Psychotherapy Research
ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/tpsr20
Compassion focused therapy in a university
counseling and psychological services center:
A feasibility trial of a new standardized group
manual
Jenn Fox , Kara Cattani & Gary M. Burlingame
To cite this article: Jenn Fox , Kara Cattani & Gary M. Burlingame (2020): Compassion focused
therapy in a university counseling and psychological services center: A feasibility trial of a new
standardized group manual, Psychotherapy Research, DOI: 10.1080/10503307.2020.1783708
To link to this article: https://doi.org/10.1080/10503307.2020.1783708
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Psychotherapy Research, 2020
https://doi.org/10.1080/10503307.2020.1783708
EMPIRICAL PAPER
Compassion focused therapy in a university counseling and
psychological services center: A feasibility trial of a new standardized
group manual
JENN FOX, KARA CATTANI, & GARY M. BURLINGAME
Brigham Young University, Provo, UT, USA
(Received 27 January 2020; revised 30 May 2020; accepted 11 June 2020)
ABSTRACT
Objectives: The feasibility and acceptability of a new Compassion Focused Therapy (CFT) group protocol were assessed in
a university counseling and psychological services (CAPS) center. Outcome measures included mechanisms of change,
compassion, and general psychiatric distress. Method: Eight transdiagnostic CFT groups composed of 75 clients met for
12 weekly sessions. Clients completed measures of fears of compassion, flows of compassion, self-reassurance, selfcriticism, shame, and psychiatric distress at pre, mid, and post time points. Self-report feasibility and acceptability data
were collected from therapists and clients, respectively. Significant and reliable change was assessed along with exploratory
analysis of CFT mechanisms of change using correlational analysis. Results: Significant and reliable change was found for
fears of self-compassion, fears of compassion from others, fears of compassion to others, self-compassion, compassion
from others, self-reassurance, self-criticism, shame, and psychological distress. Improvements in fears and flows of
compassion predicted improvements in self-reassurance, self-criticism, shame, and psychiatric distress. Conclusion: The
new CFT group protocol appears to be feasible, acceptable, and effective in a transdiagnostic CAPS population. The
identified mechanisms of change support the theory of CFT that transdiagnostic pathological constructs of self-criticism
and shame can improve by decreasing fears and increasing flows of compassion.
Keywords: group psychotherapy; mental health services research; outcome research
Clinical or methodological significance of this article: Compassion focused therapy—CFT research to date has been
based on different, non-standardized protocols, making it impossible to draw clear conclusions across studies. The present
study is the first to test a standardized group protocol created by the developer of CFT, Paul Gilbert. Each of the 12modules not only captures the core CFT components but also has a fidelity checklist to insure reliable delivery and make
further replication possible.
CFT is a trans-diagnostic model targeting self-criticism, shame and blame that have been shown to be
highly correlated with psychiatric distress. The
results of this study demonstrate that the new protocol replicates past effects on self-criticism, shame,
and blame along with larger effects on psychiatric distress measured by the OQ-45. The standardized
manual with additional therapist helps material
enables CFT groups to be run with fidelity checks
in clinical practice.
Research on compassion has found a number of positive associations, such as positive correlations with
mental health (e.g., MacBeth & Gumley, 2012) and
social relationships (e.g., Yarnell & Neff, 2013).
Not surprisingly, a variety of compassion-based treatments have been created in the past few decades
including Compassion-Focused Therapy (Gilbert,
2014); Mindful Self-Compassion (Neff & Germer,
2013); Compassion Cultivation Training (Jazaieri
et al., 2013); Cognitively Based Compassion Training (Pace et al., 2009); Cultivating Emotional
Balance (Kemeny et al., 2012); and Compassion
and
Loving-Kindness
Meditations
(e.g.,
Hoffmann et al., 2011). A recent meta-analysis
(Kirby et al., 2017) of compassion-based
Correspondence concerning this article should be addressed to Gary M. Burlingame Brigham Young University, 238 TLRB, Provo, UT
84602, USA. Email: gary_burlingame@byu.edu
© 2020 Society for Psychotherapy Research
2
J. Fox et al.
interventions found moderate pre–post effect sizes on
measures of compassion and psychiatric distress
(i.e., depression, anxiety) with both wait-list and
active control comparisons. These authors note particular promise for Compassion Focused Therapy
(CFT).
CFT is an integrated, evolution-informed biopsychosocial approach which combines traditional Buddhist teachings about mindfulness with compassion.
It’s theoretical underpinnings include attachment
theory, evolutionary psychology, and social mentality
theory (Gilbert, 2014). CFT recognizes that humans
evolved with a more advanced set of caring behaviors
than other mammals since our young are dependent
on parents far longer. These caring behaviors correspond to the physiological responses of soothing
and reassurance and are linked to the autonomic
nervous system and frontal cortex (Porges, 2017).
Compassion is a direct result of this strong caregiving
motivation in humans. Indeed, compassion in CFT is
defined as “sensitivity to suffering in self and others
with a desire to try to alleviate and prevent that suffering.” By activating these compassion processes, CFT
helps clients activate their innate caregiving processes
and the physiological systems that decrease one’s
sense of threat and self-criticism and increase one’s
sense of calm, reassurance, and emotion regulation.
Following the definition of compassion as sensitivity to suffering in self and others with a commitment to try to alleviate and prevent it, CFT
cultivates each of component. First, clients work to
develop a motivation to engage with suffering, their
ability to approach and tolerate it. Second, clients
are assisted in cultivating a corresponding commitment to act in a way to try to alleviate and prevent suffering along with the skills to do this successfully
(Gilbert, 2014). Therapists work with clients to facilitate activation of the client’s caring motivational
system by developing insight and tolerance of
emotions and working through fears, blocks, and
resistances to compassion. CFT uses psychoeducation, emotional modeling, meditative and imagery
practices, and experiential interventions to help
clients gain insight and build compassionate capacity
(Gilbert & Irons, 2005). Many of these processes are
utilized in other therapies, but CFT emphasizes that
they must be experienced with a compassionate, prosocial affect in order to obtain the desired physiological and psychological impact.
CFT was developed to address the transdiagnostic
pathological processes of self-criticism and shame
that can contribute to and maintain a range of
mental health problems (Gilbert & Procter, 2006).
The association between shame, self-criticism, and
psychopathology has been well-established (e.g.,
Allan & Gilbert, 1997; Gilbert et al., 2010; Kelly &
Carter, 2013; Lucre & Corten, 2013; PintoGouveia et al., 2014), particularly with depression
(e.g., Kelly et al., 2009; Marshall et al., 2008). Selfcriticism is the perception of the self as inadequate
or inferior leading to internal dialogue directed at
self-correction, self-attacking, or self-hatred (Castilho et al., 2017). Shame is the perception of our
self as unattractive, undesirable, incompetent, or
inadequate with the belief that we are creating negative emotions in the mind of the other—anger,
disgust, contempt, or ridicule (Gilbert, 2007). CFT
counteracts self-criticism and shame by helping
clients build the capacity to experience compassion,
thus activating the caregiving system to regulate and
reassure the self.
CFT transdiagnostic research has found that CFTI
is associated with significant reductions in symptoms
such as anxiety, depression, self-criticism, shame,
inferiority, submissive behavior, and overall distress
as well as increases in self-compassion, self-esteem,
and self-reassurance (e.g., Braehler et al., 2013;
Gilbert & Procter, 2006; Heriot-Maitland et al.,
2014; Judge et al., 2012; Laithwaite et al., 2009;
Lucre & Corten, 2013; Mayhew & Gilbert, 2008).
CFT groups have also been shown to be an effective
group intervention (e.g., Ashworth et al., 2011;
Braehler et al., 2013; Gale et al., 2014; Lucre &
Corten, 2013; Mayhew & Gilbert, 2008) in recent
transdiagnostic group research (Cuppage et al.,
2018; Heriot-Maitland et al., 2014; Judge et al.,
2012; McManus et al., 2018).
Transdiagnostic groups are beneficial on two
fronts. First, transdiagnostic groups composed of
mixed anxiety or mood disorders are easier to
create in many practice settings compared to homogenous groups. Moreover, available evidence
suggests that transdiagnostic groups produce equivalent outcomes compared to single-diagnosis groups
(Burlingame et al., 2013). Indeed, transdiagnostic
groups are often composed of individuals with
either anxiety or mood disorders. Stated differently,
CFT transdiagnostic groups allows clients with
similar complaints (e.g., anxiety disorders) to
benefit from an effective intervention. By removing
the restriction of membership to a single diagnosis
(e.g., generalized anxiety disorder), one facilitates
quicker access to treatment. Second, clients with differing diagnoses may be particularly well-suited for
CFT groups since the treatment targets common
underlying psychological constructs (i.e., shame and
self-criticism), rather than symptoms associated
with a specific psychiatric diagnosis.
Despite the significant research base for CFT, it has
yet to be assessed in a university counseling and
psychological services (CAPS) center. Group treatments in CAPS centers are often transdiagnostic due
Psychotherapy Research 3
to unique characteristics of this clinical population
(Ribeiro et al., 2017). More specifically, a typical
CAPS center service mandate includes immediate or
short-term access, which often leads to reliance on
transdiagnostic groups. CAPS service mandates also
require service to both the clinically distressed and
those who present with subclinical distress. Thus,
this clinical setting may be a particularly good match
to test the transdiagnostic CFT focus. To date,
research has only focused on non-clinical university
populations with CFT leading to increased self-compassion and decreased negative thoughts and emotions
(Arimitsu, 2016). However, no studies have directly
implemented CFT interventions in a CAPS center.
Although CFT has been studied for decades, several
limitations have prevented it from producing high
quality, adequately powered randomized controlled
trials (RCT). The largest and most pressing concern
is the lack of a standardized manual. Researchers
trained in CFT by Dr. Gilbert have created and
tested various treatment protocols for compassion
focused therapy (e.g., Braehler et al., 2013; Gilbert
& Procter, 2006; Judge et al., 2012; Lucre & Corten,
2013). However, there is little consistency in content
presented, exercises used, and number of sessions
among these protocols, and each was typically used
in a single study with no replication. There is an
inherent difficulty in manualizing CFT since it is
multi-modal and integrates processes across developmental psychology, social psychology, and more traditional psychotherapies. Given this rich theoretical
foundation, CFT proponents argue against an overly
rigid or mechanical therapy manual. A second limitation is that many compassion studies fail to measure
protocol adherence to determine the fidelity of intervention delivery (Kirby et al., 2017); standard practice
in evidence-based research insuring reproducibility.
Stated differently, without a standardized manual,
CFT research has been stuck in the feasibility stage
and unable to move into the RCT stage where protocol fidelity is the gold standard.
Another limitation in CFT research is inadequate
assessment and testing of the proposed mechanisms
of change. For instance, CFT theory posits that reducing an individual’s fears of compassion leads to an
increased ability to engage in the three flows of compassion, which, in turn, will lead to a reduction in
the primary outcomes of shame and self-criticism.
After these changes occur, decreased psychiatric distress is expected. A few studies have investigated
these mechanisms of change and found promising
change in primary outcomes (self-reassurance, self-criticism) and psychiatric distress (Cuppage et al., 2018;
Sommers-Spijkerman et al., 2018). However, past
research has failed to simultaneously and temporally
measure how changes in the fears and resistances to
compassion predict changes in the three flows of compassion and if these differentially predict the primary
outcomes of CFT.
Current Study
The current study addressed the above limitations by
creating a standardized group manual for a CAPS
population (Cattani et al., 2020) that was based
upon a larger manual from the CFT developer,
Paul Gilbert and his colleagues (in press). After
developing the CAPS manual, we next focused on
verifying the feasibility and acceptability of this
manual from both a group leader and client perspective. Finally, we simultaneously assessed CFT mechanisms of change (three fears and flows of
compassion); primary outcomes (self-reassurance,
self-criticism, and shame); and distal outcome (psychiatric distress). The decision to focus on three
rather than the traditional single primary outcome
was made based on the fact that CFT is a transtheoretical intervention designed to target change in all
three outcomes. Furthermore, previous literature
has measured these three outcomes (Joeng &
Turner, 2015; Kirby et al., 2019; Matos et al.,
2017; Naismith et al., 2020) with promising results.
Finally, we examined if measures specifically
designed for CFT by Gilbert produced the same
change patterns as measures of the same construct
developed by others. This analysis was intended to
assess for measure bias, specifically exaggerated
CFT effects on Gilbert measures.
The primary aims of the current study were to: (1)
assess the feasibility and acceptability of a new standardized 12-session transdiagnostic group CFT protocol in a CAPS center from both a client and
therapist perspective; (2) determine whether the
CFT protocol showed the anticipated effect of significant increases in flows of compassion and self-reassurance and decreases in fears of compassion, selfcriticism, shame, and psychiatric distress; and (3)
explore if the early, middle, and late change in proposed mechanisms of change (i.e., decreases in
fears of compassion and increases in flows of compassion) predicted longitudinal change in primary
outcomes (i.e., decreases in self-criticism and
shame) and distal outcome (i.e., decreases in psychiatric distress) as predicted by CFT theory.
Method
Clients
Clients were students presenting for treatment at a
university CAPS center. Inclusion criteria included
4
J. Fox et al.
a primary presenting concern related to shame or selfcriticism, willingness to have group be their primary
mode of treatment, and pre-treatment distress at a
clinical level (OQ-45 at or above 64). As CFT is
transdiagnostic, client concerns relating to self-criticism and shame were considered more important
than a specific diagnosis so no standardized diagnostic interview was used. Loss of clients over time
occurred due to students choosing to discontinue in
the study, failing to complete measures, or dropping
out of groups. We began with 109 clients who were
registered for CFT groups but only 75 completed
initial measures and 45 completed the entire assessment battery and treatment (Figure 1). Of the 75
clients who completed measures, 73.5% were
female and race was 85.5% Caucasian, 7.2% Hispanic, 3.6% multi-racial, 2.4% Native Hawaiian or
Pacific Islander, and 1.2% Asian. Clients ranged in
age from 18 to 29 with a mean of 22.7; 99% identified
as Christian. Primary presenting complaints were
based upon client responses to the Student Concerns
Questionnaire (Pedersen & Smart, 2007) and were
as follows: depression (28%), perfectionism (20%),
anxiety (11%), interpersonal (9%), stress (4%), identity development (4%), trauma (4%), adjustment
(2%), self-harm (2%), OCD (2%), emotional dysregulation (2%), and assorted others (12%).
Treatment
CFT first uses psychoeducation to help clients
understand the nature of the human mind and the
benefits of mindfulness and compassion (Gilbert,
2009). Indeed, considerable time is invested in
early sessions linking the human brain, genetics,
and life experience to emotional regulation and how
CFT will help client use their bodies to support
their minds. Clients then build the compassion
skills through exercises, imagery, and guided meditation which are later used to address symptom distress
(Gilbert & Choden, 2013). Each session includes
didactic, experiential, and discussion portions supported by handouts (Gilbert, 2017). At the end of
each session, worksheets for compassion practices
and audio recordings of meditations and imagery
exercises to be completed between sessions are
handed out. Table I briefly overviews the topics and
key elements of the 12 CFT session in our manual
(Cattani et al., 2020).
Measures
Feasibility and Acceptability. Fidelity checks
were created for each session that contained a brief
description of the core psychoeducation, skill, and
behavioral practices. Each leader independently completed these checklists immediately following each
session to check for inter-rater reliability. Observer
ratings of fidelity were not completed as it was
outside the scope of this feasibility study as well as
privacy concerns of the members of the group who
elected not to participate in the study. However, a
new CFT competency measure was created as a
result of this study which will be used in future
studies with this manual. At the end of each
session, clients were asked to complete a brief five
item questionnaire relating to acceptability (see
online supplement Figure 1).
Figure 1. Flow of study participants.
Mechanisms of Change. Fears of Compassion
(FCS; Gilbert et al., 2011) is designed to assess the
fears, blocks, and resistances to compassion. The
FCS has three subscales: Fear of Compassion for
Psychotherapy Research 5
Table I. Overview of group sessions.
Session Topic
Key Elements
1. Compassion
Exploration of compassion: definition,
fears of compassion
2. Emotion Systems
Influences of evolved brain, genetics,
and social context on behavior
Three emotion systems
3. Mindfulness &
Attention
Using attention intentionally for
awareness and amplification
Use of soothing system to regulate
activating systems
4. Safeness vs Safety
“Safe place” imagery
“Compassionate Other” imagery
5. Compassionate Self
“Compassionate Self” imagery
6. Self-criticism
Exploration of self-criticism—purpose
and effects
Using “compassionate self” imagery
to address self-critic
7. Shame
Exploration of shame & guilt
Addressing shame & guilt with
Compassionate Self
8. Multiple Selves
Exploring multiple emotions in threat
system
Addressing multiple emotions
through Compassionate Self
9. Compassion for Self
Cultivating compassion for self
Compassionate letter writing
10. Compassion for
Others
Shifting from empathy to compassion
Compassionate forgiveness
11. Compassionate
Communication
Understanding and expressing needs
and feelings
Asking for needs & responding to
requests compassionately
12. Continuing
Compassion
Review and relapse prevention
Wrap-up and goodbyes
Self, Fear of Compassion from Others, and Fear of
Compassion for Others. Items are rated on a fivepoint Likert scale (0 = Don’t agree at all, 4 = Completely agree). Gilbert reported a Cronbach’s alpha of
0.85 for fear of compassion for self; 0.87 for fear of
compassion for others, and 0.78 for fear of compassion for others. A reliable change index—RCI
(Jacobson & Truax, 1991) for each subscale was calculated at: 8.4 for fears of compassion for self, 6.9 for
fears of compassion for others, and 7 for fears of compassion from others.
The Compassionate Engagement and Action Scales
(CEAS; Gilbert et al., 2017) measures the ability to
engage with and act on compassion for self, compassion for others, and compassion from others.
Clients rate each statement according to how frequently it occurs on a scale of 1–10 (1 = Never; 10
= Always). The scale has recently been validated
with a good Cronbach’s alphas and factor structure.
A RCI for each subscale were calculated as 12.4 for
compassion for self, 7.2 for compassion to others,
and 7.6 for compassion from others.
Primary Outcomes—CFT Measures. Forms of
Self Criticism and Self Reassuring Scale (FSCRS;
Gilbert et al., 2004) has two subscales for self-criticism: Inadequate self, which measures the sense of
personal inadequacy, and Hated self, which focuses
on the desire to hurt or persecute the self. A third subscale, Reassured Self, measures the individual’s
ability to be self-reassuring and supportive when
things go wrong. Items are scored using a five-point
scale (ranging from 0 = not at all like me to 4 = extremely like me). Cronbach’s alphas for the subscales
are .90 for inadequate self, .86 for hated self and
.86 for reassured self (Gilbert et al., 2004). A RCI
for each subscale was calculated as 4.3 for reassured
self, 5.2 for inadequate self, and 3.4 for hated self.
Primary Outcomes—Independent measures.
Depressive Experiences Questionnaire 48 McGill Revision—Self Criticism Subscale (DEQ; Santor et al.,
1997) assesses various self-criticism on a sevenpoint Likert scale ranging from 1 (strongly disagree)
to 7 (strongly agree). Reliability coefficients were
measured at .72 for men and .76 for women. A
RCI was calculated as 15.6.
Tests of Self-Conscious effect —Shame Subscale
(TOSCA; Tangney et al., 2000) asks respondents to
rate the likelihood of their shame response to brief
scenarios on a five-point Likert scale ranging from 1
(“not likely”) to 5 (“very likely”). Cronbach’s α for
the full 16-item TOSCA-3 was reported ranging
from .76 to .88 for shame-proneness in three
samples of university students (Tangney & Dearing,
2002). A RCI was calculated as 7.2.
Distal Outcome. Outcome Questionnaire-45
measures client distress on interpersonal relations,
symptom distress, and social role questions on a 7point Likert scale. The OQ has a reported internal
consistency of .93 and a test-retest reliability of .84
(Lambert & Ogles, 2004). The reliable change
index for the OQ has been calculated as 14 points.
Procedure
The study received ethical approval from the Institutional Review Board at Brigham Young University.
CAPS clients were referred to the CFT groups by
their individual therapists. Clients were assigned to
groups based on schedule availability. As group was
6
J. Fox et al.
the primary form of treatment, clients were asked to
meet with their individual therapists no more than
once every three weeks. The 12-session weekly outpatient CFT groups were led by 2 doctoral-level psychologists experienced in group therapy. Three
primary leaders (JF, KC & GB) were trained by
Gilbert and his colleagues in CFT during an
extended professional development leave (3
months) in the United Kingdom and 8 co-leaders
engaged in CFT self-study prior to the group. The
primary group leaders received weekly supervision
from Dr. Gilbert to address questions about the protocol and clinical issues. All leaders met each week as
a treatment team to discuss adherence and acceptability issues with the primary leaders and to participate in CFT group supervision led by the three
Gilbert-trained therapists.
Groups had 7–14 clients with an average of 9.4
clients per group, met for 120 min, with an average
of 11.5 sessions across the eight groups; four groups
combined two sessions due to holidays and final
exams. Clients were sent a Qualtrics survey link to
sign an informed consent form and complete the
first round of assessments; the same link was sent
after the 6th (mid-treatment) and final session
(post-treatment) and clients completed a weekly
OQ-45 online. Clients were considered dropouts if
they missed three consecutive sessions. However,
after inspecting the dropout data, we subdivided it
into “partial” if they attended at least half of the sessions and “full dropout” if they attended less than half
the sessions.
Data Analyses
Pre-treatment client data were included for analysis if
they met inclusion criteria and had a valid and complete pre-assessment within 21 days of the first
session. These criteria resulted in 75 clients being
included in analyses for mechanisms of change and
primary outcomes. Missing data for mid and post
assessments used the last observation carried
forward rule. The distal outcome (OQ) had more
missing data than other measures because it was
administered through CAPS’ existing processes,
rather than by the researchers in the CFT battery;
CAPS typically has a low level of completion of the
OQ. Based on the CAPS center’s data analyst who
is an OQ expert (D. Erekson, Ph.D., personal communication, August 30, 2018), a 30-day window
before and 15-day after the first session was used
for pre-treatment distress and, a 15-day window
before and 30-day after was used for the final
session. These screening criteria resulted in 30
clients contributing OQ data for analyses of distal
outcome. All analyses were done in SPSS 20 at p
< .05.
Feasibility data were examined descriptively using
means and standard deviations. Acceptability from
the client feedback forms for each session was also
examined using means and standard deviations but
average session attendance and attrition rates were
also used as indirect measures of client acceptance.
These rates were compared to average center rates
using the remaining 25–30 groups run during the
same semester.
Due to the nested nature of group data where individuals are situated within groups, we calculated the
variance due to groups to determine if a significant
intra-group dependency was present using the intraclass correlation coefficient (ICC) and whether the
analyses needed to account for nesting. There were
no significant group effects.
All measures were assessed for change between
pre-, mid-, and post-treatment time points. Measures
that produced both overall and subscale scores (FCS
and CEAS) were analyzed with repeated measure
MANOVAs; Wilks’ lambda and Huynh-Feldt are
reported for multivariate and univariate tests,
respectively. Measures that produced only subscales
level (FSCRS) were analyzed with repeated-measures
ANOVA; Wilks’ lambda is reported. Independent
measures of the primary outcome (DEQ-self-criticism and TOSCA Shame) assessed at pre- and
post-treatment and analyzed using paired t-tests
while the distal outcome measure (OQ-45) assessed
at pre-, mid-, and post-treatment was analyzed
using a repeated-measures ANOVA; Wilks’ lambda
is reported. Effect sizes were calculated using
Cohen’s d. Pearson correlations were used to
explore the association between change in mechanism of change measures and change in self-criticism,
shame, and psychiatric distress.
Results
Feasibility and Acceptability
Our first aim was to establish the feasibility and
acceptability of this new protocol. The average therapist fidelity scores for the CFT psychoeducation, skill
and behavioral practices listed for each session
ranged between “mostly present” and “fully
present” (M=2.33 out of 3.00, SD=0.17; see online
supplement Table 1). Similarly, average client
session ratings on the 5-feedback items was 4.11
out of 5.00 possible (SD = 0.53; see online supplement Table 2). On average, clients attended
56% of sessions. Of the 73 who attended at least
one group, nearly two-thirds (61.6%) completed
the protocol (49.3% full completers and 12.3%
Psychotherapy Research 7
Table II. All subscale means for pre, mid, and post time points.
Pre
Mid
Post
Measure
Mean
SD
Mean
SD
Mean
SD
FCS
Fears of self-compassion
Fears of compassion from others
Fears of compassion to others
28.08
24.20
13.63
11.68
9.84
6.03
24.21
22.49
12.79
11.46
9.96
5.69
21.81
20.97
12.07
12.47
10.33
5.72
CEAS
Self-Compassion
Compassion from Others
Compassion to Others
49.23
54.95
78.89
10.03
16.11
10.95
54.00
59.39
77.59
11.70
18.01
10.99
57.51
59.39
78.03
14.20
17.61
9.87
FSCRS
Reassured Self
Hated Self
Inadequate Self
10.77
9.65
28.61
5.57
5.04
5.32
11.91
8.68
26.09
6.06
5.19
6.90
13.27
7.93
23.65
6.81
5.19
8.36
139.11
11.99
131.92
16.32
TOSCA Shame
39.64
5.00
37.99
5.13
Outcome Questionnaire
75.72
22.57
70.69
24.77
DEQ Self-Criticism
partial completers). This attendance pattern is similar
to the semester rates from the 25–30 groups/week at
the counseling center during the course of the
study, with absences typically due to the student’s
exam schedules and trips out of town for holidays
or family visits.
Significant and Reliable Change
Since this was the first study to use CFT in a CAPS
center, we first report the means and standard
errors for all subscales from our sample (Table II)
and descriptively compare these to pre-intervention
means from the CFT literature (online supplement
Table 3). Our clients average pre-treatment scores
typically fell between literature-based values for
non-clinical and clinical samples on flows and fears
of compassion as well as shame and self-criticism.
However, our clients scores indicated unusual ease
in compassion to others (higher than both non-clinical and clinical population), with pre-treatment
scores closer to what would be expected at post-treatment, suggesting a “ceiling effect” for compassion to
others. Additionally, on the independent measure of
self-criticism (DEQ), our clients had significantly
higher ratings than both the literature-based nonclinical and clinical samples. For psychiatric distress
(OQ) our clients matched the clinical norm for
CAPS.
We expected that the new standardized CFT protocol would replicate past research findings and
indeed, we found significant change on all but one
subscale (Table III). We also calculated pre–post
74.88
24.20
effect sizes finding one large, nine medium and four
small effects. The absence of change on the compassion to others subscales is likely related to the
pre-treatment ceiling effects noted above. We also
calculated reliable change (see online supplement
Table 2) and found a third of clients improving on
compassion (self-compassion and compassion from
others), fears (self-compassion) and self-criticism
(inadequate self) measures. A fourth showed
Table III. Significant change over time.
Measure
FCS 1
Fears of self-compassion
Fears of compassion from
others
Fears of compassion to others
1
CEAS
Self-Compassion
Compassion from Others
Compassion to Others
FSCRS 2
Reassured Self
Hated Self
Inadequate Self
DEQ Self Criticism3
3
TOSCA Shame
Outcome Questionnaire
2
df
F
Sig.
Cohen’s d
6
1.50
1.50
5.414
22.48
11.06
0.00
0.00
0.00
−0.60
−0.63
−0.43
1.80
8.50
0.00
−0.41
6
1.68
1.77
1.87
7.86
29.94
8.13
1.69
0.00
0.00
0.00
0.19
0.54
0.75
0.36
0.14
2
2
2
15.67
15.33
18.76
0.00
0.00
0.00
0.63
−0.62
−0.71
74
−2.26
0.00
−0.59
74
−2.05
0.00
−0.48
2
8.26
0.00
−0.63
Notes: 1Repeated measures MANOVA.
2
Repeated measures ANOVA.
3
Paired t-tests.
8
J. Fox et al.
improvement on the remaining subscales assessing
fears (compassion from others) and self-criticism
subscales (hated self, self-criticism, and reassured
self) with a small percent (12%) showing improvement in shame and nearly half improving on psychiatric distress measures.
Relationship Between CFT Mechanism of
Change and Primary Outcomes
Since this is the first study to simultaneously
measure CFT putative mechanisms of change
(FCS & CEAS) and primary outcomes using both
CFT (FSCRS) and independent measures (DEQ
& TOSCA) in a CAPS population, we wanted to
explore the relationship of change among these
measures. This was done by correlating change on
the CFT mechanisms of change (i.e., fears and
flows of compassion) with change on primary outcomes (i.e., self-criticism and shame). Given that
compassion to others did not show significant
change, it was not considered.
In interpreting the correlations there were a
number of patterns we expected to find based on
CFT theory that are summarized in online supplement Table 5. To summarize, we expected that
early change (pre-mid treatment) in the mechanisms
of change would predict later change (mid-post) in
the primary outcomes; that is, that change in the
mechanisms of change would precede a change in
primary outcomes. Another expected CFT change
pattern would be a simultaneous change in the mechanisms of change and primary outcomes. For
instance, as clients shift in their flow of compassion,
change in primary outcomes would begin at the
same time and continue throughout therapy.
However, we also outline change patterns that do
not fit CFT theory (online supplement Table 5).
Late change in the mechanisms of change should
not occur in the presence of early change in the
primary outcomes. For instance, according to CFT
theory, early improvement in self-criticism should
not occur before an increase in the flows of
compassion.
As predicted, both the fears and flows of compassion to self and compassion from others (online
supplement Tables 6 & 7, respectively) had
medium to large correlations with changes in
shame, psychiatric distress, and both CFT and independent measures of self-criticism. These followed
the predicted trend of changing simultaneously
(e.g., early change in self-compassion predicted
early change in self-criticism). Typically, the largest
correlations were between overall change in both
mechanisms of change and outcomes.
Discussion
The results herein supported the primary aims of this
study: to create a feasible and acceptable manual that
showed improvement that matched previous CFT
studies and change patterns that provide indirect
support for CFTs mechanisms of change. As
reported by therapists and clients, the standardized
12-session manual was broadly feasible and acceptable in a CAPS center. Reliable change was found for
the mechanisms of change (fears and flows of compassion), primary outcomes of CFT (self-criticism,
shame, and self-reassurance), and distal outcome
(psychiatric distress). Additionally, improvement in
CFT mechanisms of change was associated with
both primary and distal outcomes.
The self-report fidelity data from therapists indicated that nearly all of the session material was delivered, supported by high-interrater agreement
(>90%). While the therapists fell slightly short of
“perfect self-report fidelity,” the protocol was judged
to be feasible to administer in a CAPS center. Sessions
10 and 12 (online supplement Table 1) posted the
lowest values (averaging at the “material mostly
present” level) due to the need to combine the last
few sessions for four of the groups. The weekly supervision session our team had with Gilbert provides
support that the manual was implemented with fidelity, although formal fidelity checklists would have
been superior. However, these supervision sessions
also revealed the occasional need for deviation from
the protocol for clinical reasons and each of these deviations were discussed with Gilbert. The clinicians
ability to deliver nearly all of the session material
addressed CFT proponents concern of an overly
rigid and mechanical CFT manual. Indeed, the flexibility of manual implementation led to a descriptive
mantra from our Gilbert supervision: “don’t sacrifice
a clinical moment for the manual.” For example,
CAPS clinicians felt the flexibility to explore client
resistance to addressing self-compassion or self-criticism while still implementing the majority of the
CFT material in the standardized manual.
Acceptability based upon aggregate client ratings
of individual sessions suggests that the treatment
was generally well-received and acceptable with
little deviation across the 12-sessions (online supplement Table 2). The attendance data also supports
acceptability with over a quarter of clients missing
one or fewer groups and nearly 60% attending over
half of the sessions. Client-recorded reasons for
missed sessions were typical of our CAPS center
(exams or project deadlines, visits to family, etc.)
and the 38% considered full dropouts falls on the
lower end of the CFT dropout range (10–80%)
reported by Leaviss and Uttley’s (2015). The CFT
Psychotherapy Research 9
literature actively discusses clinical reasons for attrition, including difficulties in confronting the fears
and blocks of compassion (e.g., Gilbert, 2014;
Lucre & Corten, 2013; Mayhew & Gilbert, 2008;
McManus et al., 2018). Thus, our attrition rates,
while comparable to other groups in our CAPS
center, may also be the result of unique challenges
inherent in the CFT protocol. Collectively, the
client feedback, attendance, and completion rates
suggest that clients found CFT sessions to be enjoyable, useful, and understandable. In addition, over
12% of the clients returned to the group after 3 or
more consecutive absences (creating the need for
our partial dropout category) which is another indicator of the acceptability of the protocol.
How do University CAPS Clients “fit” Into
the Existing CFT Literature?
In general, CAPS clients occupy a unique position of
being significantly more distressed than non-clinical
and university samples on the mechanisms of
change (fears and flows of compassion) but significantly less distressed than other clinical samples
found in the CFT literature. It is worth noting that
previous CFT studies often focused on severely distressed populations, including psychosis, personality
disorders, and eating disorders. Stated differently,
the existing CFT literature represents a very high
level of distress ( e.g., Braehler et al., 2013; Gale
et al., 2014; Heriot-Maitland et al., 2014). Thus,
we were somewhat surprised by the near-clinical
level of distress in our CAPS population on two compassion flows (self-compassion and compassion from
others). The linear increase in perfectionism in
college students over the past 30-years (Curran &
Hill, 2019) may partially explain the clinical levels
of distress in compassion we found.
A different picture emerged when it came to compassion to others, our CAPS clients began treatment
performing better than their non-clinical peer group
and far better than clinical samples. This left little
room for observable change (a ceiling effect). The
most likely explanation for the unusually high compassion to other scores is that our clients attend a
church-owned and operated university where over
98% of students are active in their faith. This faith
places a heavy emphasis on service, kindness, and
sacrifice for others. Thus, the unique culture of our
clients creates a norm for compassion to others with
unusual amounts of practice, making our sample
unrepresentative on this compassion construct.
There was a similar pattern of scores on the primary
outcomes. Our CAPS scores on self-criticism and
shame were significantly higher than nonclinical
and undergraduate samples but generally lower
than the clinical samples, although on some scales
they were equivalent to general psychiatric distress
matching CAPS norms. Thus, with the exception of
compassion for others, our CAPS sample demonstrated clinical levels on all measures, albeit lower
than past CFT clinical samples.
Significant and Reliable Change in
Compassion, Self-criticism and Shame
The primary aim was to determine if the new CFT
protocol led to significant pre-to-post change on
measures of compassion, fears of compassion, selfreassurance, self-criticism, shame, and psychiatric
distress. As expected, significant improvement was
found on all subscales except for compassion to
others. We compared the magnitude of change for
CAPS to previous effect sizes in compassion-based
intervention literature (Kirby et al., 2017) but, it is
important to note three important differences
between our effect sizes and those in Kirby et al.
First, their meta-analysis examined several compassion-based interventions, not just CFT. Second,
they only calculated change in overall compassion,
while we examined both the fears and flows of compassion (to self and others, compassion from
others) as well as unique CFT primary outcomes
(e.g., reassured, hated, and inadequate self). Third,
their effect sizes were drawn from comparisons of
compassion interventions to waitlist control, while
ours reflect pre–post change; the latter effect sizes
produce larger values. Given these differences, the
following comparisons should be viewed with
caution.
Published effect sizes for change in self-compassion (d = .70) were comparable with our study’s
effect size (d = .75). However, published effect sizes
for changes in overall compassion were smaller in
our study (d = .14–.36) than in the meta-analysis (d
= .55). Effect sizes for decreases in psychiatric distress were slightly higher in our study (d = .63) compared with the meta-analysis (d = .47). Taken
together, these comparisons are promising for the
new CFT protocol ability to produce comparable
change to other compassion-based interventions.
However, its important to keep in mind the limitations for comparison noted above.
Predictive Abilities of Changes in
Compassion
The final aim was to explore improvement on CFT
mechanisms of change (i.e., fears and flows of compassion) with change on primary (i.e., self-criticism
10
J. Fox et al.
and shame) and distal outcomes (i.e., psychiatric distress). To our knowledge, this is the first study to
examine the relationship between the three flows of
compassion and the primary CFT outcomes of selfreassurance, self-criticism, and shame. We hypothesized that improvement in mechanisms of change
would precede improvement in outcomes or, that
change in both would occur simultaneously since
increases in compassionate abilities might lead to a
rapid reduction in self-criticism and shame. Given
that our open trial status, we simply had an insufficient sample size to examine these relationships
with more sophisticated analyses (e.g., mediation
methods). Thus, we offer our findings from a descriptive perspective that might guide future research.
Nearly all the correlations supported a change in
mechanisms of change and primary outcomes occurring at the same time. In a few cases, change in the
mechanisms seemed to occur before and predict a
subsequent change in primary outcomes. These patterns of change were found on both the CFT
measures of self-criticism as well as the independent
measures of self-criticism and shame. Of note, the
largest correlations were found in the CFT measures
that assess the fears and flows of self-compassion.
Thus, there is very preliminary evidence in support
of the CFT theory that reducing clients’ fears of compassion and increasing their ability to engage and act
in the flows of compassion may lead to an improvement in self-criticism and shame.
passing of time. Clearly, the next step is to take the
standardized CFT group protocol and test it against
waitlist or known evidence-based group treatments
(treatment-as-usual) controls in a randomized clinical trial to clarify its effectiveness.
Another limitation was the reliance on self-report
fidelity. However, the revisions made to the manual
as a result of this pilot study led to a new CFT competency measure that will enable observer fidelity
ratings in future research. Our clients were highly
educated college students, white, young, religious,
from mostly higher socioeconomic backgrounds
and caution should be used in extending the results
of this study to other populations. However, given
the consistent success of CFT across a wide diversity
of settings, ages, diagnoses, and countries (Kirby
et al., 2017), it is likely that this CFT group protocol
would have similar results in other populations. A
final limitation was the difficulty inherent in doing
research in a real-world clinical setting (e.g., groups
being canceled for exam schedule or holidays, requiring sessions to be condensed). Such issues are
common in clinical research and our results show
the ability of our intervention to succeed in a realworld setting where flexibility is required and imperfection is inevitable. The results of this study are a testament to the potential of this intervention even
without ideal research conditions.
Future Directions
Limitations
Several limitations to this research should be considered. First, there were a number of constraints
inherent in a feasibility trial. Of particular note, no
previous data existed to conduct a power analysis,
and there was no comparison group. Since our
focus was testing a new standardized manual with a
new population, we were unable to conduct a
power analysis in advance. Efforts were made to
compare the results of this study to existing literature,
but as noted in the results section, our clients had
some unique patterns of responding that appear to
differentiate them from other populations. The findings herein provide preliminary data to support
power analyses for future CFT studies with this
manual and clinical population. Additionally, we
had a single treatment condition with no control
group so there is no way to determine how much
change resulted from the intervention. However,
since change took place over relatively short time
period—a semester—and on outcomes targeted by
treatment (shame and self-criticism), it seems unlikely that change can be entirely explained by the
From the beginning, this feasibility trial was meant to
launch a larger program of research. More specifically, if the CFT group protocol was found to
produce promising results, the next step would be a
randomized clinical trial (RCT). An additional
benefit of this study was the creation of a revised
group protocol using feedback from both therapists
and clients. The protocol revisions produced by this
study not only address CAPS transdiagnostic
anxiety and mood groups, but also other CAPS homogenous clinical indications (e.g., eating disorders).
The larger CFT manual (Gilbert et al., in press) is
currently being applied to other clinical populations
(e.g., seriously mentally ill, veteran, and LGBT+)
in countries associated with the CFT cooperation
(e.g., USA, Italy, Australia, and the Netherlands).
This series of studies using a common manual will
begin the process of building a stronger foundation
for future RCTs.
With the advent of a standardized CFT manual
with a fidelity checklist, we have several thoughts
regarding future research. First, adequately
powered samples are essential for the future mediator
and moderator analyses assessing the predicted
Psychotherapy Research
relationship between the mechanisms of change (i.e.,
fears and flows of compassion), primary (i.e., self-criticism and shame) and distal outcomes (i.e psychiatric distress). The findings herein are only
suggestive and they need to be tested directly using
adequately powered designs. Given CFTs incorporation of attachment theory, future studies might
assess clients experience of social safeness and interpersonal connectedness to determine if change in
these might facilitate movement from a competitive
to compassionate stance (Vimalakanthan et al.,
2018). The existence of a standardized CFT protocol
also introduces a host of opportunities to understand
the temporal change process. For instance, we need
to examine CFT effects with respect to dose (how
many sessions are needed for an effect) and practice
(how much outside practice is needed for an effect).
There is a dearth of CFT studies that have looked
at CFT treatment effects using short- and longterm follow ups, and future RCTs to must assess
this to understand if post-treatment effects are
durable. Finally, we collected qualitative comments
from our clients and plan on reporting on these in a
subsequent publication.
11
Author contributions
Jenn Fox, Gary Burlingame, and Kara Cattani contributed equally to the research program and senior
authorship should be considered interchangeable.
This study is part of a larger program of research
created by Burlingame and Cattani, who orchestrated
the vision, research design, international coordination, training, and funding required for the
ongoing program of research. Fox took primary
responsibility for the direct implementation of the
study through managing team coordination, data collection and analysis, and this paper is based on her
dissertation.
Supplemental data
Supplemental data for this article can be accessed
https://doi.org/10.1080/10503307.2020.1783708
ORCID
Gary M. Burlingame
8275-4118
http://orcid.org/0000-0002-
Conclusion
Overall, this feasibility trial was deemed to be a successful first step for the new CFT group protocol.
Therapists were able to administer the protocol
with good fidelity, and their suggestions have been
incorporated into a revised manual that will support
future randomized clinical trials. Clients reported
the sessions as enjoyable, useful, and clear and
while CAPS client attendance was sporadic at
times, there was a general pattern of returning to
group even after missing several sessions, indicating
that clients found value in the treatment. Significant
results included increases in compassion and selfreassurance and decreases in fears of compassion,
self-criticism, shame, and psychiatric distress with
medium to large pre-to-post-treatment effect sizes.
Finally, the mechanisms of change for CFT (three
flows of compassion) predicted changes in self-criticism and shame, with most correlations being
medium to large in size.
Acknowledgement
The authors would like to acknowledge the CFT coleaders—RD Boardman, Michael Buxton, Yoko
Caldwell, David Erekson, Derek Griner, Corinne
Hannan, Tyler Pederson, and Vaughn Worthen—
along with Cameron Alldredge and Hal Svien who
assisted in the data collection.
References
Allan, S., & Gilbert, P. (1997). Submissive behaviour and psychopathology. British Journal of Clinical Psychology, 36(4), 467–488.
https://doi.org/10.1111/j.2044-8260.1997.tb01255.x
Arimitsu, K. (2016). The effects of a program to enhance self-compassion in Japanese individuals: A randomized controlled pilot
study. The Journal of Positive Psychology, 11(6), 559–571.
https://doi.org/10.1080/17439760.2016.1152593.
Ashworth, F., Gracey, F., & Gilbert, P. (2011). Compassion
focused therapy after traumatic brain injury: Theoretical foundations and a case illustration. Brain Impairment, 12(02), 128–
139. https://doi.org/10.1375/brim.12.2.128
Braehler, C., Gumley, A., Harper, J., Wallace, S., Norrie, J., &
Gilbert, P. (2013). Exploring change processes in compassion
focused therapy in psychosis: Results of a feasibility randomized
controlled trial. British Journal of Clinical Psychology, 52(2), 199–
214. https://doi.org/10.1111/bjc.12009
Burlingame, G., Strauss, B., & Joyce, A. (2013). Change mechanisms and effectiveness of small group treatments. In M. J.
Lambert (Ed.), Bergin & Garfield’s Handbook of psychotherapy
and behavior change, 6th Ed (pp. 640–689). Wiley & Sons.
Castilho, P., Pinto-Gouveia, J., & Duarte, J. (2017). Two forms of
self-criticism mediate differently the shame-psychopathological
symptoms link. Psychology and Psychotherapy: Theory, Research
and Practice, 90(1), 44–54. https://doi.org/10.1111/papt.12094.
Cattani, K., Griner, D., Erekson, D., Burlingame, G., Beecher,
M., & Alldredge, C. (2020). Compassion focused group therapy
for college counseling centers. Routledge Mental Health.
Cuppage, J., Baird, K., Gibson, J., Booth, R., & Hevey, D. (2018).
Compassion focused therapy: Exploring the effectiveness with a
transdiagnostic group and potential processes of change. British
Journal of Clinical Psychology, 57(2), 240–254. https://doi.org/10.
1111/bjc.12162
12
J. Fox et al.
Curran, T., & Hill, A. (2019). Perfectionism is increasing over
time: A meta-analysis of birth cohort differences from 1989 to
2016. Psychological Bulletin, 145(4), 410–429. https://doi.org/
10.1037/bul0000138
Gale, C., Gilbert, P., Read, N., & Goss, K. (2014). An evaluation
of the impact of introducing compassion focused therapy to a
standard treatment programme for peoplewith eating disorders.
Clinical Psychology & Psychotherapy, 21(1), 1–12. https://doi.org/
10.1002/cpp.1806
Gilbert, P. (2007). Psychotherapy and counselling for depression (3rd
ed). Sage.
Gilbert, P. (2009). The compassionate mind: A new approach to the
challenges of life. Constable & Robinson.
Gilbert, P. (2014). The origins and nature of compassion focused
therapy. British Journal of Clinical Psychology, 53(1), 6–41.
https://doi.org/10.1111/bjc.12043
Gilbert, P. (2017). Compassion focused group therapy for college counseling centers. Compassionate Mind Foundation.
Gilbert, P., Catarino, F., Duarte, C., Matos, M., Kolts, R., Stubbs,
J., Ceresatto, L., Duarte, J., Pinto-Gouveia, J., & Basran, J.
(2017). The development of compassionate engagement and
action scales for self and others. Journal of Compassionate
Health Care, 4(1), 4–24. https://doi.org/10.1186/s40639-0170033-3.
Gilbert, P., & Choden (2013). Mindful compassion. Using the power
of mindfulness and compassion to Transform our Lives. Robinson.
Gilbert, P., Clarke, M., Kempel, S., Miles, J., & Irons, C. (2004).
Criticizing and reassuring oneself: An exploration of forms style
and reasons in female students. British Journal of Clinical
Psychology, 43(1), 31–50. https://doi.org/10.1348/01446650
4772812959
Gilbert, P., & Irons, C. (2005). Focused therapies and compassionate mind training for shame and self-attacking. In P. Gilbert
(Ed.), Compassion: Conceptualisations, research and use in psychotherapy (pp. 263–325). Routledge.
Gilbert, P., Kirby, J., & Petrocchi, N. (in press). Compassion focused
therapy: Group therapy Guidance. Routledge.
Gilbert, P., McEwan, K., Irons, C., Bhundia, R., Christie, R.,
Broomhead, C., & Rockliff, H. (2010). Self-harm in a mixed
clinical population: The roles of self-criticism, shame, and
social rank. British Journal of Clinical Psychology, 49(4), 563–
576. https://doi.org/10.1348/014466509X479771
Gilbert, P., McEwan, K., Matos, M., & Rivis, A. (2011). Fears of
compassion: Development of three self-report measures.
Psychology and Psychotherapy: Theory, Research and Practice, 84
(3), 239–255. https://doi.org/10.1348/147608310X526511
Gilbert, P., & Procter, S. (2006). Compassionate mind
training for people with high shame and self-criticism:
Overview and pilot study of a group therapy approach. Clinical
Psychology & Psychotherapy, 13(6), 353–379. https://doi.org/
10.1002/cpp.507
Heriot-Maitland, C., Vidal, J. B., Ball, S., & Irons, C. (2014). A
compassionate-focused therapy group approach for acute inpatients: Feasibility, initial pilot outcome data, and recommendations. British Journal of Clinical Psychology, 53(1), 78–94.
https://doi.org/10.1111/bjc.12040
Hoffmann, S., Grossman, P., & Hinton, D. (2011). Loving-kindness and compassion meditation: Potential for psychological
intervention. Clinical Psychology Review, 13, 1126–1132.
Jacobson, N. S., & Truax, P. (1991). Clinical significance: A statistical approach to defining meaningful change in psychotherapy
research. Journal of Consulting and Clinical Psychology, 59(1), 12–
19.
Jazaieri, H., Jinpa, G., McGonigal, K., Rosenberg, E., Finkelstein,
J., Simon-Thomas, E., & Goldin, P. (2013). Enhancing compassion: A randomized controlled trial of a compassion
cultivation training program. Journal of Happiness Studies, 14
(4), 1113–1126.
Joeng, J., & Turner, S. (2015). Mediators between self-criticism
and depression: Fears of compassion, self-compassion and
importance to others. Journal of Counseling Psychology, 62(3),
453. https://doi.org/10.1037/cou0000071
Judge, L., Cleghorn, A., McEwan, K., & Gilbert, P. (2012). An
exploration of group-based compassion focused therapy for a
heterogeneous range of clients presenting to a community
mental health team. International Journal of Cognitive Therapy,
5(4), 420–429. https://doi.org/10.1521/ijct.2012.5.4.420
Kelly, A., & Carter, J. (2013). Why self-critical patients present
with more severe eating disorder pathology: The mediating
role of shame. British Journal of Clinical Psychology, 52(2),
148–161.
Kelly, A. C., Zuroff, D. C., & Shapira, L. B. (2009). Soothing
oneself and resisting self-attacks: The treatment of two intrapersonal deficits in depression vulnerability. Cognitive Therapy and
Research, 33(3), 301–313. https://doi.org/10.1007/s10608-0089202-1
Kemeny, M., Foltz, C., Cavanagh, J., Cullen, M., Giese-Davis, P.,
Jennings, P., & Ekman, P. (2012). Contemplative/emotion
training reduces negative emotional behavior and promotes prosocial responses. Emotion, 12(2), 1–338.
Kirby, J., Day, J., & Sagar,, V. (2019). The “flow” of compassion:
A meta-analysis of the fears of compassion scales and psychological functioning. Clinical Psychology Review, 70, 26–39.
https://doi.org/10.1016/j.cpr.2019.03.001
Kirby, J., Tellegen, C., & Steindl, S. (2017). A meta-analysis of
compassion-based interventions: Current State of knowledge
and future Directions. Behavior Therapy, 48. https://doi.org/
10.1016/j.beth.2017.06.003
Laithwaite, H., O’Hanlon, M., Collins, P., Doyle, P., Abraham,
L., Porter, S., & Gumley, A. (2009). Recovery after psychosis
(RAP): A compassion focused programme for individuals residing in high security settings. Behavioural and Cognitive
Psychotherapy, 37(05), 511–526. https://doi.org/10.1017/
S1352465809990233
Lambert, M., & Ogles, B. (2004). The efficacy and effectiveness of
psychotherapy. Bergin and Garfield’s Handbook of Psychotherapy
and Behavior Change, 5, 139–193.
Leaviss, J., & Uttley, L. (2015). Psychotherapeutic benefits of compassion-focused therapy: An early systematic review.
Psychological Medicine, 45(5), 927–945. https://doi.org/10.
1017/S0033291714002141
Lucre, K. M., & Corten, N. (2013). An exploration of group compassion-focused therapy for personality disorder. Psychology and
Psychotherapy: Theory, Research and Practice, 86(4), 387–400.
https://doi.org/10.1111/j.2044-8341.2012.02068
MacBeth, A., & Gumley, A. (2012). Exploring compassion: A
meta-analysis of the association between self-compassion & psychopathology. Clinical Psychology Review, 32, 545–552.
Marshall, M., Zuroff, D., McBride, C., & Bagby, R. (2008). Self
criticism predicts differential response to treatment for major
depression. Journal of Clinical Psychology, 64(3), 231–244.
Matos, M., Duarte, C., Duarte, J., Pinto-Gouveia, J., Petrocchi,
N., Basran, J., & Gilbert, P. (2017). Psychological and physiological effects of compassionate mind training: A randomized
controlled study. Mindfulness, 8(6), 1699–1712. https://doi.
org/10.1007/s12671-017-0745-7.
Mayhew, S. L., & Gilbert, P. (2008). Compassionate mind training
with people who hear malevolent voices: A case series report.
Clinical Psychology & Psychotherapy, 15(2), 113–138. https://
doi.org/10.1002/cpp.566
McManus, J., Tsivos, Z., Woodward, S., Fraser, J., & Hartwell, R.
(2018). Compassion focused therapy groups: Evidence from
Psychotherapy Research
routine clinical practice. Behaviour Change, 35(3), 167–173.
https://doi.org/10.1017/bec.2018.16
Naismith, I., Ripoll, K., & Pardo, V. (2020). Group compassionbased therapy for female survivors of intimate-partner violence
and gender-based violence: A pilot study. Journal of Family
Violence, https://doi.org/10.1007/s10896-019-00127-2
Neff, K., & Germer, C. (2013). A pilot study and randomized controlled trial of the mindful self-compassion program. Journal of
Clinical Psychology, 69(1), 28–44.
Pace, T., Negi, L., Adame, D., Cole, S., Sivilli, T., Brown, T., &
Raison, C. (2009). Effect of compassion meditation on neuroendocrine, innate immune and behavioral responses to psychosocial stress. Psychoneuroendocrinology, 34(1), 87–98.
Pedersen, T., & Smart, D. (2007, August). An empirical model of
development for distressed college students [Poster presentation].
Annual convention of the American Psychological
Association, San Francisco.
Pinto-Gouveia, J., Matos, M., Castilho, P., & Xavier, A. (2014).
Differences between depression and paranoia: The role of
emotional memories, shame and subordination. Clinical
Psychology and Psychotherapy, 21(1), 49–61. https://doi.org/10.
1002/cpp.1818
Porges, S. W. (2017). The pocket guide to the polyvagal theory: The
transformative power of feeling safe. WW Norton & Co.
13
Ribeiro, M., Fross, J., & Turner, M. (2017). The college Counselor’s
guide to group Psychotherapy. Taylor and Franscis.
Santor, D., Zuroff, D., & Fielding, A. (1997). Analysis and revision
of the depressive experiences questionnaire: examining scale
performance as a function of scale length. Journal of
Personality Assessment, 69(1), 145–163. https://doi.org/10.1207/
s15327752jpa6901_8
Sommers-Spijkerman, M., Trompetter, H., Schreurs, K., &
Bohlmeijer, E. (2018). Compassion-focused therapy as
guided self-help for enhancing public mental health: A
randomized controlled trial. Journal of Consulting and
Clinical Psychology, 86(2), 101. https://doi.org/10.1037/
ccp0000268
Tangney, J., & Dearing, R. (2002). Shame and guilt. Guilford Press.
Tangney, J., Dearing, R., Wagner, P., & Gramzow, R. (2000). The
test of self- conscious affect-3 (TOSCA-3). George Mason
University.
Vimalakanthan, K., Kelly, A., & Trac, S. (2018). From competition to compassion: A caregiving approach to intervening
with appearance comparisons. Body Image, 25, 148–162.
https://doi.org/10.1016/j.bodyim.2018.03.003
Yarnell, L., & Neff, K. (2013). Self-compassion, interpersonal
conflict resolutions, and wellbeing. Self and Identity, 12, 146–
159.