Compassionate Mind

If I may return to the 'depression in heaven' idea and the cultural beliefs about the reasons that life can be so harsh, I must admit I share the Buddhist view here (Dalai Lama, 2001). And over the years I have, like many others, come to the view that compassion is a powerful antidote to depression (e.g., Rubin, 1975). Compassion is an important perceived element in therapists; that is, they are seen as empathic, as trying to understand, share in the pain of depression, and find a way out (they offer a flow of positive acceptance signals)—and certainly not as shaming or degrading. However, there can also be compassion for the 'suffering of the self', from the self. The theory behind this view is derived from what is known about the physiological effects of supportive as opposed to hostile signals (Gilbert, 2000c). If people give themselves negative signals and put themselves down a lot, they can get depressed, just as if someone else were abusing and bullying them. The brain (limbic system) responds to bullying signals it cannot defend against with stress reactions and ultimately demobilisation (Whelton, 2000). And if a person feels defeated and unlovable, this will lower PA. However, we know that if people receive positive signals in the form of being valued, supported, and cared for (and the affect of these signals is crucial), this is good for their physiology (Cacioppo et al., 2000). Hence, it can be suggested that developing self-supporting signals (or the care-giving mentality; Gilbert, 1989) for the self can be physiologically regulating. The details of the therapy approach can be found elsewhere (Gilbert, 2000c), but a flavour of it can be given briefly.

In compassionate mind work, we are trying to raise PA for the self and develop new internalised (caring), self-to-self relationships. To do this, people might first learn to identify things they feel depressed about, such as failing in a relationship for which they blame themselves. As in basic cognitive therapy, a person might test certain ideas (evidence for and against) about blame or 'being unlovable' and so forth. Hence, one may have a chain of negative thoughts and a set of alternatives. However, it can be important to help people to be empathic to their own distress (for example, it is sad that I have this difficulty) and give space to grieving, if this is appropriate. Some people bypass their sadness and grief. They do not know how to process it, are frightened of it, or may focus on anger and have thoughts such as: 'I am stupid or weak to let this upset me; I should be stronger', or 'It's my own fault anyway, so I deserve it.' They use a basic dominating, bullying style even when distressed. If they treated other people this way (kicking them when they are down), they would be seen as somewhat psychopathic.

So we try to point this out; it is not just the unreasonableness of some of the attacks but the anger and contempt that is salient (Greenberg et al., 1990). To counter this, we focus on the feelings of warmth and compassion, perhaps using imagery of a compassionate person and how such a person might look or sound as a helper. Once this affect is elicited (to some degree), they go over their 'alternative coping thoughts' in their mind, trying to generate as much compassion and warmth as possible. The therapist may say, 'Let's go though these alternative thoughts again, but as you read them through try to imagine hearing them in your mind, as if a compassionate part of you were speaking them.' Or the therapist might say, 'Can you imagine the voice of someone who is very understanding of the distress you feel, and who is speaking warmly and compassionately to you to encourage and support you.' The idea here is to get a warm emotional tone in the alternative thoughts. This can be practised a number of times in the therapy. The idea is directly to undermine the affect of the self-attacking, to get into the 'limbic' processes. In a way, it is like trying to generate an alternative incompatible affect, not unlike teaching people relaxation as a counter-affect to anxiety. Warmth can be a counter to hostility and contempt, and it touches many other aspects of ongoing work, such as forgiveness (Gilbert, 2000c;e).

To date, there is no clear evidence that this approach gives any additional advantage over evidence-based challenges and behavioural change. However, since we developed this approach with self-critical depressed people, a number of them have suggested that this was a key aspect for them in beginning to believe in their alternative thoughts and generate internal feelings of being supported. One patient said that when she felt bad she sometimes did not challenge her thinking at first, but recognised her distress (rather than focus on 'self as bad'), used her imagery, took a moment to try to focus on feelings of warmth, and then gradually was able to challenge her thinking. Helping people become compassionate to their own distress and mistakes, cope with grief processes if necessary, learn how to challenge negative automatic thoughts with warm affect in the challenge (rather than detached logic), and develop compassionate imagery is an ingredient added to a basic cognitive approach. However, helping people develop inner warmth can be difficult. For example, it can put people in touch with enormous grief that for a variety of reasons can seem overwhelming.

In the last 10 years, there has been a quiet revolution in ideas of how to work with depressed people's thinking; one form is called mindfulness (e.g., Teasdale, 1999). We lack the space to explore this here, except to say that this approach focuses on the importance of detached observation of one's own thinking, acceptance, non-judgement, non-striving, and letting go. Some of these practices are derived from Buddhist approaches to mind regulation and philosophy (for example, the Buddha's Four Noble Truths, teaching that a root of our suffering lies in our attachment to and cravings for things that are impermanent). Moreover, Buddhism has had a strong focus on metacognition (although Buddhists do not call it that) (Dalai Lama, 2001). Hence, these approaches may also be ideal for learning how to work with one's evolved archetypal mind that can push and pull in all directions. Personally, I am also interested in Buddhist approaches to compassionate healing imagery (Mullen, 2001)—an affective element not prominent in mindfulness as yet. Compassionate mind work is linked to an evolution-physiology theory about the role of external and internal supportive caring signals, and is part of a larger theory of mental processes called 'mentality theory' (Gilbert, 1992, 2000c).

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Letting Go, Moving On

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