Q&A: ACT and Compassion, with Dennis Tirch, PhD and Laura Silberstein, PsyD

Printer-friendly version

The following is a Q&A with Dennis Tirch, PhD, and Laura Silberstein, PhD, co-authors along with Benjamin Schoendorff, MA, MSc of The ACT Practitioner’s Guide to the Science of Compassion. Tirch and Silberstein have collaborated on all responses. This interview was orginally posted on the New Harbinger Publications website. 

 

You’ve made some comments about how some of the major mindfulness teachers downplay compassion or the lack of focus on compassion. Can you expand on this a little bit and explain why compassion is such an integral part of mindfulness? Is mindfulness useless without compassion?

At present, a great deal of research suggests that from the moment we are born until the day that we die our experience of kindness, support, and compassion will greatly influence our emotional and physical health. The potential extent of the influence of the presence or absence of compassion reaches from how healthy our immune system may function, to the intensity of our stress response, to the presence or absence of anxiety and depression. In some research, self-compassion appears to be a major mediator of how successful people might be in mindfulness based group or self-help text based treatments. 

Given this research, we would expect that mindfulness-based therapies would be moving towards employing compassionate mind training as a part of their approach. However, this isn’t always the case. Some mindfulness teachers believe that compassion is so inherent to mindfulness training that we don’t need to focus on it. We never viewed the situation that way. To our minds, that would be akin to saying, “There is enough cardiovascular training that shows up in weight training, so most athletes don’t need to do cardio on its own.”

Mindfulness is often defined as the kind of awareness that emerges by paying attention in the present moment, on purpose and non-judgmentally—a definition or translation of the Pali term Sati attributable to Jon Kabat-Zinn. Compassion can be defined as a sensitivity to the presence of suffering in self and others, combined with a deep motivation and commitment to the alleviation and prevention of suffering. This definition has its roots in Buddhist writings, but has been articulated and refined by Paul Gilbert, the founder of compassion-focused therapy (CFT). Clearly, these definitions stand for different concepts. And while there is some overlap in the behavioral and neural dynamics involved in mindfulness and compassion, different practices, motivations, and regions of neural activity are differentially engaged in both mindfulness and compassion activation.

Some people have described mindfulness and compassion as two wings of a bird, with both playing their role in allowing our human aspirations for transformation and personal evolution to take flight. While a poetic metaphor, we appreciate the meaning of the image, as the flow between activating our flexible, focused awareness and acting from the compassionate mind can be so essential in psychotherapy and everyday life.

Within prescientific Buddhist traditions, mindfulness training is often a beginning point for the novice monk or lay practitioner. From this foundation, the Buddhist student will proceed to learn and practice more advanced methods for cultivating a felt sense of compassion for the self, and ultimately for all beings. This is true in many schools of Buddhist practice, including Theravada, Zen, and Tibetan Buddhism. 

The sequencing of this mental training would suggest that there is a relationship between the experience of mindfulness and the experience of compassion, where mindfulness training may serve as a context for the cultivation of compassion. The Buddhist scholar B. Alan Wallace has emphasized that historically, mindfulness training has been undertaken as a foundational practice that allows the practitioner to be ready to access and embody wholesome states of mind that lead to ethical and healthy behaviors.

Mindfulness involves the nonjudgmental and decentered appreciation and acceptance of our experience, just as it is, in this very moment. However, this acceptance is not meant to serve as an end in itself, or a form of masochistic immersion in distress. From the perspective of an ACT practitioner, acceptance is an active process in the cultivation of psychological flexibility and movement towards a life of meaning, purpose, and vitality. For the Buddhist practitioner, mindful acceptance sets the stage for the cultivation of wisdom, compassion, and right action. Mindfulness alone has rarely been the aim of practical philosophies and interventions throughout history. It may be that without self-compassion, we might sometimes be forcing ourselves into contact with our pain without the supportive and protective presence of our evolved capacity for sensitivity to suffering or motivation to respond with kindness and support. Our friends Kristin Neff and Chris Germer have made the distinction that while mindfulness may be the open acceptance of our experience, compassion involves a wholehearted acceptance of the experiencer herself. To our minds and hearts, compassion feels like a psychological, and perhaps spiritual, coming home—finding a safe base from which to explore our world and face the inevitable challenges of life.

 

Can you talk a bit about how and why you decided to do a book on ACT and compassion, why you felt there was a need for it—what in your professional or personal experience led to its creation? 

[DT] I came to study Western psychology and behavior therapy after decades of Buddhist practice, and my intention since 1992 really has been to integrate Buddhist psychology with our best methods for alleviating suffering based on a scientific paradigm. [LS] I also had a long-standing passion for Buddhist psychology, and particularly the role of mind-body medicine which seemed more overt in Eastern practices like yoga and tai chi. 

When we began working together 10 years ago, we both had studied cognitive therapy, acceptance and commitment therapy, and a variety of meditation disciplines. As we both became more immersed in the practice of CFT and ACT, it became clear on a personal level that the integration of the evidence-based processes found in ACT and the brilliant model derived from affective neuroscience and developmental psychology that is found in CFT could work together to great effect.

[LS] In particular, there was a weekend workshop that Dr. Tirch was addressing at the Samye Ling Tibetan Buddhist monastery, during one of the biggest snowstorms in Scotland in 70 years, that led to this book. After speaking on compassion and meditating together, we both came to see the clear relationship between psychological flexibility and the many aspects of compassion that are trained in CFT.

About 7 years ago we began working very closely with Dr. Paul Gilbert, with one of us [DT] spending a great deal of time developing a model for how to use CFT to treat anxiety disorders.
At the same time, we increasingly discussed compassion and psychological flexibility with Kelly Wilson, Robyn Walser, Steven Hayes and others in the ACBS community. It began to make sense to systematize and codify our work integrating these approaches. Our dear friend and co-author, Benjamin Schoendorff, felt like a natural partner in this work, as we had worked with him in workshops on contextual behavioral science and self-compassion.

As cognitive and behavioral therapies have increased their emphasis on applied mindfulness- and acceptance-based approaches, it makes sense that mental training designed to intentionally foster a compassionate mind would become a growing trend in contextual behavior therapies like ACT and FAP. Contextual behavior therapies inherently address the interconnectedness between an organism and its context in a way that resonates with Buddhist psychology and the science of compassion. Additionally, this emphasis on compassion within behavioral therapies is a part of a trend toward greater integration of compassion-focused methods and Buddhist influences within psychotherapy across many theoretical approaches. 

 

The ACT model can be tricky even for advanced practitioners. Compassion is not a formal part of the hexaflex, so how and where does it fit in? What are some of the best entry points or inherently compassionate processes in the ACT model that could help practitioners begin to infuse their practice with more compassion?

In approaching this question we can begin by considering what we are looking at when we view the hexaflex. Basically, the hexaflex is meant to be a graphic illustration of the interacting, active processes that contribute to psychological flexibility. Steven Hayes has publicly stated that compassion might be the only value that is inherent in the hexaflex model. I think we can take that a bit further, actually, because compassion doesn't need to be viewed simply as a value. 
Compassion is a multifaceted process that has evolved from the caregiver mentality found in human parental care and childrearing. As such compassion involves a number of emotional, cognitive, and motivational elements.

The emerging common ground across psychological science is that compassion is an evolved motivational experience that organizes the mind into a complex and multimodal series of human behaviors with clear antecedents in the repertoire-broadening influence of secure attachment experiences. Importantly, compassion involves the activation of the emotions that arise in connected, intimate, and close relationships. We refer to these emotions—which involve empathy, warmth, and care—as affiliative emotions. Activation of networks of affiliative emotions can promote focused, flexible attention and a broadening of the range of possible actions in the presence of stimuli that typically narrow behavioral repertoires. Indeed, research has increasingly established that compassion can facilitate lasting change in the way we experience and respond to suffering.

On the basis of the significant overlap between the attributes and skills that emerge from a compassionate mind and the components of psychological flexibility, we have offered a definition of “compassionate flexibility” in our work that relates the hexaflex to compassion. So rather than compassion sitting in any one place “on” the hexaflex, compassionate flexibility reflects a particular quality of engaged psychological flexibility. 

We define compassionate flexibility as the ability to contact the present moment fully, as a conscious and emotionally responsive human being with the following qualities: 

• Sensitivity to the presence of suffering in oneself and others
Motivation to alleviate and prevent human suffering in oneself and others
• Persistent adaptation to competing and changing environmental, emotional, and motivational demands, and commitment to returning attention and resources to the alleviation and prevention of suffering in oneself and others 
• The ability to flexibly shift perspective and access a broader sense of oneself and others, involving the experiences of empathy and sympathy 
• The ability to disentangle oneself from the excessive influence of evaluative, judgmental thoughts
• Maintaining an open and noncondemning perspective on human experience itself, thereby cultivating necessary and sufficient willingness to tolerate the distress encountered in oneself and others

 

The title of this book changed a few times. Can you talk about that process a little bit? Is compassion the third piece of mindfulness and acceptance? Or is compassion more a quality to draw into M&A?

The book’s original title was: “ACT with Compassion” and it was meant to reflect the natural flow from ACT work to compassion work. The next working title we had involved mindfulness, acceptance, and compassion; that was meant to reflect how interrelated these processes can be. With clients, we might emphasize that mindfulness allows us to wake up in the present moment, and attend to what is happening here and now. Compassion allows us to rest in kindness in this present moment and access our capacity to feel emboldened in the face of suffering. This experience of compassion can facilitate greater acceptance as we find it in ourselves to turn towards those painful and distressing experiences which might be very difficult to address without the stabilizing influence of a self compassionate presence. So, yes, we can consider compassion as a quality that we can bring to our mindfulness and acceptance based practices. However, this quality is not so much conceptual as it is an embodied order of human intelligence which emerges from our distinctively human, species-preservative, care-giving repertoires.

 

The approach you present in the book is a guide to the clinical application of compassion; how is your approach different from straight compassion-focused therapy?

While CFT is often practiced as a freestanding therapy modality in its own right, its methods have been designed in such a way that they can be used by practitioners who operate primarily in other therapy models. As Paul Gilbert has often stated in trainings, “We call this compassion-focused therapy, and not compassion therapy, because it is a way of bringing a compassion focus to the therapy that you have learned to practice.” As a result, many practitioners of CBT, ACT, and other forms of psychotherapy have integrated elements of CFT and compassionate mind training into their practice without divesting themselves of their prior learning and becoming “CFT therapists” in every sense. There is clear value in exploring training in CFT, in its own right and in an undiluted form—indeed, two of the authors of this book have made the theory, research, and practice of CFT central to their professional missions. However, just some exposure to the literature on the science of compassion and the methods of CFT can provide ACT therapists with an evidence-based entrée into integrating this approach into their practice and alert them to theoretical and practical possibilities for bringing processes and procedures from CFT into an ACT-consistent intervention, creating a compassion-focused ACT. 

 

The ACT community is beginning to turn attention and effort toward the science of compassion. What are some compelling specific examples of research or cases where this is evident?

A number of people within the ACT community have been exploring the role of compassion in ACT. Steve Hayes has been speaking on the evolutionary roots of compassion as a key element of the psychological flexibility model. Kelly Wilson has begun to fold self-compassion and kindness into his training model as key concepts. Robyn Walser, Joann Wright, Martin Brock and other colleagues have been integrating elements of compassion training into their training models for years. Stanislaw Malicki, Emily Sandoz’s late and our group in New York have all been researching the relationship between self-compassion and psychological flexibility in various contexts. Matthew Skinta has conducted a research trail of an intervention for HIV-related shame and stigma that draws upon CFT and ACT. Jamie Yadavaia has run a controlled trial of an ACT based intervention for building self-compassion. Jason Luoma has built a compassion focus into his ACT-based approach for the treatment of chronic shame. We are now working with Trent Codd’s group on an ACT- and CFT-based randomized control trial for the treatment of anxiety, too. Most recently, Andreas Larson has begun to discuss how a CFT intervention might be best researched. So we see a lot of activity within the ACBS community on this front, and we are probably leaving a few wonderful labs and individuals off this list by accident. If we extend this research base to the number of clinical trials that exist for CFT for range of problems—including depression, personality disorders, psychosis and smoking cessation—we see a building base of evidence. Furthermore, the mounting evidence of the importance of self-compassion as a variable in well-being and the considerable neuroimaging research base that supports the effectiveness of training the mind in compassion all combine to point us in a very encouraging direction in developing compassion-focused interventions.

 

In the introduction to the book you mention an e-mail discussion about how ACT relates to Buddhism in which Steven Hayes raised a significant point—what was the gist of the conversation and his response and why was it so relevant?

A few years ago there was a discussion on the email list for ACT professionals that involved the similarities and differences between Buddhism and acceptance and commitment therapy. Several of us had noticed important areas of common ground in the basic processes involved in human well-being which were shared by both of these approaches to the alleviation of suffering. Steve made a very important point when he drew our attention to the difference between scientific and prescientific traditions. The advantage of applying the scientific method involves our testing of even our most basic assumptions as well as our techniques, in the development of ever more efficient evidence based processes and procedures. In a way, the evolutionary principles of variation, selection, and retention really do show up in the scientific method. Findings are meant to be replicable and methodology is meant to be rigorous and consistent. As a result scientific traditions tend to be progressive and can allow for change and evolution at a more rapid rate than prescientific traditions, which sometimes base their methods simply on continuity across time and a sense of intellectual and spiritual authority held by a few, or even simply found in a sacred text. Steve made a point that in the last 20 to 30 years, ACT specifically—and the cognitive and behavioral therapies more generally—have radically changed, as have other scientific disciplines related to mindfulness and compassion, such as neuroscience. The hope here is that wedding of age-old phenomenological observations about the nature of mind with a scientific approach can create a science better suited to the question of human suffering. It reminded me of a panel discussion in 1991 at Harvard, where the Dalai Lama was asked what he might wish to do if science disproved a point in Buddhism. Basically, His Holiness said that we would need to change Buddhism.

 

You also mention the parallel between CFT and ACT and Theravada and Mahayana Buddhism in the book—can you explain that here?

In answering this, I’ll present a highly simplified version of history that doesn’t do any of the schools of thought full justice. I’ll just trust the reader to look into this further if it is an interesting parallel. Fundamentally, the oldest school of Buddhist thought, Theravada, emphasized individual enlightenment as an aim, and stressed mindfulness, acceptance, equanimity, and disciplined action, some 2,600 years ago. The flowering of this school of thought changed the world. 500 or so years later, Mahayana Buddhism adopted as a central aim an altruistic aspiration for all beings to be liberated from suffering as a central aim. Compassion, concentration, and engagement with the world became key priorities at this time. To my mind, there is some parallel with our contextual psychotherapies. ACT has historically emphasized mindfulness, acceptance and commitment processes as chief areas of focus for personal growth and emotional healing. Emerging in the public consciousness a bit later, CFT has emphasized cultivating compassion, centering practices, and taking compassionate action. True to the rapid pace of the scientific method, such changes took place over 500 years in Buddhist communities, whereas the ACBS community began seriously looking at compassion about two to three years after it was formed.

 

Is it possible to integrate and build bridges across therapies without compromising the integrity of the foundations of the models?

If we are mindful that models are precisely that—models—rather than concretized and reified absolute truths, we can deeply study these models and engage in the kind of inter-theoretic discussion that can breathe life into our case conceptualization and therapy. This is very important, in that the a-ontological approach of CBS and the role of defusion in psychological flexibility allow us the opportunity to step out of slavish adherence to allegiance to theories, and to engage with different schools of thought in a pragmatic way.

 

Is an increased emphasis on compassion better suited to one particular population or another (i.e., clients dealing with shame or self-criticism)?

CFT was developed to treat patients with shame-based difficulties. However, outcome research is demonstrating effectiveness in a number of areas, such as smoking cessation, treatment of psychosis, obesity, personal disorders and other problems. Similarly, the process research we have is demonstrative of the importance of compassion for a range of key elements of well-being, from depression to social connectedness to immune system functioning. When we view compassion as more than an emotion or a value, and come to understand compassion as an evolved motivation that can create a context for effective action, we can see how bringing compassion into the equation can be helpful in most situations. We can imagine how bringing a compassionate focus to our evidence based approach might enhance the good work that we have already been engaging in.

 

The argument is made in the book that “our evolved capacity for compassion is actually an essential ingredient in psychological transformation.” Can you elaborate on that? Are you saying compassion is required in order for any real psychological change to occur?

We humans are a remarkably resilient and flexible species. Humans can flourish without sight or hearing, and can live amazingly meaningful and joyful lives even when paralyzed. It is difficult to imagine one singular human quality that would be so very essential to our well-being as compassion seems to be. So, in a sense, perhaps we can make many positive changes in life without abundant compassion. We are, after all, so tenacious.

However, when we remember the definition of compassion in its most basic terms—a sensitivity to the presence of suffering in ourselves and others, combined with a motivation to alleviate and prevent the suffering we encounter—we can see how essential this mentality is to addressing our psychological pain, as well as the dominance of limiting patterns of thought and action that keep us stuck in relentless struggle with our experience. When we recall that this compassion flows from our evolved capacity to feel connected, stabilized, and courageous when we experience affiliative emotion, we are reminded that human compassion, warmth, kindness, and mindful bravery are possibly some of the most important elements in transforming our minds and lives.

For more information on the role of compassion in ACT, check out The ACT Practitioner’s Guide to the Science of Compassion: Tools for Fostering Psychological Flexibility [https://www.newharbinger.com/act-practitioners-guide-science-compassion].

Purchase The ACT Practitioner's Guide to the Science of Compassion: Tools for Fostering Psychological Flexibility on the ACBS website.