A Case Illustration of Compassion‐Focused Therapy for Shame and Perfectionism

Received: 21 May 2020 | Revised: 25 August 2020 | Accepted: 27 August 2020 DOI: 10.1002/jclp.23055

CLINICAL CASE REPORT

“You are already all you need to be”: A case illustration of compassion‐focused therapy for shame and perfectionism

Marcela Matos1 | Stanley R. Steindl2

1Center for Research in Neuropsychology and Cognitive and Behavioral Intervention Abstract (CINEICC), Faculty of Psychology and This paper presents the case of a 28‐year‐old woman Educational Sciences, University of Coimbra, Coimbra, Portugal diagnosed with major depressive disorder, with strong 2Compassionate Mind Research Group, features of perfectionism, shame, and self‐criticism, treated School of Psychology, University of via 12 sessions of compassion‐focused therapy (CFT). CFT Queensland, Brisbane, Queensland, Australia is an integrative therapeutic approach that draws upon Correspondence evolutionary psychology, attachment theory, and applied Marcela Matos, Center for Research in Neuropsychology and Cognitive and psychological processes from neuroscience, clinical and Behavioral Intervention (CINEICC), Faculty social psychology. The effectiveness of compassion focused of Psychology and Educational Sciences University of Coimbra, Rua do Colégio Novo, approaches with perfectionism and self‐criticism across a ‐ Apartado 6153, 3001 802 Coimbra, Portugal. range of clinical disorders is becoming increasingly well‐ Email: [email protected] established. Given this mounting evidence, a four‐phase, 12‐session CFT treatment plan was developed for this case: (1–2) establishing the therapeutic relationship; (3–4) psychoeducation regarding the evolutionary model of compassion; (5–8) compassionate mind training and skills development; (9–11) working with perfectionism, shame, and self‐criticism. A follow‐up session focused on envisioning a compassionate future. Therapeutic process and clinical outcome will be discussed, as well as implications for using CFT in clinical practice, especially where perfectionism, shame, and self‐criticism are part of the clinical presentation.

KEYWORDS case illustration, compassion‐focused therapy, perfectionism, self‐criticism, shame

Scientific editing by Giancarlo Dimaggio.

1 | INTRODUCTION

Compassion has become a major focus for research over the last 20 years, with burgeoning evidence supporting its benefits for mental health, emotion regulation, and social relationships (e.g., Goleman & Davidson, 2017; MacBeth & Gumley, 2012), and its positive impacts on physiological health (e.g., Kirschner et al., 2019). In light of these significant benefits associated with compassion, a number of compassion‐based interventions and psychotherapies, that specifically aim to cultivate compassion, have received empirical support for their positive impact on mental and physical wellbeing (e.g., Kirby, Tellegen, & Steindl, 2017). One of these psychotherapeutic interventions is compassion‐focused therapy (CFT; Gilbert, 2010, 2014), which was specifically developed to work with individuals experiencing high levels of shame and self‐criticism (Gilbert & Irons, 2005), and is a promising therapeutic approach for associated perfectionism.

1.1 | CFT

CFT is an integrative therapeutic approach that draws upon evolutionary psychology, attachment theory, and applied psychological processes from neuroscience, and clinical and social psychology (Gilbert, 2010, 2014). In CFT, compassion is defined as an innate motivation, evolved out of the mammalian caring motivational system, that orients humans to a sensitivity to suffering in self and others with a commitment to try to alleviate and prevent it (Gilbert & Choden, 2013; Gilbert, 2019a). Hence, CFT focuses on two psychologies of compassion. The first psychology is linked to the motivation to engage with suffering, and the second psychology is focused on action, particularly to help alleviate and prevent suffering. CFT encompasses psychoeducation on the evolved and complex nature and functioning of the human mind and emotional functioning. In CFT, emotions are grouped into three basic emotion‐regulation systems, which have evolved in humans and other animals to facilitate our chances of survival and reproduction (Gilbert, 2010). The threat/self‐protection system is linked to emotions like anxiety, anger, and disgust, helping us quickly identify and respond to threats. This system orients us toward perceived threats and motivates us to action (i.e., defensive responses: flight, fight, or freezing/submission). The drive‐excitement system is linked to emotions of excitement and joy, which motivate and energize us to pay attention to, move towards and pursue resources (e.g., food, social status, sexual opportunities) that may be advantageous to us, our offspring, or our social group. CFT highlights people's tendency to find themselves trapped between the threat and drive systems, which often gives rise to high levels of shame, self‐criticism, and feelings of failure (Gilbert, 2014). The soothing‐affiliative system is linked to feelings of calmness, contentment, and safeness, and helps us to engage in periods of rest when we are neither threatened nor driven to pursue or achieve. This system orientates us to give and receive care from others, being particularly sensitive to affiliative social signals. The soothing system plays a crucial role in regulating our threat and drive systems (Gilbert & Choden, 2013; Gilbert, 2010; Kolts, 2016). According to CFT, compassion is rooted in a caring motivational system and can be textured by emotions arising from each of the three systems (Gilbert, 2010, 2019a). Compassion is triggered by distress and suffering stimuli, and the associated emotions are complex and context‐dependent. For example, a fire‐fighter entering the smoke‐filled house to save people might experience anxiety and feelings of urgency, someone witnessing an injustice might feel angry, or a mother empathically soothing her child after a nightmare might experience calmness and tenderness (Gilbert, 2019a). Neurophysiological evidence has established that the activation of the threat system is associated with physiological arousal (e.g., activation of the sympathetic nervous system), interfering with neural structures related to metacognitive and theory of mind functioning (e.g., prefrontal cortex; amygdala) and the processing of socio- emotional stimuli, therefore decreasing one's ability for higher‐order cognitive capacities (e.g., theory of mind, empathizing, perspective taking; LeDoux, 1998; Petrocchi, & Cheli, 2019). On the contrary, the soothing‐affiliative MATOS AND STEINDL | 2081 system is associated with the activation of the parasympathetic nervous system, which supports social brain functioning and provides feelings of safeness, increases the ability to activate the prefrontal cortex, enables metalization capacities, and fosters emotion regulation (Kirby, Doty, Petrocchi, & Gilbert, 2017; Petrocchi, & Cheli, 2019). Importantly, research has consistently shown that compassion training is linked to parasympathetic nervous system activation and higher heart‐rate variability (HRV, a physiological marker of increased emotion regulation which facilitates, and is facilitated by, an approach motivation to suffering), and the inhibition of the neurophysiological default threat response (Di Bello et al., 2020; Kirby et al., 2017; Petrocchi, & Cheli, 2019). CFT uses breathing practices, friendly voice tones, facial and body expressions, and imagery practices, that focus on activating and developing soothing‐affiliative processing systems (e.g., parasympathetic system) that facilitate the regulation of affect (e.g., downregulation of the threat system), and help soothe and calm individuals when distressed (Gilbert, 2010, 2014;Kirbyetal.,2017). Extensive studies on HRV and the physiological underpinnings of social brain/motives have empirically supported the CFT model and its practices (Di Bello et al., 2020;Kirbyetal.,2017; Matos et al., 2017; Petrocchi, & Cheli, 2019). CFT also includes psychoeducation and focuses on helping people understand that the way that the human brain has evolved makes us vulnerable to negativity bias, self‐critical self‐monitoring, fearful imagining, and rumination. Such insights shift attention from shaming and blaming the self for these difficulties to working with them compassionately (Gilbert & Choden, 2013). CFT incorporates case formulation, psychoeducation, and a variety of compassionate mind training (CMT) practices, as well as working with fears, blocks and resistances to compassion as they arise (Gilbert, 2010, 2014; Kolts, 2016). CMT includes exercises that aim to develop the client's soothing‐affiliative system, such as breathing (e.g., soothing rhythm breathing) and imagery (e.g., safe place imagery), and a set of exercises (e.g., multiple selves), imagery practices (e.g., cultivating the compassionate self), and acting techniques (e.g., embodiment of the compassionate self), focused on the cultivation of the client's own ideal compassionate self and on compassionate mind skills development, as well as working with self‐criticism and conflicting or difficult emotions. A number of these exercises are described as part of Section 2 below. These practices aim to develop the physical and mental competencies that facilitate self‐grounding, mind awareness, the ability to slow down and take a compassionate focus and orientation to self, to others, and to help balance different types of emotion and work with life's difficulties (Gilbert & Choden, 2013; Gilbert, 2010). The therapeutic effectiveness of CFT and CMT in working with shame and self‐criticism in the context of a range of clinical disorders and nonclinical populations, is becoming increasingly well‐established (e.g., Kirby et al., 2017; Leaviss & Uttley, 2015; Matos et al., 2017).

1.2 | Shame and self‐criticism

Shame is a self‐conscious and socially‐focused emotion that involves feelings of inferiority, social unattractiveness, defectiveness, and powerlessness, along with a desire to escape, hide, or conceal deficiencies. This universal, sometimes incapacitating emotion, is central to one's sense of self, social and moral behavior, and vulnerability to mental health problems (Gilbert, 2019b; Tangney & Dearing, 2002). In CFT, shame is viewed in light of an evolutionary biopsychosocial model (Gilbert, 2007; Matos, Steindl, Gilbert, & Pinto‐Gouveia, 2020), according to which it is triggered by threats to one's social self and status via criticisms and rejections, acting as an involuntary defensive response to the awareness that one's social attractiveness is under threat or has been lost, alerting individuals to disruptions in their social rank and social relationships. It is thought to have evolved as a damage limitation strategy to keep the self safe from rejection, exclusion, attacks or disengagement from others, and corresponds to evolved behavioral adaptations that assist humans to address these threats and successfully navigate their social environments, ensuring human's (social) survival and welfare (Gilbert, 2007, 2019b). Shame is therefore linked to a competitive social mentality, where higher‐order cognitive abilities, such as the theory of 2082 | MATOS AND STEINDL mind or mentalizing, are recruited in the monitoring and processing of social cues about one's attractiveness in the eyes of others (Gilbert, 2007). However, we now know that experiencing failure in competitive contexts impairs one's abilities to mentalize and think about one's and others’ mental states (Colle et al., 2020). Hence, the potential for shame is universal, although it can vary in terms of triggers, intensity, and chronicity (Matos et al., 2020). According to this model, shame includes two types of evaluation and feelings that often come fused together in shame experience: external and internal shame (Gilbert, 2007). External shame relates to the experience of oneself as existing negatively in the minds of others, as having deficits, failures or flaws exposed. One believes that others see the self as unattractive, inferior, inadequate, disgusting, worthless or bad, and that others are looking down on the self with a contemptuous or condemning view and might (or already have) disengage, reject, exclude or even attack the self. One's attention and cognitive processing are attuned outwardly, directed to what is going on in the mind of the other about the self, and one's emotional reaction to such perceptions (e.g., fear and anger) textures the full shame response. The behavior is orientated towards trying to positively influence one's image in the mind of other (e.g., by submitting, appeasing, or displaying desirable qualities; Gilbert, 2007). Internal shame is linked to the inner dynamics of the self and to how one judges and feels oneself (Gilbert, 2007). It is linked to global self‐ devaluations and feelings of being inadequate, inferior, undesirable, weak, disgusting, or globally bad. The attention and cognitive processing are directed inwardly to one's emotions, personal attributes, and behavior, and focused on the self's flaws and shortcomings. According to Gilbert (2007), internal shame can be seen as an internalizing defensive response to external shame, where one may begin to identify with the mind of the other and engage in negative self‐evaluations and feelings, seeing the self, in the same way, others have (as flawed, inferior, undesired and globally self‐condemning), for purposes of restoring one's image and protect the self against rejection or attacks from others. Internal shame can be related to a process of internal shaming, linked to the painful internal experience of self‐criticism and self‐persecution (Gilbert, 2007; Gilbert, Clarke, Hempel, Miles, & Irons, 2004). Shame‐proneness and self‐criticism may be rooted in shame experiences in childhood and adolescence (Matos et al., 2020). Self‐criticism is a process of self‐to‐self relating, characterized by critical and hostile self‐evaluation. Self‐ critical individuals often experience feelings of shame, inferiority, worthlessness, and failure and tend to be focused on goal achievement, engage in harsh self‐judgment, and being unable to derive pleasure from achievements (Blatt & Zuroff, 1992). Self‐criticism can be seen as an internal self‐monitoring evolved defensive strategy typically activated when people feel they have failed in important tasks, or if things go wrong (Gilbert et al., 2004), According to Gilbert, self‐criticism is not a single process but varies in terms of forms and functions, which mirror and are adapted from evolved competencies that regulate external relationships. One form of self‐criticism is focused on disappointment, inferiority, and feelings of inadequacy; the other form of self‐criticism is much more pathogenic and focuses on self‐disgust and self‐hatred. However, an alternative response to failure can be compassion for the self, focused on self‐reassurance, one's positives, and active coping (Gilbert et al., 2004). Research has shown that both these forms of self‐criticism are positively correlated to psychopathology indicators, whereas the ability to be self‐reassuring is negatively associated with such indicators (e.g., Gilbert et al., 2004; Werner, Tibubos, Rohrmann, & Reiss, 2019). Shame and self‐criticism are transdiagnostic, permeate many disorders, increase vulnerability to psychopathology, affect the expression of symptoms, elevate the risk of relapse, and influence psychotherapy outcome (e.g., Gilbert & Irons, 2005; Tangney & Dearing, 2002; for reviews see Kim, Thibodeau, & Jorgensen, 2011; Löw, Schauenburg, & Dinger, 2020; Werner et al., 2019).

1.3 | Perfectionism

Research indicates that shame and self‐criticism are associated with forms of perfectionism, and that individuals’ perfectionistic characteristics related to shame and being criticized are particularly pathogenic (e.g., MATOS AND STEINDL | 2083

Ashby, Rice, & Martin, 2006; Dunkley, Blankstein, Zuroff, Lecce, & Hui, 2006; Dunkley, Zuroff, & Blankstein, 2006; Fedewa, Burns, & Gomez, 2005; Gilbert, Durrant, & McEwan, 2006; Stoeber, Harris, & Moon, 2007). Perfectionism has been described as “striving for flawlessness” and is perceived as a multidimensional and multifaceted characteristic (e.g., Flett & Hewitt, 2002; Frost, Marten, Lahart, & Rosenblate, 1990). Individuals with high levels of perfectionism are characterized by setting excessively high standards for performance accompanied by tendencies for overly critical evaluations of their behavior and increased proneness to experience shame (Flett & Hewitt, 2002; Frost et al., 1990; Stoeber et al., 2007). Perfectionism is present in a variety of clinical presentations, being related to various psychological difficulties such as rumination, depression, anxiety, obsessive‐compulsive disorder, eating psychopathology, and personality disorders (e.g., for a review see Limburg, Watson, Hagger, & Egan, 2017). Importantly, mounting research suggests that self‐compassion can be a protective factor against the pathogenic impact of perfectionism. Self‐compassion was found to reduce the strength of the relationship between maladaptive perfectionism and depression in adolescents and adult samples (Ferrari, Yap, Scott, Einstein, & Ciarrochi, 2018) and to partially mediate this relationship in college students (Mehr & Adams, 2016). Also, self‐ compassion was found to mediate the association between perfectionism and body image satisfaction in college women (Barnett & Sharp, 2016). However, research exploring the efficacy of CFT for perfectionism, in particular a randomized clinical trial study, is still lacking. Therefore, a therapeutic intervention like CFT, by focusing on cultivating compassion and promoting adaptive affect regulation, while also working with shame and self‐criticism, is especially suitable for individuals where perfectionism emerges as a central feature of their clinical presentation and is related to their current symptomatology. This paper presents a clinical illustration of a CFT approach to work with perfectionism in the context of major depressive disorder and obsessive‐compulsive disorder comorbidity.

2 | CASE ILLUSTRATION

2.1 | Presenting problem and client description

Mary, a 28‐year‐old single woman studying accounting at university as a full‐time student, presented with a severely depressed mood that had persisted for several months throughout the second semester of her third‐year studies. At the time of the presentation, she was approaching her final exams and felt unable to complete them, given the effects of a depressed mood on her ability to study. She described feeling down most of the day, most days of the week. Her sleep was severely disturbed, and she experienced onset and maintenance insomnia. She felt tired and lethargic all day, and prone to falling asleep during the day. Her motivation was severely compromised and she was no longer attending lectures or doing the required study. She reported that whenever she tried to study she could not concentrate, having to read and reread sections until she felt exasperated and tearful. She indicated a poor appetite, had lost about 3 kg, and had lost interest or pleasure in a number of activities she once enjoyed, such as her regular exercise and participation in music. According to Mary, she had first become depressed about 6 months before, just as she approached the examination period of the previous semester. A highly academically successful student up until that point, Mary described how the pressure to continue performing at that level had become overwhelming by the start of her third year. She said that her goal was to pursue postgraduate studies after her undergraduate studies were complete, and she felt an unrelenting internal pressure to continue to get excellent grades, despite having an almost “perfect” grade point average in her course so far. She had received awards and commendations for her work and achievements, however, she felt very concerned about maintaining these results. In fact, she said that her previous success gave her no consolation, as it set a precedent that she felt she could not maintain, and she did not see it as evidence of her capacity for future success. 2084 | MATOS AND STEINDL

On further inquiry, it became evident that Mary exhibited perfectionistic and self‐critical thinking styles. For example, she said, “I mustn't make mistakes…I'm just a total failure…If I don't get into the post‐graduate studies it'll just mean I'm worthless…People will see me as a fraud…I need to do more than most people to do ok at uni…I just need to work harder…Nothing ever seems good enough…Sometimes I just feel disgusted with myself…” Mary was the only child to a father who was a medical specialist and a mother who had been a nurse but ceased paid work when Mary was born and has focused on home duties since then, as well as volunteering first at Mary's school and later at an animal shelter. Mary described her father as absent much of the time due to work, and aloof and lacking in warmth when he was home. She said her mother was over‐involved and highly anxious, often worried about what others thought of her and Mary, and insisting that Mary be on her best behavior and always “top of the class.” According to Mary, performing well at school “got Dad's attention and got Mum of my back.” Throughout school, Mary had a small number of friends and was often studying, practicing piano, and attending dance school when her friends or other young people from school were socializing. She achieved dux at high school and immediately after school she attended university and studied medicine, “probably to please Dad.” After completing her medical degree she decided that she did not want to be a doctor, worked for 2 years as a receptionist in an accounting firm, and eventually decided to return to university to enroll in an accounting degree.

Mary completed six questionnaires at intake and posttreatment: 1. Depression Anxiety and Stress Scale (DASS‐21; Lovibond & Lovibond, 1995). 2. Multidimensional Perfectionism Scale‐Short Form (MPS‐SF; Hewitt and Flett, 1991). 3. Forms of Self‐Criticism and Self‐Reassuring Scale (FSCSRS; Gilbert et al., 2004). 4. External and Internal Shame Scale (EISS; Ferreira, Moura‐Ramos, Matos, & Galhardo, 2020). 5. Compassion Engagement and Action Scale (CEAS; Gilbert et al., 2017), and 6. Fears of Compassion Scale (FCS; Gilbert, McEwan, Matos, & Rivis, 2011).

Mary's results on these measures at intake, as well as posttreatment, compared with normative means derived from each measure's source article above, can be found in Table 1. Mary scored in the extremely severe range for depression, and above average on perfectionism compared to a clinical sample. She was also very elevated on self‐criticism and shame. In terms of compassion, she score in the average range for both compassion for others and fears of compassion for others but scored below average on receiving compassion from others and self‐compassion, and above average on fears of receiving compassion from others and self‐compassion.

2.2 | Case formulation

At the time of her initial presentation for therapy, Mary met diagnostic criteria for major depressive disorder, severe, single episode according to the Diagnostic and Statistical Manual of Mental Disorders‐Fifth Edition (DSM‐5; American Psychiatric Association, 2013). Given Mary's preoccupation with work and study to the exclusion of leisure activities and friendships, an additional diagnosis of obsessive‐compulsive personality disorder (OCPD) was considered. However, while she presented with OCPD traits, this diagnosis was ruled out as she did not meet four or more of the DSM‐5 diagnostic criteria for OCPD. There was also no history of trauma or posttraumtic stress. However, Mary's depressive disorder was characterized by high levels of perfectionism, self‐criticism, and external and internal shame. The CFT case formulation (see Figure 1, adapted from Kolts, 2016) aims to develop an understanding of the origins of the presenting problem and maintaining factors to guide treatment, as well as to provide the client with an understanding of themselves that helps to de‐shame and de‐blame. To achieve this the client and therapist firstly explore historical influences, such as memories of early life experiences, especially emotional memories of warmth and safeness versus threat and shame. In Mary's case, her MATOS AND STEINDL | 2085

TABLE 1 Assessment results for intake and posttreatment

Questionnaire Intake Posttreatment

DASS‐21a Depression 14 (Extremely Severe) 6 (Mild) Anxiety 10 (Extremely Severe) 6 (Moderate) Stress 14 (Severe) 8 (Mild)

MPS‐SFb Self‐oriented perfectionism 23 (0.2 SD above the mean) 15 (0.9 SD below the mean) Other‐oriented perfectionism 26 (0.8 SD above the mean) 20 (0.1 SD below the mean) Socially prescribed perfectionism 22 (0.2 SD above the mean) 18 (0.4 SD below the mean)

FSCSRSc Inadequate self 33 (1.9 SD above the mean) 17 (0.0 SD above the mean) Hated self 10 (1.3 SD above the mean) 4 (0.0 SD above the mean) Reassured self 9 (1.8 SD below the mean) 15 (0.8 SD below the mean)

EISS External shame 9 (1.1 SD above the mean) 6 (0.0 SD above the mean) Internal shame 13 (2.6 SD above the mean) 8 (1.0 SD above the mean)

CEAS Compassion for others 73 (0.0 SD above the mean) 72 (0.0 SD below the mean) Compassion from others 46 (0.6 SD below the mean) 40 (1.0 SD below the mean) Self‐compassion 45 (0.9 SD below the mean) 51 (0.5 SD below the mean)

FCS

Fears of compassion for others 16 (0.5 SD below the mean) 17 (0.4 SD below the mean)

Fears of compassion from others 32 (1.5 SD above the mean) 20 (0.3 SD above the mean)

Fears of self‐compassion 39 (1.8 SD above the mean) 24 (0.6 SD above the mean)

Abbreviations: CEAS, Compassion Engagement and Action Scale; DASS‐21, Depression Anxiety and Stress Scale; EISS, External and Internal Shame Scale; FCS, Fears of Compassion Scale; FSCSRS, Forms of Self‐Criticism and Self‐Reassuring Scale; MPS‐SF, Multidimensional Perfectionism Scale‐Short Form. aDASS‐21 scores were compared with severity labels; bMPS‐SF scores were compared with means and standard deviations from the source article, which examined a clinical sample; cFSCSRS, EISS, CEAS, and FCS scores were compared with the means and standard deviations from the sources articles, which examined nonclinical samples.

early emotional memories were of a father who was distant and lacking in warmth, and a mother who was anxious and threat‐activating, specifically self‐conscious, social threats. She had few friends throughout her schooling and was often alone, lonely, and under pressure to perform. She developed a sense of herself as inadequate, and always felt a pressure to prove herself. The only sense of worth she had was in her ability to achieve academic success, and yet this rarely alleviated the pressure. To her, others were demanding, unavailable, focused on their own needs, and rarely there for her unless she succeeded. Others, such as her parents, were not experienced as caring or soothing, or willing or able to meet her needs above their own. Having established the historical influences in terms of significant early life experiences and learning history, the client and therapist identify the key fears that arose from those experiences. For Mary, the key external fears related to being judged by others as inadequate, unworthy, and ultimately shamed or rejected. The minds of others, and how she might be represented in those minds, became a source of great threat. 2086 | MATOS AND STEINDL

FIGURE 1 The compassion‐focused therapy formulation as presented to Mary

Her key internal fears were that she herself is a fraud and a failure, that she might lose control and be discovered, and ultimately, that she is unloveable. Key external and internal fears are very painful and often cause marked distress, and so people often make desperate attempts to alleviate or avoid this distress. These attempts present as external and internal safety strategies and defensive behaviours. Mary's externalized safety strategies have long taken the form of behavioral expressions of perfectionism, such as working harder, studying more, achieving, and succeeding. These external safety strategies were designed to evoke care and attention from her father, and reduce her mother's anxiety and over‐involvement. Internally, her primary safety strategies were her perfectionistic and self‐critical thinking styles. She was always insecurely striving for perfection, never consoled by past successes, and yet constantly attacking herself with hostile, self‐hating self‐criticism. Mary saw both perfectionism and self‐criticism as protecting her from her own feelings of inadequacy and shame, being motivating and helpful. Unfortunately, safety strategies and defensive behaviors can have maladaptive unintended consequences that maintain or exacerbate the person's presenting problems. The unintended consequences of Mary's safety behaviors were numerous. From an external point of view, she experienced greater isolation, largely from the amount of time she was alone working and studying, and fewer opportunities to experience attention and care from friends or other close relationships. Her father began to expect her excellent results and gradually reduced his interest in how well she achieved, becoming more aloof and disconnected from her. Her hard work and successes positively reinforced her mother's over‐involved behavior, so those increased. From an internal point of view, Mary felt increasingly isolated, lonely, and unloved. She felt overwhelming pressure to maintain her level of achievement. She became stressed and eventually burnt out, leading to her episode of depression. This leads to perpetuating changes to how the client experiences themselves relating to themselves and others. Mary was now caught in very difficult cognitive loops of perfectionism and self‐criticism. Her experience of that felt out of control and impossible to stop. By the time she presented for therapy, she was relating to herself with vicious self‐criticism and deep feelings of shame, given the way the depression had prevented her from doing any of her previous safety behaviors and caused her to feel more isolated and alone. She was relating to others as if no one was there for her, no one cared for her or supported her in the way she needed, and saw her as too much of a burden. And all she had to go back to was the old safety strategies that she had always relied on. MATOS AND STEINDL | 2087

3 | COURSE OF TREATMENT

Mary was referred to therapy by her general medical practitioner under an Australian Mental Health Care Plan that offers government‐funded Medicare rebates for up to 10 individual therapy sessions with a private practicing clinical psychologist per year. Mary attended 12 weekly 1‐h sessions, and a 13th follow‐up session, over the course of her therapy plan, 10 sessions covered by Medicare, and three‐session self‐funded. The session by session CFT treatment plan can be found in Table 2.Atthe time of her initial session, Mary had been prescribed antidepressant medication for the previous three months. She had not presented for individual psychotherapy before, and had been trying to manage her depressed mood with medication.

TABLE 2 Session by session compassion‐focused therapy treatment plan

Session Treatment phases number Session content

Phase 1: Establishing the therapeutic Session 1 Clinical interview, administering psychometric relationship questionnaires, developing an effective therapeutic relationship Session 2 CFT case formulation, de‐blaming and de‐shaming, identifying tasks and goals, agreeing on a treatment plan

Phase 2: Psychoeducation regarding the Session 3 Understanding the evolved nature of the “tricky brain”, evolutionary model of compassion “old” and “new” brain loops, the Three Circles Model Session 4 Introducing compassion, exploring the three flows of compassion (compassion for others, receiving compassion from others, and self‐compassion), working with fears, blocks and resistances to compassion

Phase 3: Compassionate mind training Session 5 Body‐based practices, including Soothing Rhythm and skills development Breathing, to create groundedness and stability Session 6 Differentiating “safety and safeness”, introducing the use of imagery, practicing Safe Place Imagery Session 7 Constructing an Ideal Compassionate Other, including wisdom, strength, and caring‐commitment Session 8 Learning, practicing and embodying the Compassionate Self, using a method acting approach

Phase 4: Working with perfectionism, self‐ Session 9 Exploring multiplicity, Multiple Selves Exercise: angry criticism, and shame self, anxious self, sad self, and compassionate self Session 10 Exploring the function of the perfect self and critical self, activating the compassionate self Session 11 Psychoeducation, shame and the evolutionary model, external and internal shame, exploring shame memories Session 12 Working with the shamed self via imagery regarding a shame memory, activating the compassionate self

Follow‐up Session 13 Follow‐up assessment, review of treatment, envisioning a compassionate future, planning ahead for practicing the three flows and anticipating trouble spots 2088 | MATOS AND STEINDL

3.1 | Phase 1: Establishing the therapeutic relationship

3.1.1 | Assessment, formulation, therapeutic relationship, safety and safeness, tasks and goals

Session one involved intake assessment, including the clinical interview and administration of psychometric questionnaires. While there was an information gathering component to this first session, emphasis was placed on developing a strong and effective therapeutic relationship. During this first phase of CFT, the clinician used reflective listening to help Mary feel heard and understood, accepted, validated, and valued. Accurate empathy helped the clinician understand Mary and develop a formulation. Given that as CFT progressed the client and therapist would be exploring the role of empathy in compassion, experiencing empathy early in therapy can inform those later discussions. Furthermore, reflective listening assisted guided discovery, guiding Mary toward dis- covering her own intrinsic wisdom, a key aspect of CFT. At one point during session one the clinician reflected, “ You work so hard, and you make a lot of sacrifices to do well in your studies, but then when you are successful, and get excellent marks, you never really feel it, or feel reassured by that.” Mary responded, “Yes, that's it exactly. The marks I get almost don't matter in the end, because I don't believe them and I think I'm just going to fail next time.” In session two, the clinician provided MarywiththeformulationinFigure1. The purpose of sharing the formulation is twofold. First, sharing the formulation helped to provide a rational for the treatment itself, and in the context of the formulation, the tasks and goals were discussed and established with Mary. In this case, Mary's goals for treatment were to work with her key fears, explore changes in her safety behaviors, and repair the unintended consequences. Taking a compassion‐focused approach was proposed, as something of an “antidote” to perfectionism and self‐criticism, and Mary agreed to proceed in this way. Second, having a clear sense of the formulation helped Mary to de‐shame and de‐blame herself for the situation she found herself in. She was able to see how the version of herself that she had become was shaped by her experiences. De‐shaming and de‐blaming would be themes that would continue to thread their way through the whole of the treatment plan, starting with the formulation.

3.2 | Phase 2: Psychoeducation regarding the evolutionary model of compassion

3.2.1 | Tricky brain, three‐circles model, what is compassion, why compassion, memories of giving and receiving compassion, intuitive wisdom, fears, blocks, and resistances, motivational enhancement

The purpose of session three of the CFT treatment plan was to help Mary develop mind awareness and understanding, especially understanding the evolved nature of the brain, the adaptive functions of the brain that aided human survival and reproduction, but that also come with various trade‐offs resulting in greater suffering. In CFT, this is colloquially referred to as “our tricky brain.” The discussion around the “tricky brain” elaborated upon what the therapist described as “old” and “new” brain functions. In this context, “old” and “new” are terms used to distinguish brain functions that are considered to have evolved at different times. “Old” brain functions are those that evolved earlier and are generally thought to be shared with other species, such as reptiles and mammals. “New” brain functions referred to those that evolved later, and are considered more specific to the human brain. With respect to old brain functions, Mary and the therapist explored the Three Circles Model, developed by Gilbert (2010), to capture in plain language the three key emotion regulation systems of the brain. This model incorporates threat, drive, and soothing systems of the brain, each represented by red, blue, and green circles, respectively. Mary was very aware of the threat system from the perspective of the fight/flight/freeze/appease response and its relationship with anger, anxiety, and disgust, and she related strongly with the notion of the drive MATOS AND STEINDL | 2089 system, especially the need for obtaining and achieving. At one point in session three, she said, “I think what I do is I use the drive system to compensate for the threat system.” This self‐discovery of her “threat‐based drive” was very important in her ongoing awareness and understanding of herself and how her perfectionism is maintained. Mary was least familiar with the soothing system, which refers to the important role of affiliation, connection, care, nurturing, and sense of social safeness in human survival. When discussing the soothing system May began to cry. After a few moments, she said, “This is the bit that's always been missing.” She went on to elaborate about how she never felt soothed as a child and the concept of feeling soothed was quite foreign to her. She found it very difficult to relate to the idea of self‐soothing. With respect to new brain functions, Mary and the therapist discussed the capacity of the human brain to imagine, remember, and be self‐aware. They also explored the hypersocial nature of humans, and the way humans monitor ourselves in relationship to others, including how oneself might be seen in the minds of others. Mary and the therapist discussed social rank theory, and humans’ constant endeavors to avoid being down‐ranked socially. The purpose of these discussions was to develop mind awareness and understanding around how the old and new brains can “get caught up in loops.” For example, the old brain threat system can be activated by new brain fearful imagining or imagined social threat. Mary reported that these new brain functions, and the way they can cause us difficulties, strongly resonated for her. She could see how fearful imagination and worry about the future, and ruminative recalling of the past, were drivers of her perfectionism. She also said, “I'm always so worried about what other people think. Sometimes I feel like I lose myself in my concerns about others, trying to please them or be approved of. And I can be so negative about myself.” At this point, the therapist introduced self‐criticism as part of the discussion and the way this arises from tricky loops in the brain, such old brain anxiety and disgust looping with new brain fearful imagination and concerns that others see her as inadequate or unworthy. Thus Mary and the therapist came to an agreed understanding of her “tricky brain” and the role of worry, rumination, perfectionism, and self‐criticism in her presenting problems. In session four the therapist introduced “compassion” more formally as “…a sensitivity of suffering in self and others, with a commitment to try to alleviate and prevent it.” Compassion was explored further by inviting Mary to describe her own experiences of receiving compassion. She found this difficult to do at first, however, she persisted and recalled a female teacher at junior high school who she felt had treated her compassionately. This had been a particularly difficult year for her socially at school, and she remembered the teacher had approached her one day in the library and “just started chatting.” She said the teacher was a “really good listener” and that she “seemed to know that I was struggling with things.” Mary described the teacher as having a number of qualities, such as warmth and care, wisdom and common sense, acceptance and nonjudgement, and playfulness and humor. Having drawn upon her intrinsic wisdom about compassion, the therapist then introduced the six attributes of the compassionate mind, including sensitivity, care for well‐being, sympathy, distress tolerance, empathy, and nonjudgement. She reported that these made sense to her, and so Mary and the therapist explored a time when she had been compassionate towards someone else. At this point, she described how she had found an injured blue tongue lizard in her front yard just a few days before. She had felt concerned for its well‐being and motivated to help. She was scared of touching it, but she found a towel and carefully picked up the hissing, wriggling lizard. She took the lizard to a 24‐h veterinarian who were very grateful that she had brought the lizard in, assuring her that they would keep the lizard and it should fully recover. She felt that was an example of her being compassionate, and was able to identify some key aspects of the compassionate mind: courageously engaging with suffering, and taking committed action to help. At this point, Mary abruptly said, “Yeah, but I don't deserve any of that.” She and the therapist started to explore the three flows of compassion (compassion for others, receiving compassion from others and self‐compassion) as well as the common fears, blocks, and resistances (inhibitors) to each of the three flows. Mary indicated that she was good at being compassionate towards others, but she felt very uncomfortable about receiving compassion from others or being compassionate towards herself. She was worried that receiving compassion would mean she was weak or self‐pitying, and the last thing she wanted was to be self‐pitying. The therapist engaged Mary in a motivational interviewing process 2090 | MATOS AND STEINDL to help her explore further both the inhibitors to compassion, as well as her perspective on the benefits, reasons, and motivations (facilitators) for compassion. Working with the inhibitors continued throughout the course of treatment, however, Mary reported that she could see the benefits and wanted to explore self‐compassion as a way to manage her perfectionism and self‐criticism better.

3.3 | Phase 3: CMT and skills development

3.3.1 | Body‐based and imagery practices, building wisdom, strength and caring‐ commitment, creating an ideal compassionate other, cultivating and embodying the compassionate self

CFT sessions five through eight were focused on compassionate mind skills development, drawing on six skill domains, including imagery, reasoning, behavior, sensory, feeling, and attention. Throughout the process of this skills development, CFT uses experiential exercises and activities designed ultimately to cultivate the compassionate self. Session five began with body‐based practices to develop behavioral, sensory and attentional skills, including an exercise in which Mary was invited to close her eyes and move into a compassionate posture involving feet flat on the floor, shoulders back, chest open, upright yet relaxed and eyes facing the horizon, bringing a friendly expression to her face, and creating a warm and friendly tone to her inner voice. To this, the therapist added soothing rhythm breathing, a slow, steady, smooth breathing rhythm designed to activate the parasympathetic nervous system and down‐regulate the mind and the body. Mary's initial response was to feel relaxed and sleepy in response to these exercises. While this is a positive effect, the intention of soothing rhythm breathing is also to find a way to create a sense of groundedness and stability, and so Mary tried the exercise again standing up. She said, “That felt different, I felt stronger or more solid or something. It was still relaxing, but not in a floppy way, more solid.” Mary was asked to practice this exercise regularly for homework. Next, in session six, the therapist added imagery and feeling elements to the exercise, incorporating the image of a safe place and associated feelings of safeness. Mary began with the body‐based practices, and then tried to imagine a place where she felt safe, peaceful, and comfortable. She was given a number of options to consider: home or nearby home, or somewhere further afield such as a beach or forest scene, or perhaps an imaginary place. She reported that she imagined a dam at her Uncle and Aunt's property where she visited on a number of occasions as a child. She remembered swimming in the dam, catching “yabbies,” and having “curious cows come over to watch me.” Mary was asked to play with safe place imagery for homework and bring to mind other scenes or memories, or find photographs of places that evoked a sense of safeness. Session seven involved constructing her version of an ideal compassionate other. Mary and the therapist worked together identifying what qualities she would really like to have in this ideal compassionate other. She came up with a list of qualities including calm, clever, friendly, warm, flexible but also takes things seriously when need be. Mary referenced the character of Professor McGonagall from the Harry Potter series as an example of her ideal compassionate other. This was discussed further in terms of the appearance, facial expressions, voice tones, and feelings of the ideal compassionate other, adding the qualities of wisdom, strength and courage, and caring‐commitment. The previous exercise was expanded, beginning with the body‐based practices, developing the image of a safe place, and then inviting the ideal compassionate other to visit Mary in this safe place and exploring what the ideal compassionate image might say or do to be helpful. After the exercise, Mary said, “Professor McGonagall said to me, ‘You are already all you need to be.’ It was amazing.” Finally, in session eight, the therapist began to incorporate the qualities of the ideal compassionate other, especially wisdom, strength and courage, and caring‐commitment, into a compassionate self. An imagery exercise was used to help Mary connect with a sense of herself as having these qualities, even if she didn't feel like she possessed these qualities yet, but just to imagine she had these qualities. MATOS AND STEINDL | 2091

Other practices were also used to help Mary embody her compassionate self. A “method acting” approach was taken. She was asked to take on the role of her compassionate self, stand in the therapy room, walk around, acting as her compassionate self. It was a playful and fun process, and Mary said, “It feels like my awareness of the world around me has just opened up. Just by raising my head and rolling my shoulders back, and slowing my breath, I feel I can walk around in a completely different state.” Thebrainandbodypatternsthatperfectionismandself‐criticism entail were discussed, namely a brain and body pattern that is closed, bowed, and narrow, while a compassionate brain and body pattern is open, playful, and exploring. Mary was asked to practice the method acting approach and see if she were able to move from learning about and practicing the compassionate self to embodying the compassionate self.

3.4 | Phase 4: Working with perfectionism, self‐criticism, and shame

3.4.1 | Understanding multiplicity, exploring the function of perfectionism and self‐criticism, understanding shame and shame memories, and bringing the compassionate self to the shamed self

Phase 4 of Mary's CFT treatment plan involved putting the compassionate self to work with difficult emotions. This began with Mary and the therapist exploring multiplicity, in other words, the idea that humans are multiples, with a range of brain and body patterns that may be activated to greater or lesser extents in any given situation. Session nine introduced the concept of multiple selves, specifically focusing on “the big three”: angry self, anxious self, and sad self. Mary explored each of these three in detail in terms of feelings, thoughts, physical sensations, focus of attention, behavioral urges, and underlying motives associated with a recent incident she had experienced with her father. The compassionate self was activated through the strategies that had been learned and practiced up to this point, and then explored Mary's compassionate self‐perspective of the incident with her father, across the same dimensions. The early work of psychoeducation and compassionate mind skill development helped prepare Mary to embody her compassionate self to work with difficult emotions associated with a real situation. For example, the words of her ideal compassionate other from session seven came spontaneously to mind. Her insights regarding her multiples selves, including the compassionate self, can be found in Table 3. Furthering this process, Mary and the therapist turned their attention to perfectionism and self‐criticism in session 10. The therapist conducted an analysis of the function of her “perfect self” via an imagery exercise. In this exercise, Mary was asked to bring to mind something about herself that she feels she should do perfectly, but about which she feels critical. She was asked to choose something in the moderate range of severity to begin with. She chose the current state of her apartment. In discussing what she thought might be the function of the perfect self, she said, “Well, it motivates me, makes me work harder and do better.” Mary and the therapist then explored her greatest fears were she to lose her perfectionism. She said, “I'd probably just fall apart, do nothing, achieve nothing, and for that matter everyone's opinions of me would be proven right. I am pathetic.” Mary and the therapist proceeded with the functional analysis exercise, which involved closing her eyes and bringing to mind her perfect self, as if it could take its own form, and imagine what it might look and sound like, what it might say, and how it might be feeling about her or want to do to her. The effect of this imagery exercise for Mary was to leave her feeling flat, frustrated and sad, and de‐motivated. She then activated the compassionate self, and repeated the same exercise regarding the current state of her apartment, but this time bringing to mind her compassionate self, as if it could take a form of its own, and imagine what it might look and sound like, what the compassionate self might say, how it might feel about her and importantly what sort of relationship the compassionate self wants to have with her. Mary: I see what you mean. I feel completely different after the second exercise. Using perfectionism and self‐criticism just doesn't achieve what it's supposed to. They make me feel worse. I'm stupid to keep going with it. Clinician: Did you notice what happened there? 2092 | MATOS AND STEINDL

TABLE 3 Exploring multiplicity and understanding Mary's multiple selves

Angry self Anxious self

Feelings: Frustrated, agitated, wronged. Feelings: Panicky, really worried.

Sensations: Worked up, tense, heart racing. Sensations: Heart racing, can't catch my breath.

Thoughts: “He's never there for me, he should Thoughts: What if he just doesn't love me, what if he doesn't care care like a proper father!” and just thinks I'm no good?”

Attention: Internally focused on memories of Attention: Scouring the incident for proof that he really doesn't feeling let down and wronged by the father. care, and fearful images.

Urges: To yell and scream at him, and make him Urges: To do something to please him, get his attention, make see just what a terrible father he has been. him care.

Motives: Righting the wrong, hurting him back, Motives: Protection from the threat of abandonment, from making him see what he's done. ending up alone. Sad self Compassionate self

Feelings: Despair, hurt, grief. Feelings: Calm, grounded, clear‐headed.

Sensations: Weak, crying, floppy at the knees. Sensations: Heart rate is slower, more stable in the body, my mind is calm.

Thoughts: “I've never had the father I needed. All I Thoughts: “This is really hard. It makes sense that you would want ever wanted was to be loved.” your father to love you. You'll be ok. You're already all you need to be. Let's breathe, go for a walk and call a friend.”

Attention: Focused on being alone, lonely, and Attention: Open to possibilities. depressed, can't see any hope.

Urges: To hide away, curl up, disappear, and to call Urges: To practice strategies and call a friend. my father to show him how upset I am.

Motives: Seeking care, comfort, nurturance, Motives: To be helpful, rather than harmful. wanting needs to be met.

Mary: [pause] Oh, yeah…self‐criticism. Clinician: “Mm…it's tricky, isn't it! How was the compassionate self part of the exercise for you? Mary: Well, the compassionate self really has my best interests at heart. It still wants me to do well, but in a much more supportive way. More encouraging.” Clinician: How did you feel after that second exercise? Mary: Well, I felt a bit more motivated, to be honest. I feel like giving the apartment a little bit of a clean, without overdoing it, and then going for a walk to clear the head. I think I'll do that! The final two sessions of Phase 4 were focused on working with shame. During session 11 the therapist returned to psychoeducation, defining shame as a universal human experience involving an intensely painful self‐conscious emotion where one feels inadequate, inferior, unworthy, or unloveable. Mary and the therapist discussed how shame is an evolved human emotion with adaptive functions to assist with identifying and responding to social threat, especially the threat of being viewed as unworthy, cast out of the group and left to survive on one's own. They discussed external shame, the belief that one is viewed by others as inadequate, inferior, unworthy, and unlovable, versus internal shame, one's own view that one is all of those things. Referring back to Mary's history, and the formulation, she and her therapist identified early emotional memories of shame experiences, and a lack of memories of warmth and safeness, as being the origins of her shame now, as well as the origins of her fears of receiving compassion from others or self‐ compassion. She began to see shame as lying behind her perfectionism and self‐criticism, and ultimately her depression. In session 12, Mary and her therapist worked with shame in an experiential way. The therapist began with an exercise that invited Mary to bring a shame memory to mind, and imagine the scene: where she was, who was there, MATOS AND STEINDL | 2093 what they were saying, their tone of voice, facial expression, and what they were doing. She was asked to imagine what they were thinking about her, what they were feeling about her. And then directing her attention internally in that moment of the shame memory, how she felt in the body, her posture, facial expression, urges, and what she wished she could do. Mary was invited to embody her shamed self, take on the felt sense of her shamed self in terms of posture, facial expression, and movement, and imagine seeing the world through the eyes of the shamed self. As the exercise continued, Mary was invited to move her body to a compassionate posture, bring a friendly expression to her face, create a warm and friendly tone to her inner voice, and slow down her breath into a soothing rhythm. With each out‐breath, she was asked to let go of tension, and slow her body and her mind. Following this, Mary was asked to activate the compassionate self, connecting with compassionate wisdom, strength and courage, and a caring‐commitment, imagining that she has these qualities and can embody this compassionate self. She was asked to reflect on what might be the compassionate self's greatest wishes for her, imagining its appearance, facial expression, and tone of voice. And then, Mary was asked to bring the shame memory to mind, but this time taking the perspective of the compassionate self, as if observing the experience play out, and trying to see behind the shame, understanding the shamed self, and how that part of her is suffering. Mary was asked to consider:

• What message would the compassionate self like to give the shamed self? • How might the compassionate self validate the hurt and suffering of the shamed self? • How might the compassionate self reassure the shamed self? • What encouragement might the compassionate self offer?

Finally, Mary was prompted to recall the method acting approach introduced in session eight, and to embody the compassionate self, standing, moving about the room, noticing her body posture, how she moved, her facial expression, and where she directed her attention. She was asked to just spend some time trying her best to embody her compassionate self before returning to her seat, sitting and breathing for a few moments, and bringing the exercise to a close. Clinician: How was that for you? Mary: That was hard. Clinician: Mm. Mary: Powerful. Clinician: Uh huh. Mary: I could really feel what it was like when my mother came into class one day and in front of everyone had a massive argument with the teacher because I didn't get 100% on a maths test. I felt so small, so worthless, so stupid! But then my compassionate self, and it was me this time, me now, and it felt like the whole scene became lighter, not so much darkness, and I just gave that 16‐year‐old version of myself a hug and I imagined us just hugging and crying together. And then, when you asked me to stand and move around, I took her with me, and imagined us wandering around together and telling her she wasn't alone anymore.” Clinician: Oh! Thank you, Mary, that sounds powerful indeed. Thank you for showing so much courage to approach all this. It's tough stuff. But also showing so much wisdom. You really know a thing or two about how to be compassionate with yourself. Mary: Yeah. Huh! Thanks.

4 | OUTCOME AND PROGNOSIS

Mary returned for one final, follow‐up session. At this point, Mary and the therapist reflected on the treatment they had worked through together, and reviewed some of the key points of compassion and self‐compassion, and cultivating the compassionate self to work with perfectionism and self‐criticism, and the shame that lay 2094 | MATOS AND STEINDL behind all that. They also spent some time imagining a compassionate future, identifying ways she could continue practicing compassion across the three flows, especially self‐compassion but also receiving compassion from others. They brainstormed the possible trouble spots that might be ahead, such as what to do about the university, and how to develop effective relationships with her parents. Mary was re‐administered the questionnaires from session one, and the results can be found in Table 1.Ascanbeseen,Maryimproved across the various measures, with her depression improving and moving into the mild category. Her perfectionism and self‐criticism both improved, as did her feelings of shame. Regarding compassion variables, her compassion for others and fears of compassion for others did not substantially change, however, these were both in the average range at intake. Her scores for self‐compassion, and fears of self‐compassion and receiving compassion from others all improved. Her scores on receiving compassion from others did not change, however, examining the items of this scale suggests that it measures the availability of people in her life to offer her compassion, and unfortunately this did not change across the treatment. Thus, Mary showed a significant amount of progress across the CFT intervention, however, a number of factors help inform prognosis. First, Mary presented after longstanding perfectionism throughout her childhood, adolescence, and adulthood. Second, it was identified that self‐criticism and shame played key roles in maintaining and exacerbating this perfection. Third, the limited amount of time for the intervention meant that perfectionism, self‐criticism, and shame were only directly targeted across four sessions, and while the early sessions provide important preparation for this later work, these aspects of the presentation could be addressed over additional sessions if time allowed. Finally, the finding on the CEAS regarding receiving compassion from others suggests that future CFT intervention may target her relationships, such as giving attention to fostering her family and friend relationships, helping her open up to receiving compassion from others, developing compassionate assertiveness in her interactions with others, and working with forgiveness. Some of this future work targeting her relationships might focus specifically on her relationship with her parents. Nevertheless, given her engagement with treatment, her implementation of the practices and techniques in her daily life, and the significant improvement she showed over the course of treatment, her prognosis is considered to be good.

5 | CLINICAL PRACTICES AND SUMMARY

Perfectionism has a critical role in psychopathology, and is often perceived as a transdiagnostic risk and maintaining factor for multiple psychological disorders. Shame and self‐criticism are known to be associated with perfectionism, and are also key vulnerability and maintenance factors for several mental health problems. CFT is an effective therapeutic intervention to work with shame and self‐criticism in the context of a variety of clinical disorders, and can be particularly relevant for individuals with high levels of perfectionism. This article described how CFT can be applied to reduce perfectionism by focusing on (a) developing a shared CFT case formulation; (b) offering psychoeducation regarding the evolved and complex nature of the human mind, the three affect regulation systems, and the evolutionary model and importance of compassion; (c) assessing and working with fears, blocks and resistances to compassion and enhance motivation; (d) cultivate compassion skills and competencies using CMT practices; (e) working self‐criticism and shame, and addressing perfectionism. Therefore, taking a CFT approach, cultivating compassion, promoting affect regulation and targeting shame and self‐criticism, can be especially fitting for individuals where perfectionism emerges as a dominant feature of their clinical presentation. Future research should pursue to empirically support the benefits of CFT in working with perfectionism.

ORCID Marcela Matos http://orcid.org/0000-0001-7320-7107 Stanley R. Steindl https://orcid.org/0000-0001-8934-5096 MATOS AND STEINDL | 2095

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How to cite this article: Matos M, Steindl SR. “You are already all you need to be”: A case illustration of compassion‐focused therapy for shame and perfectionism. J. Clin. Psychol. 2020;76:2079–2096. https://doi.org/10.1002/jclp.23055