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- [00:01]
A
Hi, I'm Dr. Stan Steindl. Welcome back to Compassion in a T shirt. Today I'm joined by Lisa Williams, a highly experienced cognitive behaviour therapist and the manager and principal CBT therapist at South London and Maudsley NHS Foundation Trust. Lisa specialises in treating anxiety disorders including obsessive compulsive disorder and integrates compassion focused therapy into her work. In this episode we're diving into how CFT can be applied to ocd. How we might formulate OCD through a compassion focused lens. The role of early life experiences and how those interact with our tricky evolved brains. How giving and receiving compassion can help us manage loops in the mind and how CFT can be integrated with traditional approaches to the treatment of ocd like exposure and response prevention. Lisa brings a wealth of knowledge and hands on experience. So whether you're a therapist, someone struggling with OCD or just interested in compassion in action, there is a lot to take away from this episode. The bit towards the end where Lisa talks about how the compassionate self can really support people approaching exposure and response prevention is fascinating. And so I bring you Lisa Williams.
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B
Okay, everything's phones are all off, Stan. I'm all ready.
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A
Lisa. Lisa Williams, welcome to Compassion in a T shirt.
- [01:42]
B
Oh, thanks so much Stan. It's so lovely to see you and to chat with you after all this time. I haven't seen you for a while but it's, it's really nice to be here.
- [01:50]
A
It's great to connect with you again after a little while. So yeah, that's, I completely agree. You're a cognitive behavior therapist and a compassion focused therapist and I noticed that your training in CFT was really some time ago, I guess goes back a decade or so. But I suppose I was curious first of all, what sort of drew you to incorporate CFT into your therapy, therapy practice and perhaps, you know what, what unique sorts of value does it bring to your therapy?
- [02:23]
B
Wow, that's such a big question. But I guess the good place to start is that I trained, I trained as a nurse when I first went to university and then I retrained in cognitive behavioral therapy and I was working in London working with clients with trauma at the time. This was after qualifying and I, I was fascinated. CBT was really, really helped a lot of the clients I was working with. But there were, there was this constant question that kept coming up in supervision and that was, I mean I use it in these terms now because I know from Paul Gilbert this is how he describes it, but there was a head heart lag and that's What I was seeing from my clients, that they would say, I know this stuff, I understand it logically, cognitively, but I just don't feel how I was hoping to feel. I don't feel any different on my supervisor at the time, wonderful guy called Nick Gray, some of you may know. He said to me, lisa, I think what would be really helpful for you is to read this book. And it was Paul Gilbert's book on Compassion Focus Therapy. And it was just like reading something that I'd always hoped to read, and not just, not just in a way to help my clients, but for me too. You know, I, I, there's not often that I get a textbook where I get excited. I go to a shop and I buy it. And then by about chapter four, I've drifted into something else, to be honest, and I don't have that attention span. But this was a book that, that fascinated me and drew me in right from the start and, and it started to make sense for my own life. But then I, it helped me with my clients. And Nick said to me at the time, he said, oh, look, there's this course you can do with Paul Gilbert in Derby. I was like, oh, no. I said no to any more training for a while. But anyway, I looked it up and I thought, no, that sounds brilliant. So I went to Derby and I did. I, I think it's still running. It's the diploma in, in, in cft Compassion Focused Therapy with, It was with Paul Gilbert and Wendy Wood and Michelle Cree. And it was, it was one of the best courses I've ever done. I cried a lot myself. I wasn't allowed to get away with much. You know, I think Paul Gilbert said to me, or Lisa, it's the emotion that you don't bring to this experience with the therapist that we're interested in. And for me, it's like, wow, like now working in an anxiety unit. Yes, anxiety is a given, you know, otherwise they wouldn't be referred to us. But I'm always now looking at what emotion am I not seeing? And, and so for so many reasons, Compassion Focused Therapy just changed my own life. But also I started to see the person in a much more sort of longitudinal way. Seeing that, actually helping them to understand that some of the symptoms, I guess, were their best efforts at keeping themselves safe at a time when they couldn't in childhood. Maybe it was just a different way of, of looking at a traditional formulation, I guess, and really seeing the person in the context of the life that they'd lived as a child. With their families, but also in the utero, you know. Goes back so far, doesn't it? And just the language I just thought was so much more compassionate.
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A
Yes.
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B
And it showed so much more sort of humility. And the language was, you know, it was a language that I understood and it, and it's wrong to say it's simplified, but it just meant that you didn't. Otherwise the person sitting in front of you, you were two humans in the room with, with tricky brains trying to, trying to get through life, which is inherently hard. If I read. That's a long answer, isn't it?
- [06:34]
A
That's, that's wonderful. One little quick question. Which book was it actually of Paul's. Do you recall which.
- [06:41]
B
It was the original, it was the original Compassionate Mind. What's it called?
- [06:47]
A
The, the Compassionate Mind.
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B
The Compassionate Mind. Yeah.
- [06:51]
A
Yeah, yeah, yeah. No, that's. I, I really. Yeah, like what you say there. I, I feel similar, similarly that, where, you know, when we start to bring a compassion focus to, to our, our, our work, it, it, it starts to sort of infiltrate our lives too. You know, like there is that real feeling of, of the flows of compassion and the, the way that we're all sort of in this together and, and ourselves and the people we're working with included. And we're able to sort of see ourselves in various different lights too, and kind of trying to keep those flows of compassion in balance. But certainly those we're working with, it is the longitudinal thing and it goes back in utero, as you say, but it goes back across the millennia of evolution. I mean, that's the other piece too. Is that really actually understanding ourselves and each other and our tricky brains, but from that really, that 11 evolutionary perspective. And, you know, it's not our fault, but it is our responsibility. All that sort of stuff just really brings a whole nother lens to see.
- [07:58]
B
People and that sense of like common humanity. I think, and I am, because we are, you know, that sense of being in this together, I think that that was a language I really resonated with and I still continue to today, I guess as a team. We're looking at where I work, we're looking at our own formulations and we look at what do we need to flourish alongside our clients so that actually we can increase our own psychological safeness as therapists. And that replicity means that actually our clients hopefully will feel safer amongst us. So I think that's something slightly different from anywhere I've worked.
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A
And that speaks to the head, heart lag and hopefully the heart catching up, I guess, because I suppose it is sort of safeness, isn't it? It's safeness that we are hoping to cultivate for our clients. And partly that's about cultivating safeness for ourselves and the team and the context and the therapeutic relationship, of course. And it's that felt sense of feeling understood and feeling safe and then maybe even starting to be able to approach those parts of ourselves that we perhaps don't like so much and feeling differently there as well, and thinking about, like.
- [09:33]
B
The version that we bring to work, you know, and just taking a moment before we interact with another and just thinking around our body language and the way we're breathing. And I think it's. Is it Tobin Bell's book that's, you know, the Inside Out?
- [09:48]
A
Oh, yes.
- [09:49]
B
You know, working from the inside out, you know, and thinking about us as therapists working from the inside out. So what do we need to flourish in those moments?
- [09:57]
A
Yeah, yeah. Paul Gilbert's work is very inspiring in that way. I, I mean, I'm. I'm a sort of a devotee, really, as well. And I think it is because it, it makes such an impact on the, the interpersonal, the intrapersonal, the, the kind of, the way that we start seeing ourselves and others and, and, you know, it spreads kind of thing. I. I suppose, yeah. The, the, you know, a lot of your work at the NHS in London is. Is working with people with obsessive compulsive dis. I was wanting to take a sort of a relatively specific look at that from a CFT point of view today in our conversation, but I suppose first I wondered whether you could just give us a little bit of a sense of OCD and perhaps describe there and what that experience can be like for people, really, the people that you're working with.
- [10:52]
B
First and foremost, it's very distressing for the individual with ocd. Very disabling for them and their families and the communities that support that client or that resident. We call the people here residents, actually, because they live with us, but I'll probably use those interchangeably throughout. Dan. But for the person that's really struggling with ocd, it really impacts significantly on their lives and they're. They struggle within, you know, with intrusive thoughts which are repetitive. They feel sometimes that they have no control over them. They take up a lot of their time in their mind, you know, And I would say that for many of our clients, their. There's a lot of shame. And we can, I guess, explore that around one, having those Thoughts and then the behaviors that are attached to those thoughts, like trying to either reduce having them or trying to push those thoughts away because they're repugnant or repulsive. And they can be thoughts, but they can also be urges. They can be images, but they're of a repetitive, intensive nature. And then I guess when those thoughts come into our mind and they're seen as sort of unwanted, intrusive thoughts, the client often finds them disgusting or unbearable or out of sync with their moral code or feel like it means something about them as a person or the people around them. And then they try with everything they've got to try and get rid of those thoughts by pushing them away or by. By engaging in a behavior which negates that thought, like, I don't know, singing a nursery rhyme once they've had that thought to try and neutralize that thought. And that constant battle between having a thought and then being involved in a behavior, trying to get rid of that thought. You can see how distressing it is for our clients and how much time it takes up and how it limits day to day functioning and stops them flourishing in the way that they so deserve to flourish. So many of our clients have not gone to work. They've not been able to. If their intrusive thoughts are related to sexuality, they might not have been able to hold their children, for example, or hug their loved ones, or contamination. Not being able to even hold hands with someone or do basic tasks like washing up or cooking a meal for someone. So you can see how not only is it debilitating, but also so much shame around not being able to do that, those things that other people around them are able to do. So there's a lot of grief, actually, there's a lot of grief for a life not lived often. And there's a grief for feeling like they're less than because they've got this condition. So traditionally, many of our clients have had traditional cbt, cognitive behavioral therapy with erp, exposure response prevention. And they may have had years of that. And that's not to say that the people that have given the therapy are not good at their therapy. I think they're some of the most excellent therapists I've met giving cbt. But there's something that the client has been missing from their treatment that has meant that that has not may have worked at the time, but it may not have worked long term. Over a period of time, some of the OCD symptoms may have come back, or it may have meant that it's never really worked. And so we're really curious here. We're a CBT service, Stan, but we're really curious about thinking about what are those fears, blocks and resistances maybe that have led to the treatment not working the traditional cbt, but also seeing the person in front of us and really trying to listen to what those symptoms are really trying to tell us, I guess. And maybe, maybe it's not just about. Well, this is one of my beliefs, really. It's not about symptom reduction, but maybe those compulsions that maybe hand washing or any of those things. I mentioned a strategy that has enabled that client to keep themselves safe at a time that they felt unable to for whatever reason. And maybe what we need to be really listening to is what is that trying to communicate to us? What are those compulsions really trying to communicate to us? Because there's one thing that I'm certain about is that it's disconnected them from themselves, their emotions of each other. And what we're trying to help our clients to do is to move towards connecting with those things that they've been avoiding for so long.
- [15:55]
A
Yeah, thank you for, for just really sort of reminding us that the suffering that is associated with something like ocd, it sometimes can be somewhat forgotten, can't it, in the, in the, in the sort of general society, and even talked about flippantly. But OCD really does represent a very, you know, intensely felt suffering from a couple of points of view on, on the one hand, the obsessional thoughts or the intrusive thoughts and so on, that they are extremely, you know, sort of frightening at best, but shame inducing, you know, as well. And so enormous suffering there. And then the more compulsive behaviors or the behavioral responses to those intrusive thoughts themselves, you know, kind of create other suffering that the person, you know, goes through in terms of, as you say, the different types of compulsive behaviors and how that might affect the person and their family and people around them and their, their lives and so on. And then it kind of folds back on itself as, as more, more shame, more guilt, more grief, more rage or whatever it might be that, that the person, it goes in a, in a very, very difficult, you know, very vicious sort of cycle of suffering. But you've mentioned or you've started to allude to. Yeah, just, just how we might conceptualize that or, or begin to, to build a bit of a formulation through, through a CFT lens and, and thinking about the behaviors in terms of some of those, you know, the sort of the safety. Safety strategies or the. The consequences to certain safety strategies, but where those safety strategies perhaps have arisen from. Could you give us a bit of a sense, what is a sort of CFT formulation really of ocd or how might we start to build a CFT formulation there?
- [17:56]
B
I guess what we're. First, we're trying to really understand what it was like for that person when they were their most vulnerable. So often we do talk about childhood, actually, and we say, were there moments in your life? There's so many questions that are coming to mind actually, Stan. But one of them, I guess, is how old does your anxiety make you feel? Which is a really good opening question. And it sometimes can take the client back to a time and they go, oh, it actually makes me feel 13. Okay, tell me about what was going on for you when you were 13. And that can be really a lovely way to open up into that environment when the child was, maybe adult, was vulnerable as a child. And then. And then we say, when were there times when you felt alone or frightened and. Or you had thoughts or difficulties? Where. Where did you go with that? To get a sense of whether there was any form of communication that was helpful or support that was helpful at the time? And did you feel like you get what. What did you feel like you needed at the time? And what did you actually get from. From the other at the time? So getting a sense of when I was, you know, just thinking about client I was working with yesterday, I felt really alone. My dad was around, and my dad never really said, I love you, but he showed me love doing practical tasks, that he took me to football. But actually, what I needed at the time was to be sat down and have a hug and to really understand what was going on for me internally. So if you didn't have that, what did you do? Well, I learned to push that feeling I had, which felt so uncomfortable down. You know, I pushed it away and I engaged in really academic work because actually. And I became very good at it and very skilled at it. Okay, that's really interesting. And so on, all tense and purposes, your dad thought you were flourishing and, you know, you were doing well. And he was like, yeah, he did, but he didn't know what was underneath that, you know. And what was underneath that was an extreme sadness. I was getting bullied at school, but I didn't really know how to express myself at that time. So we're just trying to explore those early experiences. But more than that, it may not just be one event. And many people say, oh, I didn't have a traumatic time of my life. There's nothing I can pinpoint. And they always say, I like X over there. That client over there. There'. Discreet. You know, there's a lot of comparing that goes on and we try to get away from comparing suffering, but really recognizing that at those moments you felt very vulnerable, you felt in pain or you felt like you were alone in the world. Where. Where did you go with that? And doesn't that make sense that you engaged in X and Y and Z to. To sort of survive, I guess, and to get through day to day? And it worked at the time. You know, those strategies worked at the time. But then when you've gone into adulthood, they either don't work or you've added new ones to them to be able to get through the day. So we're really curious, I guess we don't. We do follow the lovely formulation that Paul Gilbert, you know, a CFT formulation, a standardised formulation. But I guess in the early stages of treatment here, our residents stay with us for 16 weeks. We're really trying to listen to the client's story, to be curious about how their life experiences were. What did they do when they felt in pain or alone or frightened, where did they go with those emotions and how have they sort of functioned day to day? And are there emotions that they don't engage with or they feel frightened about having? And underneath, often, like extreme anxiety, I would say the other emotions that are suppressed underneath that tend to be sadness and grief and anger. And we don't often see our clients showing us those things when they come to our unit for treatment. So we're always in the back of our mind as a therapist, curious about where those emotions sit, either in the body or through different behaviors, you know. And what I find fascinating is, like, around week eight, I don't know why it's week eight or six to eight, that sort of time is that people start to get very sad and feel low in mood and there's a lot of tears and crying or. And they feel grief and they go, oh, the treatment's not working. And I'm like, no, no, no. This is the treatment. You know, this is like golden. This is. This is what you've been sort of running away from yourself from. This is what you've been moving away from. This is what you've been disconnected from. And what we're going to try and help you to do is to connect with that. And there's so many different ways we're very fortunate to help our clients Reconnect with themselves here through yoga, through music, through massage, through you know, lots and lot pottery, baking. There's so many ways that we're helping the client to reconnect with themselves and those difficult, what they term difficult emotions.
- [23:15]
A
Yeah, well, I'm just to sort of reflect on what you've sort of said so far. You just that notion of kind of sort of humbly curiously exploring sort of life experiences I guess. And that is a really important question. You know, what, how old does the anxiety make you feel? I mean that's an amazing way in that I haven't really tried before. Will be you know, mental note on, on some of the questions that you've, you've mentioned there. But, but yeah, trying to explore sort of I guess shaped by experiences what, what has been the experience in especially in the attachment or the, the caregiving care receiving, relational part of of life growing up and exploring sort of the needs and the unmet needs perhaps and, and how the person was responded to and what they did next to, to sort of cope or survive in, in response to the patterns that were established early on that either grew or shape shifted a little bit or you know, kind of became the version that they, they are today. And that, that, that notion of yes, the, the multiple emotions that, that might be at play, some of which are really more prominent and seemingly running the show and, and others that are more beneath the surface but being able to access those again is really a big part of the treatment.
- [24:44]
B
And also it's frightening, isn't it, to experience emotions that you haven't turned towards for many, many years maybe, or have beliefs around what that emotion may mean about us. Like if I feel, if I experience sadness it means that I'm weak or if I experience sadness I won't be able to cope. You know, I, I, I'm functioning by being highly anxious but, and I'm managing to hold down a job or look after my children but if I turn towards sadness for the first time I might crumble in a heap on the floor and not be able to do day to day tasks that are required of me. So there's a lot of fear around expression or feeling of, or making room for emotions. Yeah.
- [25:31]
A
And I can sort of imagine the, the example that you gave that a very anxious perfectionistic style that actually resulted in good grades at school or whatever was probably praised and reinforced or rewarded or whatever. Whereas you know, how is the person responded to with those more vulnerable emotions or more difficult emotions and perhaps they were punished for sadness or punished for Punished for anger as well. And so it's the sort of this. It's might not be a moment in time type trauma, but rather this process of just learning, associative learning and so on. Conditioning that happens around emotions and what's okay and what's not okay and how to manage it as life continues on.
- [26:23]
B
And I guess, also thinking about safety, I guess they're called safety behaviors, aren't they, in CBT terms? But I guess when you were saying about how do we sort of understand it as a CFT formulation, we're looking at the client's best efforts at keeping themselves safe at a time when they didn't know what they didn't know, you know, and so the language is slightly different, I guess, because we're, we're looking at what those strategies, what this. Those strategies are trying to tell us.
- [26:56]
A
You know, does that then move a little bit to the sort of the. I might be a little bit sort of concrete here, thinking concretely, but, but does that then become the kind of key fears column, perhaps of the, of the CFT formulation, just sort of what, what these mean to us and so on?
- [27:16]
B
Yeah, definitely. Definitely the key fears. What, what they mean to us. And actually, if, if I, If I stop doing these behaviors, what do I fear too? You know, because they've. I've been doing them for, for so long and they've taken up so much time and they've maybe kept me away from feelings, memories, emotions that I haven't wanted to feel or haven't felt for a very long time. So I don't actually know what it would feel like if that. If those strategies weren't there.
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A
Yes, there's multiple, multiple layers, isn't there, of meanings or fears or implications of things.
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B
So I think for me, that's really important because it's not just about stopping a behavior. I mean, if I, if I'd been using a behavior, because the reason I've been doing that was because of a very, very difficult time in my life or a very different way I felt about the world, myself or other people, to just stop it. That's hard, you know, and it can be very painful and, you know, it can be extremely. I don't know, it can be traumatic, I guess. So we wouldn't think about stopping those things unless, I guess it's like, I think it was, Deborah Lee may have told me, it's like, you know, putting on the armor. This. There's a. Safety strategies have become like armor, really, but you don't take off the Armor and leave someone exposed underneath. Unless you've built up a compassionate shield.
- [29:09]
A
Right, yes.
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B
You know, so sort of you, you don't remove armor which is exhausting and heavy to carry and means you're disconnected and unable to touch and really feel stuff unless you've got this wonderful sort of compassionate shield that helps you move through life.
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A
Yes, yes. There can be unintended consequences to the safety strategies, of course, and, and so we're quite aware of that and we can see that sort of playing out, but there can be unintended consequences for unwise change of those safety strategies perhaps as well. If that's why wisdom really is part of the, you know, sort of the choices, the helpful choices we might be making. And so we're really trying to develop that compassionate shield, you know, rather than leaving ourselves just exposed through change or symptom reduction.
- [30:04]
B
Yeah. And really I think it's the language, isn't it around that these were your best efforts at keeping yourself safe, that it's, it's not your fault. Yes, there's a. Obviously the responsibility part, but that really de. Shaming because a lot of people feel really ashamed about some of the behaviors or strategies they've engaged in. So that's a really key message. I think, you know, that just like you, if I was in that situation in my life, I may have developed these strategies just like you, you know, so it, it's the language around that too, I think, Stan, that we find is very helpful. I think.
- [30:42]
A
Yeah, you've sort of mentioned the, the, the experiences and, and the way that certain emotional memories and, and so on might influence the, the, the version of ourselves that we become. But, and the not your fault sort of piece. What role do you find the evolutionary psychology and perhaps even the three circles model or the emotion regulation systems, is that a prominent part of your work with people with OCD or how does that kind of get interpreted into this sort of presentation?
- [31:19]
B
Yeah, I think that's another way to sort of de shame, isn't it? Is to look at the evolution of our minds and actually understanding that sort of evolutionary cycle that, you know, this our minds were built for us, not by us, and that they've got these inherently tricky loops that we're all trying to work out and we all struggle with. So a lot of our work is we have like an eight week compassion focused therapy group alongside traditional cbt, the individual therapy as well. But also what for me is just like really helpful is drawing out the three circle model with a client at the beginning of their Therapy as like a visual heuristic. And then at the end they draw the same at the end. So it's much more visual I think. But what's really clear about that is for many of our clients they would draw a huge circle that's red because I guess we're still using the colors because it's you know, so the threat system and the drive for many of our clients can be big from some. For some it's, it's not so much so the drive like they're either heavily into exercise or academia maybe. And then the soothing system is pee like you know, it's tiny. And so just for the clients and the residents to see, we share our own as well because we've all got our own ones here. We're able to share what ours were like and actually how we're trying to develop that soothing system and that sometimes you know, that can fluctuate too that it's not so fixed as it being it grows and then it stays there. That actually this is a lifelong practice in some ways and how quickly our most vulnerable states that we can go back to old ways of being, you know. So I always use the examples like when I was a nurse and I was really really stressed, the wards that I was working on. If I was tired and stressed and I had a lot going on in my own personal life, I may seek more reassurance while I used to. Even though there were some practices that I'd done for years and I felt on other days really confident I would be. I would be doubting myself more or I'd be reading a lot more because I'd be doubting myself. So I might put myself in these different states and my self critic might come to the forefront of my mind. Whereas on other days when I was feeling more less overwhelmed I guess my soothing system was felt stronger, you know. And so it's, it's recognizing that having an awareness of our minds and I think that sort of diffusion techniques are really helpful early on really understanding that. Actually I guess that's quite act based isn't it? But having that thought that you know, noticing and then taking a further step back and noticing some more, you know, rather than being so sort of entwined with our thinking. So I guess looking at all of those things is, is. Is really important Stan, isn't it?
- [34:52]
A
Yeah, there's definitely multiple ways that the beloved three circles model can really be very practical. You're using it as a pre post almost visual assessment really of things and you're also thinking about it in terms of how it changes over time. And not only that, but depending on context and bringing the contextual factors in to raise that mind awareness around the shifting sands of the three circles, really. And, and how we can, I guess, give attention to soothing affiliative system and, you know, cultivate and develop some of that.
- [35:37]
B
And also, I guess, you know, for me as well, like learning, I think early on that sometimes in society we can really celebrate drive, can't we? And recognizing that actually if I weren't engaged in X, Y and Z, these behaviors, these drive behaviors, like what, what do I fear? You know, underneath that and seeing that sometimes that that threat system is dry is sort of driving. The drive is underneath the drive, you know, and for many of our clients here especially, they're like, ah, you know, I've been, I've been doing so much exercise, been so much praised for that, but if I stop exercise, then my threat system shows up and, and that's frightening, you know, and so you can see how the drive has been taken away from feelings of failure, for example, that may be underneath all of that. So that sort of curiosity about the function of behavior for me is like really helpful. So always looking at what the function of people's behaviours are. And also if you were to not do that activity or that behavior, what would that look like? And are there any fears that come up in that experience? I'm just thinking aloud. There's so much to talk about, isn't it? And then, and then just thinking about like the self soothing and the fears attached to that as well. You know, what it means to offer yourself compassion, that actually slowing down can be really frightening experience for a lot of our clients and for others, not just clients, but just that slowing down, engaging with soothing rhythm, breathing, all of those things are not as easy as reading it and doing it. I guess that's what I'm trying to say is that actually they often hold fears themselves. For many of our clients, they're brilliant in a community at offering each other compassion and really noticing when they're moving towards things that they're struggling with or leaning into their difficulties in each other. They're able to say, I saw you doing that. And that was so courageous and really well done and championing that. But they find it very difficult to do that for themselves. But also many of them find it very difficult to receive that compassion from others. And then exploring what. Why would that be? And being curious about that too.
- [38:15]
A
Yes, very, very sort of caught in the. The threat and the Drive and, and in a very, very well practiced kind of combination there that that is, is all meant to reduce threat I suppose and, and create a sense of safety and, and the threat based drive is, is keeping them going and even has some positives probably you know, in terms of outcomes for them, but is also keeping them very trapped in, in threat system. Threat system is really, you know, running the show there. And to let go of that, I mean they, people might sort of really hold very tightly to that, that combination of, of emotion regulation systems, you know, that are at play there that it, it feels terrifying really to slow it all down or to, to try to, to stop and find calm and, and, and so there's a lot of fears, blocks and resistances that arise there and across various flows of compassion I suppose is what we then start to think about actually. At what point does just the concept of compassion and the three flows and so on. When would you introduce something like that? And how do people in this sense kind of typically respond or sometimes respond?
- [39:40]
B
So we introduced that straight, straight away. Really? Okay, yeah, yeah, yeah, really. I think it's just, I remember that sort of curiosity. Some people go oh, compassion's not for me. And I always say, I really love that response because, because I, I'm really then curious about why you think compassion's not for you. And let's see what you think at the end of the 16 week treatment here. You know, so for me it's about exploring why they may say that. But yeah, we start very early on and I guess it's the language of the therapists here. We're sort of a compassionate community. So the language is very compassion based. We also, you know, I think it's that sort of sense that success is being psychologically safe in your own mind. I think there's some sort of societal thoughts around success and some of our clients come in with, are slowing down is, is not being a successful human. So it even we're not trying to change people's minds I guess, but having open conversations about that and then it's just wonderful to see how people relate to a compassionate mind at the end of treatment, you know, and, and, and then I guess working with families, I think that's important. If we can help them to understand compassionate mind as well, then you've got two people working at it at the same time. And the, and so I guess for OCD and body dysmorphia, people go into their own homes and they maybe have developed a sort of compassionate mind and way of relating to Themselves trying to be less self critical and all of those things. But if they're going into a home environment and then they're met with, you know, maybe criticism from the people that they're living with or being further shamed, not for anyone's intent, you know, fault, but I guess there's a lot of tension created around mental health in homes and especially if you, your loved one has been struggling with that for a long time, suddenly the client starts to change, but maybe the family haven't caught up with that change. And, and I guess that's important to really think about that I think is bringing families into the treatment as well. And if we can help them understand what compassion focused therapy is, not like giving them full treatment necessarily, but information on it, then you've got two people with an understanding about how important being compassionate towards yourself is. Because otherwise, yeah, you're, you're just, you're, you're developing your compassionate mind. But it's really hard when you're vulnerable to be met with a threatened mind.
- [42:35]
A
Yes, yeah, yeah. So they might arrive and, and like many of us, you know, the first hear it and feel a bit dubious of it, especially compassion for them, for themselves and you know, whether from, from others or from themselves actually. Do you find that people who are really deep in a kind of threat based drive that compassion for others is also a little bit tricky or that there's a sort of social rank or social comparison stuff that makes compassion for others tricky as well? Or is that often one that does flow more easily for them? It's the receiving that's harder?
- [43:20]
B
I think it's a bit of both really. And I guess I think every morning we meet at 9 o' clock, so we talk about what we might be doing in the day that sort of helps us lean into the things that we're fearing. And so in a group setting you're hearing what other people are struggling with and then we ask for gratitude. And I think that even if it feels like a foreign concept, you're starting to offer compassion to each other as well. So we ask people to notice in the other what they have managed to do that week or the courage that they've faced. So even if it's something that they're not used to, I guess by the end of the time with us, they're starting to notice or mentalize or experience the other and it's no fault of their own. Is it like if you're highly, highly distressed, you're in a threatened mind and you're just like Going, get safe, be safe, get safe, be safe. It's near impossible in those states to then think, oh, there's somebody else suffering to my left or my right. And I always think it's amazing that our clients are able to do that alongside their own distress. Right. But the capacity to do that definitely increases over time. So even if they're in those mind states, we're just trying in those moments to just take a moment to think outside of their own mind and look around the room. So it's like very subtle ways, but I guess that builds over time.
- [44:59]
A
I sense that over time there's two things sort of happening. One is the skill development around the three flows, really, of compassion. And then the other is almost like a exposure or a habituation to doing it and experiencing it and feeling gradually safe to give and receive compassion. So those. It's almost like the morning meeting and the group work and so on really has those dual purposes.
- [45:28]
B
Definitely, definitely. But it's like you say, it's not compassion for the other seems to be not for everyone, but the majority easier than the other two flows.
- [45:41]
A
Yeah, yeah. And I can imagine that by the time perhaps they do return home or they're dealing with family members or friends or, you know, people in. In their natural environment, so to speak, that they might be compassionately setting more boundaries or being a little bit more assertive or express certain needs and so on. And that can be met sometimes with, you know, unsettling kind of. People feel unsettled by this. This different version of. Of their loved one. And. And so I can certainly see that, yes, some sort of looping in for the family might be really important to. To prepare them for that. Things are. Are changing from here.
- [46:26]
B
Yeah, yeah. And just paying attention to sort of body language. I think it's, you know, the importance of a smile and that repetitity between two people and how you hold yourself and sort that method acting as well. And I think that definitely, like, even if it's. They're small changes, they do impact on the environment, don't they, and the interaction you have with others. So there's small things that can. Can. You can make a real difference too, I think. Yeah.
- [47:04]
A
So what would be some of the specific CFT strategies that, you know, that you would use or that seem to be kind of particularly helpful for people with ocd, I guess, specifically too, are there set pieces, as Paul Gilbert would say, that you feel are really important there?
- [47:25]
B
Yeah, I guess it's. It's like there are set pieces, but it feels like it's a smorgasbord of CFT approaches, I guess, because if I start with the body, we do method acting through sort of drama and those things. So we're thinking about the version of us, you know, that we want to grow. And what would you know Charlie Herriot Maitland's lovely video, you know, about compassion for voices. And that lovely image of how he holds himself and the way he talks to himself in that. I think it's lovely. So we're thinking about yoga. We do yoga here because I think not only are you slowing down, getting into soothing breath, but also you're getting back, reconnecting with your body. So it's a lot to do with reconnection with the self that you've been running away from for a long time. There's no. There's music as well. And I know there's lots of studies on compassion for music, but we offer. We offer music to each other in a. In a music group and really give a gift of compassion to each other through music. So that's quite an important part. So they're sort of things that. And the cooking and all of those sort of bread making and all those sort of things where we're sort of, I don't know, on the outside, which are just as important. I think they're all sort of got compassionate intentions to them. And then we have like the key sort of compassion focused therapy skills. So, you know, soothing rhythm, breathing is a daily thing that our clients get into. I think Paul Gilbert calls it compassion under the duvet. Like really thinking about before you get up in the moment, like orientating yourself to the day. We do compassionate imagery. So a lot of the imagery work, compassionate other thinking about, you know, the self critic and how we talk to ourselves and how we would sort of warm up how we talk to ourselves and offering ourselves a different way of relating to ourselves through the way we talk to ourselves. Grounding techniques, diffusion techniques. Wow, there's just so many a smorgasbord indeed.
- [49:40]
A
Yeah.
- [49:42]
B
But I think for many of our clients is that they may not have had a carer that they have felt they can identify as being compassionate. And so when we're developing compassionate imagery, I think that's such an important part. I think loneliness is something that we really need to explore more with. With clients. Many of our clients are desperately lonely and that they may be in families, they may have lots of people around them, but they still feel a sense of loneliness. And so having having a compassionate other that they sort of take with them in life from the moment they get up to the time they go to bed. You know that we spend a lot of time developing that, the compassionate imagery work.
- [50:36]
A
I was wondering about compassionate imagery and how that fits for people with ocd, particularly if they're experiencing intrusive thoughts or images and that, that's part of the sort of their daily battle, I guess, is the product of the mind and how that just arises for them. And then they're trying to manage that with, with certain behaviors or that sort of thing. And I wondered whether you use imagery, adapt the imagery, or whether there's sort of ways that you've noticed people sort of struggle with the imagery in particular in this cohort.
- [51:16]
B
Yeah, I think there's some people that can be very good at developing imagery and then there's people that really, really struggle with, that really struggle. And there's an also, I think we spend a long time sort of exploring the difficulties around imagery. I know that when I first started to do imagery, I thought that you had to get like a perfect photographic imagery. Like, I remember speaking to Paul about it when I was doing my course was like, I said, I can't do this because I thought like, if you packed a picture of bike, you had to picture both wheels, the saddle, the steering wheel, you know, the, the brakes and everything all at once. You know, I, I didn't realize that imagery is like your brain can't do that. It just may focus on the wheel at one point and the saddle another. It doesn't have to be a complete image. And I, and that was helpful for me. So I do share that with some of the clients. But sometimes it's not that they have like a compassionate image that comes to mind in human form. And it may mean that some of them say, well, actually I felt unconditional love for my cat as I was growing up. And, and so we often start of, okay, the qualities around that cat, that pet that they had. Let's, let's start there. And also that sense of touch and go. Like, it, it, it's not like, oh, we, we do a session on that and then you're all set and ready to go. But actually these things take time and there may be moments where it's easier and sometimes when it's harder, but that's okay. You know, rather than getting into being self critical about not being able to.
- [53:00]
A
Do imagery, not being able to do it straight away or, yeah, not being able to do it this time even though I did it last time, or, you know, there's yeah, it's a. It's a. It's a flow as well. It's a fluctuating course a little bit. And we, you know, we. Over time, we're really gradually building and. And embodying the. The compassionate part. I like that point about how, you know, just to check with people, their. Their sort of way of doing imagery and, and that it doesn't have to be a perfect picture of a bicycle, but you might just have. You might have sort of glimpses of. Or it might even just be a felt sense of what a bicycle is or whatever, but, you know, just being really able to evoke a little bit from them their sense of how imagery works for them. And I remember Paul mentioning the. The one where you might sort of ask someone, if you think about your breakfast this morning or what you had for breakfast, you know, and you bring that to mind, how does that appear for you? Or how do you sort of recall your breakfast? And there's a way to, you know, just to sort of assess how people's imagery might work for them and, and go with that, I suppose, is.
- [54:15]
B
Yeah.
- [54:17]
A
Useful.
- [54:17]
B
And also, I guess we might. We might start with some of our clients about. Have. Within their day, have they. Have they felt compassion from somebody else? And, and what. What were the qualities of that. That. How did it make you feel? And what. What were the qualities that made you feel that way? And. And say. They say, oh, you know, they were just like, sat down next to me, talked in a really sort of kind voice. It was calm and. And they just said, I noticed you today. You did something really courageous and, you know, like, well done. And it's like, oh, and how did that make you feel? Or it just. I don't know what the words are, but I had this feeling like this warm glow or this glimmer of something that was different from how I'd yesterday when I felt really anxious. Oh, that's interesting. So trying to sometimes move away from calling it anything but just exploring the. This. The moment or the glimmer at which they felt something that we would term compassion. But I guess it's like a moment that they felt something different to anxiety. And what did that look like, you know?
- [55:30]
A
Yeah, really sort of really exploring the experience and not getting too caught up with it by the sounds, but it sounds like there's almost a subtlety to that conversation, a curiosity, but a gentle curiosity. It's not even really trying to make a point, but rather, you know, just sort of. Ah, okay. Yeah, that's. Tell us more about yeah. What was that like? And what did you notice? And. Okay, well, that's, you know, sort of, you know, note to self sort of thing. That, that, that's a, that's an important experience today. And tapping into memories, I guess, to experiences to, to. To do all of that.
- [56:12]
B
Yeah. And the memory thing we haven't talked about really, but I guess that's, that's important is like, have there been any other times in your life when, when you felt this way and what was that like? And then, you know, and then it can take people back to places. I don't know. When I was in holiday and I met this person on the beach and you know, we chatted and we played in the sea and I was 6 years old and you know, so you start to build up the qualities that would make up a compassionate other.
- [56:38]
A
Yes, I wondered about that earlier in our conversation. I nearly asked the question that we were thinking about, you know, how, how old does this does anxiety feel to you? And let's explore sort of some of those experiences and so on. It sounds like you might use a similar kind of strategy or approach to explore the memories of warmth and safeness or other kind of memories that, that are also the genesis of, of some of these feelings or motivations, even around compassion. Self compassion.
- [57:10]
B
Yeah, definitely.
- [57:15]
A
I think you said a moment ago you are doing the CFT sort of in parallel with CBT there by the sounds of it. And I suppose exposure and response prevention you mentioned earlier, and it seems to be a, I guess an evidence based approach or whatever to working with ocd. How do you integrate those sorts of things? Is there a compassion focused way to do exposure and response prevention? Or are they more parallel and kind of independent from each other? What does that look like in integration?
- [57:49]
B
I think they've very much integrated, actually. Sam. Stan, I don't think they're separate entities. I think, I think when I first I first started CBT and then I was doing compassion focused therapy, it felt like they were two, two separate things. But now I feel like everything is through. Sorry. Through a lens of compassion focused therapy. So. Yeah, it's hard, isn't it? It's hard now to pull it apart when you've been doing it for so long together.
- [58:22]
A
Yes. Yeah. It's kind of part of the wisdom, strength and courage of compassion, I suppose is what we're bringing to that is, you know, what is it that might be helpful? And in fact, moving forward towards some of those CBT strategies is very difficult, but is helpful, perhaps.
- [58:43]
B
Yeah. Or could be yeah, no, definitely. And I think it's the version that you take to your erp, I think, I think gotcha. So for many of our clients, they would say, and I explore this with them, do you grit your teeth through erp? Are you happy when it's over, but you feel like, thank goodness for that, I never have to do it again? Or are you doing it because you want to, like, please your therapist that you've done this task? You know, and it may be all of those things, it may be none of them, but it's really worth exploring because clients will say, yeah, you know, I've had previous therapy where I just gritted my teeth through it and just couldn't bear it and got it over and done with. And then I ticked the box that I'd done erp, and actually that doesn't allow you to be your most curious to really understand that. And so that's why it's really not just about symptom reduction and it's listening to that. This is your best efforts at keeping yourself safe. And it's been a strategy for that for so long and it's moved your way. It's disconnected you from yourself and other people and the world around you. And so how can we best understand that? How can we best listen to those strategies? You know, so when we're going into an erp, erp, if I went in with a critical mind, a really seriously critical mind, you're not getting the most understanding and curiosity. You're not in a curious space, are you? Because you're going, get safe, be safe. You're going into an ERP session, get safe, be safe. Whereas if you can go into that, and also there's a lot of shame if you don't do it in the way that's been set out in an ERP task that's been set, if you don't do it or you don't get the reduction in distress that's expected, or it's not been done in the way that expects, you're just fueling a shame cycle again. Whereas if we can go into ERP without saying, I'm making a towards move right now, and, and it's in line with my values, I, I've. I understand why I need to do this, because I want this on the other side. I want to live a full, meaningful life in line with my values. I want to be able to take my children to school and hold their hand across the road. You know, I want to have a sexual. I want to be sexually intimate with My partner and I haven't been able to touch her since, for the last 20 years because of my OCD. I want to go back to work because work gives me so much meaning and value. It means that you can enter your ERP with a purpose, I guess, and a curiosity, but also with a mind that says, you know what? This is a hugely courageous thing to do. And you're choosing to move towards something that was your best efforts at keeping yourself safe at a time when you felt possibly alone and afraid and disconnected from the world around you. And we're asking you to do something huge here. So I'm using the wisdom and my courage to move towards something that's going to be potentially really painful and might cause me upset, and it might mean that I engage with anger and grief and all of those things, but I'm doing it because actually I feel like there's a purpose to it and I'm taking my compassionate self with me on that journey.
- [62:14]
A
Beautiful answer to the question. Yeah. And there's so many aspects of therapy where that sort of answer, I think applies, you know, that it just takes so much courage to go there and to have that sense of that compassionate motivation, that compassionate self alongside and sort of readying ourselves and steadying ourselves to kind of move towards all of that. And it's, it's, it just enhances really, I guess, the experience there and perhaps even the, the likelihood that it might be helpful.
- [62:51]
B
And also the. I feel like it, sometimes it can be really helpful to that. Imagine that team around you, you know, that are willing you on in those moments as well, that you're not alone.
- [63:05]
A
You know, which team is that? Is that your team of compassionate others or is that like literally the people around you?
- [63:14]
B
It could be both, I guess, but I guess it's the compassionate others.
- [63:19]
A
Yes. Lovely. Yeah.
- [63:21]
B
Yeah. And also I think it's like, I'm here because my ancestors survived, you know, and my, my clients have said, like, isn't that incredible? Yes, that, that moment, like, I'm. I'm taking their strength and their courage and their wisdom along with me too. And I. And that was like. I was like, wow, that's. That's amazing thing, you know?
- [63:47]
A
Yes, it is.
- [63:48]
B
And then it made me start thinking about my own grandparents that were really in my life and not. It's not for everyone's life, but they were for me, the wisdom, you know, and they showed great courage and, and there was something about the essence of their being that I was able to bring with me in difficult situations. So we explore all of that with, with our clients, you know.
- [64:11]
A
Yeah.
- [64:11]
B
It may be the cat that they bring along, you know, whatever it is for that person that provides meaning for their. For them.
- [64:21]
A
Yes. It's sort of spine tingling, isn't it, when, when people come. Come up with that sort of wisdom and, and just reflecting on the. That those who've come before and who've sort of walked the world and met each other and you know, sort of fallen in love or, you know, kind of had brief encounters or whatever it might be, but have sort of survived and, and you know, on it goes from. From generation to generation and here we are, you know, with all of that behind us in a way and the wisdom and strength that goes with all of that. It reminds me of Return of Return of Skywalker when Rey was visited by all the previous Jedi who encouraged him to take on Palpatine. I probably shouldn't go too deep into Star wars, but that's just what popped in mind.
- [65:13]
B
Yeah. There's an artist called Nick Mulvey. Have you heard of him? Is a musician and he's got his amazing. He's quite influenced by Rumi and people like that. But he. One of his songs, I can't remember what it is, he says it's the courage to feel it all, you know. Yeah, yeah, yeah. And that's not easy.
- [65:36]
A
Well, I, I will let you go in a moment, Lisa. That's been. Yeah. Very inspiring all that you've said and I look forward to re. Listening and thinking about some of the pearls of wisdom that have. That have come through. Do you have any suggestions about resources or you know, for therapists perhaps, but maybe for people who are themselves curious for their own journeys, you know, are there any resources out there for CFT and OCD and that sort of thing?
- [66:09]
B
I mean I use so many people. People's resources, I guess. Chris Irons and Elaine Beaumont, we use every client gets given their book. I'm just trying to think of the names of all their workbook and we. For people that can afford it would. We would signpost to the app as well. And for many of their families they use the app. So that's been really helpful. For our therapists we use Tobin Bell. I think it's Tobin Bell's book on, you know, working from the inside out. So that's a really good resource. My. I love Deborah Lee's book on trauma and I find that really sort of, I don't know, quite very user friendly. For many of our clients that have had traumatic past, there's just so many, aren't there? Of course, the seminal book by Paul Gilbert. And then I just tend to there's your lovely book, Stan, and then there's you know, like Russell Colt's book for Anger. So whatever books out there, I have them all on my shelf, I think and use them all in equal, you know, for various things for the groups, to support the groups. But for anyone interested, I think the Compassionate Mind foundation website has got a lot on there, hasn't it? And there's the conference I know I haven't been to for a few years, but I'm planning to go this year. So. Yeah. And also the list serve for people that are interesting, you know, interested on, on the Internet.
- [67:37]
A
Wow.
- [67:37]
B
There's just so much.
- [67:39]
A
There's, there's a lot. And actually I will, I will take this opportunity to, to list all those out in, in the notes in the description below, as they say. And, and, and also yes, the, the, the diploma of CFT too probably I might put absolutely a link down there because that is still going from strength to strength from what I've heard in terms of it. You know, the really growing program that's been very, very effective for helping people learn CFT so well. Lisa Williams, it was lovely to connect again and really inspiring, as I say, to hear your words of wisdom. So thank you for being on Compassion.
- [68:19]
B
In addition. Thank you and have a really good evening.