In these emotionally enlightened times, some say the world’s gone soft. Feelings beat facts, offense is derived from almost anything and parental mollycoddling has hit record levels.

To the uninitiated, then, the idea of ‘compassion-focused therapy (CFT)’ might sound like yet another sign of barmy snowflakery.

But as growing numbers of psychotherapists are proving, it is, in fact, emerging as a highly effective approach in post-brain injury rehab.

CFT was conceived by Paul Gilbert, a world- renowned clinical psychologist who founded the Compassionate Mind Foundation in 2006; and published ‘The Compassionate Mind: A New Approach to Life’s Challenges and Overcoming Depression’ in 2009.

It brings together cognitive behavioural therapy (CBT) techniques, neuroscience, evolutionary and social psychology and even Buddhist teachings.

Recipients are encouraged to be compassionate toward themselves and other people – and to understand basic emotional regulation systems and the importance of bringing them into balance.

A key concern, says Gilbert, is “to help people develop and work with experiences of inner warmth, safeness and soothing, via compassion and self-compassion.”

A study led by Fiona Ashworth, representing Anglia Ruskin University, exploring CFT in acquired brain injury (ABI) patients was published last year.

In it, 12 patients received a combination of CFT group and individual intervention. Self-report measures of self-criticism, self-reassurance and symptoms of anxiety and depression were collected and analysed before and after the programme.

CFT was associated with significant reductions in measures of self-criticism, anxiety and depression, while the ability to reassure the self increased.

It summarised that CFT is “well accepted in ABI survivors” within the context of neuro-rehab. Also, the report concluded: “The results indicate that further research into CFT for psychological problems after ABI is needed and there may be key aspects which are specific to CFT intervention, which could reduce psychological difficulties after ABI.”

Dr Emma Ferguson (pictured), a Health and Care Professions Council-registered clinical psychologist at Neurolink Psychology, has also been actively exploring CFT’s potential for people with neurological challenges.

Her recent case study, ‘How CFT can tackle CBT’s limitations after brain injury’, applied the therapy to a 35-year-old man who suffered a traumatic brain injury in a road accident. She showed how: “Integrating a CFT approach into a CBT framework had a successful outcome.”

The man had difficulties with memory, processing speed, generating ideas and regulating his emotions. He also had anxiety and low confidence after the injury.

After the CBT treatment he said: “I automatically talk to myself in a warmer, softer voice… I’m occasionally anxious but I’m actively working to minimise [its] effects on my life.” He also managed to return to work, get married and have a son.

An important aspect of CFT is the ‘three circles’ model. This separates the three emotional regulation systems of threat (depicted as a red circle), drive (a blue circle) and soothing (a green circle).

Ferguson says: “After a brain injury, people are often operating in ‘threat’. They are doing things to replace the feeling of being threatened. Perhaps they can’t do things they used to do and that threat system may be necessary from a ‘fight or flight’ perspective.

But their threat system could be overactive. Maybe they are constantly in a state of negative emotions such as fear, anger and self-criticism. CFT could help them to notice that happening and encourage the client to operate from a different system, perhaps moving to green to calm their threat system down.”

Engaging the drive system as clients pursue goals can also be problematic, she says. “Sometimes goals come from a position of threat. For example, they may think ‘oh no, I can’t do these things, my goal is to do them how I used to’. This might lead to them going into overdrive, trying to keep going on as they did before the injury, regardless of fatigue or cognitive difficulties.

“We try to help them come up with goals that are more from a green, soothing place. It’s about being kinder to yourself in your goal-setting.”

The individual in Ferguson’s recent paper underwent this shift, with CFT enabling him to move away from aspirations that were doomed to fail.

“Prior to his injury, he was very focused on his career as a research fellow. His main focus was to go back to work full-time, with no changes at all to his work situation. The difficulty was that he was getting quite fatigued and anxious and he needed more time to process things. One of his jobs was to review papers but he needed a lot more time than previously to complete these tasks. “We were concerned that he might fail and this could have a huge impact on his self- confidence and emotionally.”

The prospect of following a gradual path back to work was not hugely motivational to the man, however, until CFT and its ‘three circles’ notion was introduced.

“He was able to be more compassionate towards himself rather than beating himself up for not being able to do things.”

Ferguson stresses that CFT is not about lowering client expectations, but rather encouraging them to be kinder to themselves.

“It could mean being more accepting of the fact that you might need to do things in a completely different way to achieve the same goal. It’s about doing things from a place of kindness and soothing, instead of fear and an attitude of ‘I can’t do this so I need to work as hard as I can until I burn out’ – which we see quite often in clients that are desperate to get back to where they were.”

CFT sessions can involve many different approaches and techniques. Typically they may focus on self-soothing skills, increasing distress tolerance, fostering the compassionate self and identifying the self-critic.

On the latter, Ferguson says: “One of the key parts of CFT is thinking about the role self- criticism might be playing in maintaining the individual’s distress. Sometime we encourage clients to identify who or what their self critic is, to externalise it from them.

“It may remind them of, or sound like, someone such as a parent or an old teacher. We use a lot of imagery to visualise it as a something that pops up and says things like ‘I can’t do it’ and ‘I’m rubbish’ and is activating the threat system. “Brain injury or no brain injury, we can all identify with the idea of a self-critic who’s there internally some of the time.

“A prevalent feeling is that self-criticism is a necessary part of being productive. The idea that ‘if I don’t tell myself off, I won’t get things done’ is very common. But, actually, you don’t need to criticise yourself as a motivator to achieve things. You can be compassionate towards yourself and still keep pushing towards goals or changing things about life that aren’t working for you.”

As well as using CFT to help patients in rehab, it might also have implications for healthcare workers themselves, according to various research papers on the impact of compassion training.

One study (Beaumont et al, 2016) – involving 28 healthcare staff, including counsellors and psychotherapists – measured self-compassion, criticism, persecution and correction before and after they underwent CFT training. The results generally showed an increase in self-compassion and a reduction in self-critical judgment after the training.

It concluded: “Developing self-compassion and compassionately responding to our own self-critic may lead the way forward in the development of more compassionate care among healthcare professionals. Training people in compassion-based exercises may bring changes in levels of self-compassion and self-critical judgment. The findings are exciting in that they suggest the potential benefits of training healthcare providers and educators in compassion-focused practices.”

Ferguson agrees that CFT has potential in helping healthcare professionals.

“We are considering using CFT training in the staff teams we work with. It’s a therapy that could be used one-to-one or in a group setting to support staff in coping with the work they are doing.”

The outlook for CFT as a means of aiding the recovery of brain injury survivors looks promising. The British Psychological Society has an upcoming, two-day event in London purely focused on CFT in neuropsychological rehabilitation. Its neuropsychology division, which is organising the event, says: “Many neuropsychologists working in rehabilitation have found that CFT is a very useful model in helping their patients and clients.

“There is a growing number of us that are passionate about applying this model in our work settings but also in better understanding ourselves as humans with the same ‘tricky’ brains.”

Such events highlight CFT’s emergence as a useful approach after brain injury. And Ferguson is hopeful that more and more practitioners will consider it in future.

“There is no reference to CFT in NICE guidelines and, generally, CBT tends to be held up as the gold standard for most mental health, post-brain injury problems. But there is also a growing acceptance of mindfulness and its use as part of CBT and other approaches; obviously mindfulness is also a big part of CFT in terms of the soothing element of it.

“We are a long way off from large scale clinical trials into CFT but there is definitely growing interest in it among psychologists in the neuro-rehab world.”

It may indeed take years for unshakeable evidence for CFT to build, but it certainly shows promise and is easily accessible to any psychologists keen to trial it with their clients. Ferguson says: “Psychologists working in neuro-rehab are used to adapting approaches to suit their clients – and actually there is a lack of evidence and guidance for brain injured populations for many of the standard therapy practises too.

“We are continually adapting our materials and the structure of sessions, so CFT could be implemented alongside CBT, for example. “What really struck me from working with the client in my research was that he found CFT really easy to understand and it therefore stuck with him. People like things that are visual and simple to follow, like the red, blue and green hook that’s so easy to remember.

“The use of imagery and the playful way the self-critic can be identified, means that it could also work well with children. CFT is already being used in schools to help people to develop emotional regulation skills from a younger age, so I don’t see why it couldn’t work with children and parents affected by brain injury.

“Hopefully we will see more psychologists bringing elements of CFT into their sessions,” she adds.