2009b) acknowledges the debt
to Buddhism but argues that compassion evolved out of caring behavior and for its
full functioning requires the integration of a number of different components of mind.
These are outlined clearly in Gilbert’s article in this issue.
An important point to discuss with clients is that compassion is absolutely not
about “hearts and flowers,” “treating oneself,” “abdicating responsibility,” and “doing
whatever one feels like.” On the contrary, CFT spends a great deal of time exploring
the person’s ability to be kind, supportive, and nurturing toward himself or herself,
in contrast to being self-critical and subsequently behaving in ways which advance his
or her welfare. It is about generating the strength and courage, for example, to face the
world after being indoors for 10 years, standing up for oneself in the face of an unhelp-
ful relationship, or recognizing and validating feelings of anger and sadness through
kindness and understanding rather than self-bullying, self-criticism, and hostility.

BLAMING VERSES TAKING RESPONSIBILITY

CFT makes a clear distinction between shame and guilt. Shame is focused on a nega-
tive (inferior, inadequate, bad) self with self-criticism. The emotions are threatening
ones of anger, anxiety, or disgust, and behavior is focused on repairing/avoiding (fur-
ther) damage to the self. In contrast guilt focuses on being open and taking responsi-
bility for one’s behavior, and if one has done some harm to oneself and others, having
feelings of sorrow and remorse with efforts at appropriate reparation. In shame the
attention is self-focused, in guilt it is other focused. Shame does not require much
empathy whereas guilt does (Gilbert, 1998, 2009b).

CASE EXAMPLE: USING THE THREE SYSTEMS MODEL TO

FORMULATE AND IDENTIFY THE THERAPEUTIC FOCUS

CFT monitors carefully the emotional tones of people’s efforts in working with their
anxiety. This is done in a number of ways such as practicing compassionate voicing,
compassionate thinking, using compassionate images, and generating compassionate
AN APPROACH TO ANXIETY DISORDERS 131

Drive Soothing/
Safeness
Got to strive to be like other Limited
people./to achieve opportunities
Got to make myself a better
Person/achieve my
potential

Threat
External
Mum’s illness (H)
Mum being very threat focussed (H)
Lots of changes (H)
Teachers & peers being critical (H)
Internal
Being different/not like others (H & C)
Thinking difference (H & C)
Got to protect myself – sometimes
Withdrawing, defensive, attacking
(verbally). Often submissive,
always 'on guard’

BUT

UNINTENDED CONSEQUENCES

Anxiety and worry

Exhaustion
Never meeting unrealistic targets
Shame
Not getting to know people
Beating self up all the time
Profound sadness
Depression
Anger
Sense of nothing inside

Conclusion: Need to be compassionate towards story of why I am sat here now

Need to build up safeness because every human being needs it

FIGURE 1. Formulation using the three circle model.

behavior. To indicate how CFT is integrated into cognitive behavioral approaches this
article will now outline some key features of a case. In order to avoid identification the
case is a synthesis of a number of individuals.
Stephen came to therapy with very high levels of anxiety. He was clearly frus-
trated that he had “not achieved anything, despite being pretty bright” and frustrated
because despite his best efforts he could not conquer his anxiety. Stephen had had a
difficult childhood. His mum had been in and out of hospital due to breast cancer
since Stephen was born. She eventually died “out of the blue” when Stephen was 8,
leaving his dad and his two younger siblings.
132 WELFORD

After explaining the basic three circle model, and the power of our thinking and
imagery to stimulate different systems of the brain, we formulated Stephen’s circum-
stances using this model rather than the more regularly used four column CFT formu-
lation diagram. This was because Stephen had found the three circle system extremely
empowering and normalizing of both his difficulties and his needs (see Figure 1).
Starting with the soothing/safeness system we discussed and documented that
Stephen had limited opportunities to develop this extremely important system due to
his mum’s absence from the family home, the impact her illness had on her while she
was at home and his father’s functional rather that emotional role in the family.
In contrast to this underdeveloped system, Stephen’s threat system was discussed
and formulated as extremely well developed, given the circumstances of his childhood.
Of note we found it beneficial to differentiate between historical (H) and current (C)
threats (see Figure 1).
Historically his mum’s illness meant there was a lot of focus on illness within
the family. This anxiety understandably lead to a more pervasive threat focus about a
whole range of things. Stephen’s family moved three times while he was growing up,
initially to be closer to the specialist hospital where his mum was being treated. Fol-
lowing his mother’s death they moved to be near other forms of social support and
again when Stephen’s father changed jobs. Stephen reported “struggling” with friend-
ships and with schoolwork and this was met by criticism from others.
Stephen experienced a threatening internal world in which he perceived himself
as “different” and not like others. He believed he thought differently from others, had
angry thoughts and emotions, and this lead to him withdrawing and being defensive
at times, at other times attacking or submissive, but always “on guard” or on the watch
for potential threat from others or potential threat from his own internal world. He
was also very anxious about this own mental health.
Stephen’s drive system was not about seeking pleasure, but rather avoiding nega-
tives and threats; for example, achieving to avoid rejection. He reported being “on
the lookout” and monitoring all the time, both his internal thoughts, fantasies, and
emotions and external world pertaining to other people. He strove to be like others or
what he perceived he should be, and he tried to achieve at everything. Stephen report-
ed that he was driven to make himself a better person and achieve his “true potential”
and it was his self-critic that he thought would best help him achieve this.
So Stephen reported feeling a huge amount of anxiety and worry. He felt ex-
hausted due to the effort required to achieve his goals and shame associated with how
he felt and how he coped with things. Stephen felt dislocated from others and hostile
toward himself. Profound sadness, depression, anxiety, and a sense of “nothing inside”
were all experienced and conceptualized as unintended consequences of both his situ-
ation and his best efforts to deal with life.
The therapist discussed with Stephen how a lot of what was happening for him
was perfectly understandable and distressing consequences from the life he had had,
the struggles that he had had to cope with (the cancer and then death of his mother),
and what that struggle had done to his inner world. For example, his experiences had
stimulated both fear and anger—because he both wanted and loved his mother but
was also angry he had to have a mother with cancer; then there was disappointment
with his father who was not much of a soothing agent and lost in his own worries
and distress. When he encountered anxiety and bullying, when trying to fit into new
schools, there was no one to help him and he felt very alone. As Stephen came to
understand what had happened to him he gradually became more compassionate and
AN APPROACH TO ANXIETY DISORDERS 133

caring for the child who had had to go through all that—he became able to recognize
the natural fears and safety behaviors that he had automatically developed, and how
they had given rise to the unintended consequences and current emotional problems.
They were not evidence of a bad person “going mad,” being inadequate, or needing
to prove himself.
In CFT a core component is the functional analysis of the protective nature of
safety strategies—and developing deep compassion to that part of the self that had
to develop them. Of note, CFT is not overly focused on identifying core beliefs or
schema—although if they arise and seem useful they could be a focus.
This conceptualization was experienced as hugely validating to Stephen. He was
able to look at his present difficulties in the context of early life events. He was also
able to acknowledge that some of the things he now did to protect himself also had
unintended consequences. In the short term they were deemed appropriate or help-
ful but in the long term lead to further difficulties. Experiencing the formulation as a
compassionate view of Stephen’s story also set out a credible, scientific rationale for
why concentrating on developing self-compassion was important to help regulate his
very well-developed threat and drive based systems.

GREATEST FEARS ASSOCIATED WITH THE

DEVELOPMENT OF COMPASSION

Discussion was spent on exploring the value of developing the soothing circle via
compassion and collaborating on this as a therapeutic goal. So, following Stephen
developing a rationale for working to “tone up” the soothing system, the first “exer-
cise” Stephen embarked on was discussion around his greatest fears associated with
the development of different components of compassion. This highlighted areas that
may have acted as blocks in therapy. For example, it elicited fears that Stephen would
start to grieve and feel overwhelming sadness if he started to develop compassion.
As such this concern was normalized as understandable, the process of grief was dis-
cussed and he was reassured that wherever the journey took us we would “walk the
path together.” In addition, we explored this in terms of “step at a time” with him in
control—that getting in touch with grief need not be “all or nothing.”
However painful, emotions like this, and unprocessed affects and memories need
to be addressed—and in this sense it is similar to CBT approaches aimed at working
with trauma. The ability to tolerate the emotions associated with memories is ex-
tremely important. Most trauma work focuses on fear but Gilbert has highlighted the
importance of focusing on grief and the fear of the pain of grieving. In the case of grief
it’s a process that can take some time. In CFT working with trauma and loss memories
can play a key role in recovery (Gilbert & Irons, 2005).

DEVELOPING A “SOOTHING BREATHING RHYTHM”

A key aspect of CFT is the awareness of body processes and in particular the value of
slowing before engaging with difficult material. A useful element which links with,
but is different to mindfulness, is soothing rhythm breathing—where the individual
134 WELFORD

learns how to breathe slightly slower and slightly deeper and focus on the experience
of “body slowing.”
As a preparation for some of the imagery exercises we spent time building up a
soothing breathing rhythm. As with many of the exercises there are a number of ways
one can do this. While some individuals take to it immediately, others find it helpful
to try different methods until one is found that is useful. As such it is always beneficial
for the stance to be explorative. Each exercise is set up as an opportunity for learning
and differentiating what is helpful from what is not. The therapist takes part in such
exercises rather than merely facilitating them.
Although Stephen initially attempted to concentrate focusing the mind on the
nose septum, between the nostrils, Stephen found that simply concentrating on the
breath was the most helpful method. He was initially uncomfortable with closing his
eyes so we started off simply looking toward the floor then built up the time spent in
this exercise. Without prompting he started to close his eyes approximately 3 weeks
into the practice. Instructions given were akin to those used in mindfulness, normaliz-
ing digressions of the mind but when one was mindful of them, bringing the attention
back to the breath. Stephen practiced this exercise outside of sessions supplemented
by a taped recording of the specific part of that week’s session in which we practiced
the exercise.

COMPASSIONATE IMAGERY

CFT has developed a wide repertoire of imagery exercises from a range of sources,
such as Buddhist meditations and clinical feedback (see Gilbert, 2009b, 2010, and
www.compassionatemind.co.uk). As with the previous exercise Stephen practiced a
range of exercises, finding the “ideal compassionate self ” (Gilbert, 2000) to be the
most productive in giving him a feeling of warmth and compassion. This was then the
compassion focus that we concentrated on and used throughout our work together.
These exercises attempt to create a brain state (e.g., stimulating the insula; see Tirch,
this issue) which facilitates the processing of threat-based material.

COMPASSIONATE RE-EVALUATION RECORDS (CRRS)

As an adaption to classic CBT thought records, CRRs were used to bring Stephen’s
awareness to empathy for his own distress, compassionate attention, compassionate
thinking, compassionate acceptance, and compassionate feeling (see Table 1 for a sam-
ple CRR worksheet drawn up over one therapy session).
Although Stephen reported getting a lot out of the reframing exercise, compas-
sionate feelings were enhanced further by then using the compassionate-self imagery
prior to rereading the CRR. This helped Stephen call on compassionate feelings and
a frame of mind to review his alternative thoughts. The exercise involved him staying
with each entry until Stephen reported that he truly felt reassured and accepting of
such statements and they had more emotional meaning.
 TABLE 1. Worksheet 1: Compassionate Reframing Record
Triggering Events, Understanding and
Feelings or Images Feelings Thoughts / Shame / Key Fear Compassionate Reframing Change in Feelings
Not hitting a Anxious External Shame: Empathy For Own Distress: It is understandable that this was going to be difficult for me and Taking everything on board
deadline I said I Boss thinks I’m not up to it. I was going to feel anxious. I am someone who does not want to let people down and from I now feel calmer and can
would at work. early on I was “programmed” to feel this way. It is understandable. focus on caring for myself
Boss tutting and Others think I am letting the side rather than condemning
not speaking to down. myself.
me for the rest of Boss knows I’m a fake and it’s Compassionate Attention: I have done many things well and usually hit all of my deadlines.
the day. only a matter of time before My appraisal went well recently and my boss did say that he got stressed at times and did
the others do too. not achieve everything he wanted to achieve. It’s maybe true that I ex-
pected too much of myself
and made others expect it
Internal Shame: Memories / Images: too. I will just have to be
Memory of boss giving me positive feedback in my appraisal. mindful of it in the future.
I am crap.
AN APPROACH TO ANXIETY DISORDERS

I’m just not up to it – who am I Image and memory of co-worker being supportive and saying “he just gets like that, don’t take
trying to kid. it personally.”

I’m a waste of good breath-

able air. Compassionate Thinking: I’ve only been in the job just over a year and I can’t expect myself
to hit targets every time.
I will learn from this and get better.
I can only do my best.
It was a very difficult thing to do and others had questioned whether I would be able to do it
in time.
My work colleagues are more important to me than my boss and nobody likes someone who
gets everything right all of the time.
Compassionate Behavior:
Talk to key people and share my situation and thoughts with them.
Practice Compassionate Image before I go into work and briefly at the end of breaks.
Go for a nice walk when I get home.
Consider doing a behavioral change worksheet.

Imagery and emotion:

Ideal compassionate self, serene, accepting, non-judgemental stance with warmth.
135
136 WELFORD

COMPASSIONATE BEHAVIORAL CHANGE WORKSHEET

Having proceeded through the previous exercise Stephen reported an increase in his
motivation to face that which he often avoided. This was a pattern that was more
evident in the early days of therapy, namely, to complete CRRs before addressing his
behavior; however, as therapy progressed compassionate behavioral change became
more of a primary focus. For example, following a difficult situation at work, Stephen
decided to speak to his boss instead of withdrawing and avoiding. To facilitate this he
completed a behavioral change worksheet (Worksheet 2).
In future worksheets differentiations were often made between those behaviors
aimed at activating the drive system from those aimed at the affiliative. As such an
emphasis was placed on achieving “balance” that counteracted the often experienced,
but less beneficial pull toward centering much of therapy around the positive affect
system of achievement drive.

COMPASSIONATE LETTER WRITING

Throughout therapy Stephen was asked to engage in compassionate letter writing and
bring his work to sessions. These letters can be various. There is good evidence that
reflective writing about oneself and one’s experiences (Pennebaker, 1997) and com-
passion-focused letter writing (Leary et al., 2007) can be very helpful in assimilating
painful life events and facilitate coping with painful life events. Stephen’s letters were
about himself and to his mother. This allowed him to learn how to articulate feelings
and to be accepting and tolerant of them. Letter writing enabled him to work through
and process memories. Sometimes Stephen would read the letter to the therapist and
at other times the therapist would read the letter to Stephen in as compassionate and
understanding a way as possible. These “letter sharing” sessions were moving and gave
an opportunity for reflection and generating new points for view outside of session.
This helped him practice self-compassion and acceptance and also allowed the detec-
tion of signs of self-criticism or hostility. Guidelines for writing such letters can be
found on the Compassionate Mind website (www.compassionatemind.co.uk).

SELF-CRITICISM

Self-criticism is found to be a major problem for many people meeting criteria for
“anxiety disorders.” This can be a addressed by putting oneself into “compassionate-
self ” stance and then viewing one’s self-criticism with compassion until one begins to
change—which for some people can take time. By addressing self-criticism “compas-
sionately” people begin to recognize when it arises and gradually see it as a cue to
refocus on compassionate thinking. The idea is not to directly challenge or fight with
the self-critical self, because that just keeps the threat system going, but to: “notice self-
criticism, take a breath and refocus,” “notice, take a breath and refocus,” “notice take
a breath and refocus.” (The issue is slightly different if the critical voices are identified
as a past abuser—see Gilbert, 2010). Individuals, including Stephen, typically become
surprised at just how much they are self-criticizing on a day-to-day basis, but this also
gives them the opportunity a practice self-compassion regularly.
AN APPROACH TO ANXIETY DISORDERS 137

TABLE 2. Worksheet 2: Compassionate Behavioral Change

What is the thing I could do today to help me address my difficulties?
Ask my boss for a minute of his time, to speak with him about what happened the other day.
What I usually do is:
Avoid him, even avoid looking at him.
But the unintended consequences are:
I feel bad, most likely seem weird and then tell myself off for being weak willed, a joke, a walk over.
What would help me do it?
Think about/plan what it is I want to say, e.g., I’m sorry I did not hit the deadline the other day and I know it affected
you. In hindsight it was a tall order to get it done in time but I will try to make sure it does not happen again--but I’ll
say it in a confident way instead of a weak, submissive way.
Go see him when he is on top of things and doesn’t look stressed.
Practice my breathing and compassionate imagery with kindness and encouragement before I go in.
Hold my head up high and be appropriately apologetic/sorry.
What could go wrong?
a) He might not have the time.
b) He might have a go.
c) I might not have the courage.
What could I do or how could I think about it if that happened
a) I could arrange another time or bring it up in my next 1:1 time with him.
b) I could take it and be proud that I had at least not avoided the issue, then go out to the car in the break and reread
my CRR.
c) I need to think about it some more and acknowledge that changing the way I tend to do things is difficult then I could
bring it to the next appointment.
If you were able to carry it out what did happen?
I did not pick the best of times to speak with him but he was OK and did not seem to be bothered about it. He just said
try not to let it happen again. So I have shown compassionate behavior and courage to tackle a hard issue, responsibly.
What can I tell myself now?
It wasn’t that bad, I can do something other than avoid things.

CONCLUSION

This article has outlined some of the basic ideas that illustrate a compassion focused
therapy approach to anxiety. An important principle here is recognition that some-
times simply trying to change processing within the threat system is insufficient. The
reason for this is because one of the major regulators of threat processing comes from
the “soothing system” and if that’s not working properly individuals can have intel-
lectual understanding but not emotional connection. Helping bridge that gap has
resulted in the development of CFT.
Compassion textures the whole therapy including the therapeutic relationship
and the formulation. When individuals develop an appropriate formulation they’re
much more likely to be compassionate to the problems rather than ashamed of them.
Such formulations are part and parcel of the development of wisdom—which is used
when developing the compassionate self. In other words, wisdom arises because one
has better insight into the origins and functions of one’s safety behaviors, recognizes
the evolutionary elements (that we all just find ourselves here; we did not choose our
brains), and shift toward taking compassionate responsibility. This enables people to
begin to do the emotional work necessary and engage with frightening material or
actions (e.g., exposure).
138 WELFORD

CFT builds on and utilizes other therapies, because this is the practice of science—
we should not keep reinventing the wheel. CFT always involves collaborating with the
individual, sharing insights from science and exploring how to use these models to
bring better balance to our minds. As such the hope is to learn from science, and each
other, in order to promote well-being.

A CLIENT’S OWN CONCLUSION TO CFT

The following words are a personal reflection from an individual who engaged with
CFT for anxiety over an eight-month period with the author. Although she wished to
contribute to the paper, for personal reasons she asked to remain anonymous.
I used to be really down on myself and got depressed because I got so anxious about
things. I couldn’t cope, I used to shake all the time and avoid things. I used to think there
was something wrong with me, somehow I was different, defunked, incapable. My family
would get really frustrated with me and used to say I had to sort it out, pull myself together
and get on with things. My (previous) therapist told me I had to work on my thinking ‘cos it
was dysfunctional and “twisted”. Sometimes talking to people helped, they reassured me that
things were going to be ok …… if only I worked at it harder. The thought diaries helped when
we did them initially but the effect did not last. I felt as if I was useless with them. I used to
think if only I could “get it” things would be better but I never “got it” properly. I felt alone,
different, and peculiar.
Now (in CFT) I know I had reason to be anxious and fear things. Now I know what I
did to protect myself had unintended consequences. Now I have the courage to face things, I
can say “so what if I get anxious. . . . That’s me. . . . You would too if you had experienced
what I experienced.” I know I will have to continue to work on things, there is no quick fix, it’s
going to be a life-long thing because I can’t just get rid of certain parts of my brain, I have to
strengthen new parts day by day, week by week. But things will continue to get better.
The exercises help me “feel” different. Sometimes they put me in a better frame of mind
so I can take on board positive things people have said, things I have written down, rather
than discount them. Other times they just help me put things in perspective. . . . Feel warm
regardless of everything . . . so what if somebody said that to me. I don’t need to go into it, I
am an ok person.
It helps to know that Mary [compassion focused therapist] has to practice and so do I.
There’s no shame in that. . . . In fact it is actually exciting to think that the journey isn’t over
. . . I will continue to grow and blossom.
AN APPROACH TO ANXIETY DISORDERS
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