J Contemp Psychother (2015) 45:89–98 DOI 10.1007/s10879-014-9286-8 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. Ha˚kanson • E. Salomonsson • I. Johansson Published online: 6 November 2014 Ó Springer Science+Business Media New York 2014 Abstract Most forms of psychological distress encom- Introduction pass 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 Most forms of psychological distress encompass both the distance and isolation. These are often longstanding and relation to the self in the form of shame and self-criticism, pervasive problems that permeate a wide range of psy- as well as the relation to others in the form of distance and chological disorders and are difficult to treat. This paper isolation. Shame is a painful self-conscious affect associ- focuses on how problems with shame and self-criticism can ated with the perception of having a personal attribute, be addressed using compassion focused therapy (CFT). In a characteristic or behavior that others find unattractive or pilot study we tested the effectiveness of CFT with a single undesirable and that may result in rejection or being put case experimental design in six individuals suffering from down (Gilbert 1998). Included in a shameful experience are social anxiety. The aim was to establish whether CFT lead oftentimes self-critical and self-attacking cognitions (Gil- to increases in self-compassion, and reductions in shame, bert and Miles 2000). These cognitions are an important self-criticism and social anxiety. Moreover, the aim was to target for intervention as they trigger, perpetuate and investigate to what extent participants were satisfied and intensify emotional reactivity. For example, Longe et al. experienced CFT as helpful in coping with social anxiety (2010) compared the neuronal correlates of self-criticism and in increasing self-compassion. Taken together the and self-reassurance using fMRI and showed that self- preliminary results show that CFT is a promising approach. critical thinking engaged brain regions signaling greater CFT was effective for 3 of 6 participants, probably effec- error processing and behavioral inhibition. Self-reassur- tive for 1 of 6 and more questionably effective for 2 of 6 ance on the other hand, engaged brain regions similar to participants. These results add to the empirical evidence expressing compassion and empathy towards others. that CFT is a promising approach to address problems with Indeed, compassion and empathy towards the self could self-compassion. This research body is as of yet small, and be seen as the antidote of self-criticism and shame and it more studies are needed. appears that highly self-critical individuals have a very hard time mobilizing self-compassion. For example, there Keywords Compassion focused therapy Á Self-criticism Á are indications that highly self-critical individuals have Shame Á Social anxiety difficulties attenuating their physiological reactivity through compassionate self-soothing (Rockliff et al. 2008). In this study, practicing self-soothing imagery was gener- ally 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. K. Boersma (&) Á A. Ha˚kanson Á E. Salomonsson Á Moreover, several treatment studies show that high pre- I. Johansson treatment levels of self-criticism in general predict worse Department of Law, Psychology and Social Work, O¨ rebro University, O¨ rebro, Sweden treatment outcome (Cox et al. 2002; Marshall et al. 2008). e-mail: [email protected] These results indicate that self-criticism is hard to change 123 90 J Contemp Psychother (2015) 45:89–98 and that the mere (self) instruction to be more self-reas- perspective with specific cognitive, behavioral, mindful- suring and empathetic may not suffice for those who are ness and compassion focused imagery exercises that foster chronically self-critical. Over and above the direct patho- self-care in the form of compassion for self and for others. genic effect that self-criticism has in firing up the threat The aim of CFT is to, through these efforts, increase system, it seems that self-critical individuals may be unable empathy and sympathy for one’s own distress, increase to access and generate self-directed warmth and soothing. mindful awareness without judgment or blame, increase the This means that psychological interventions should not ability to refocus and activate safety-signaling processing only focus on decreasing self-criticism but also on helping systems, generate compassionate feeling (warmth and self-critical individuals access and build positive emotional affiliation) and increase compassionate attention, thinking experiences in the form of warmth, soothing and self- and behavior. reassurance. While CFT has been extensively described only a few, The concept of self-compassion has received increasing small, empirical studies have been published (e.g. Gilbert clinical and scientific interest. While there are several and Procter 2006; Laithwaite et al. 2009; Judge et al. 2012; definitions, one of the most commonly cited is Neff’s Lucre and Corten 2013; Gale et al. 2014). The results of definition (Neff 2003), describing self-compassion as being these studies are promising but there is a need to replicate kind and understanding towards oneself in instances of pain and extend these results to other populations and settings. or failure rather than being harshly self-critical; perceiving For example, no empirical data has yet been published on one’s experience as part of the larger human experience the effectiveness of CFT on social anxiety disorder, rather than seeing them as shameful and isolating failures although reports and accounts have been made of it being and holding painful thoughts and feelings in mindful used clinically (Henderson 2011). Yet, CFT might be an awareness rather than over identifying with them. These especially suited treatment for social anxiety disorder given concepts draw largely on Buddhism, but are, in many ways, its large shame and self-criticism component. For example, also related to humanistic psychology themes stressing the Cox et al. (2004) showed that self-criticism was robustly importance of self-acceptance and self-kindness (Barnard associated with social phobia in a large general population & Curry, 2011). However, the concept of self-compassion mental health survey. Moreover, Gilbert (2000) points out can be said to stretch beyond just self-acceptance and self- the great overlap between social anxiety and shame prob- kindness to incorporate a sense of inter-connectedness to lems in that both can be viewed as submissive strategies in humanity at large, equanimity, as well as hope and mean- contexts where people feel vulnerable to loss of social ing in the face of life’s difficulties (Neff et al. 2007). standing, attractiveness, rejection and/or criticism. Indeed, Several-related-treatment approaches have been devel- this study showed that there is a strong association between oped recently, as a means to specifically and directly target social anxiety and shame. In addition, there is evidence that compassion (see Singer and Botz 2013). These therapies people with social anxiety have problems with self-com- share in many ways the strengths of mindfulness oriented passion. For example, Werner et al. (2012) studied self- therapies such as Acceptance and Commitment Therapy, compassion in a clinical sample of individuals diagnosed Dialectical Behavior Therapy and Mindfulness Based with social anxiety disorder. The results showed that Stress Reduction (Barnard and Curry 2011), but stand out individuals with social anxiety disorder had significantly in their explicit focus on increasing compassion. One of lower levels of self-compassion than healthy controls and these, Compassion Focused Therapy (CFT; also referred to that low self-compassion was associated with greater fear as Compassionate Mind Training (CMT)) focuses on for both negative and positive evaluation. Thus, the large developing a warm, compassionate and accepting attitude self-criticism component and the low level of self-com- towards the self and others in order to specifically coun- passion suggest that targeting self-compassion may be teract shame, self-criticism and isolation (Gilbert 2014). particularly important in individuals with disorders that While originally designed and tested for pervasive prob- include problems with social anxiety. lems with self-criticism in chronically depressed patients Therefore, as a pilot study, we aimed to investigate the (Gilbert and Procter 2006), CFT has been extended to effect of CFT on self-compassion, shame and self-criticism conceptualize problems with shame and self-criticism in in individuals with social anxiety. As the application of this populations with for example eating disorder, psychosis treatment in this population is a largely unexplored area, and social anxiety disorder (e.g. Gale et al. 2014; Gumley we make use of a replicated single case experimental et al. 2010; Werner et al. 2012). CFT integrates influences design (Kazdin 2011). While this design provides the from cognitive behavioral theories, affective neuroscience, opportunity to draw valid inferences of treatment effec- Buddhism, attachment theory and evolution theory