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 implica- tions 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. J. Clin. Psychol. 2020;76:2079–2096. wileyonlinelibrary.com/journal/jclp © 2020 Wiley Periodicals LLC | 2079 2080 | MATOS AND STEINDL 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 phy- siological 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 neurophy- siological 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 com- passionate 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