Compassion in a T-Shirt: Treating OCD with Compassion | Lisa Williams

Host: Dr. Stan Steindl
Guest: Lisa Williams, Principal CBT Therapist and Manager, South London and Maudsley NHS Foundation Trust
Date: February 21, 2025

Episode Overview

This episode explores the integration of Compassion Focused Therapy (CFT) into the treatment of Obsessive Compulsive Disorder (OCD). Dr. Stan Steindl and guest Lisa Williams discuss how compassion can shift the way OCD is understood and treated, examining CFT’s unique lens on formulation, the impact of early experiences and attachment, and the integration of compassion with traditional CBT interventions like Exposure and Response Prevention (ERP). The conversation is rich with clinical insights, practical techniques, and heartfelt reflections on vulnerability, courage, and what it means to bring compassion into the therapy room—for both therapist and client.

Key Discussion Points and Insights

1. Lisa’s Path to CFT and Integrating Compassion into Clinical Practice

• Early Journey ([02:22])

  • Lisa initially trained as a nurse, later retrained in CBT, and found her clients often understood therapy intellectually but reported, "I just don't feel how I was hoping to feel."
  • Lisa describes the classic “head-heart lag” and how discovering Paul Gilbert’s Compassion Focused Therapy addressed this disconnect for her and her clients.
    • "I started to see the person in a much more sort of longitudinal way. Seeing that... some of the symptoms, I guess, were their best efforts at keeping themselves safe at a time when they couldn't in childhood." (B, [05:37])

• CFT’s Unique Value

  • Compassionate language, understanding of evolutionary perspectives, and a focus on humility and shared humanity.
    • "Otherwise, the person sitting in front of you, you were two humans in the room with tricky brains trying to get through life, which is inherently hard." (B, [06:11])

2. Understanding OCD Through a Compassion Lens

• Nature and Experience of OCD ([10:51])

  • Lisa describes OCD as "very distressing... and very disabling." She outlines the suffering caused by intrusive thoughts—often repugnant or at odds with a person’s morals—and their attempt to neutralize these via compulsions.
    • "There’s a lot of shame... and grief for a life not lived often." (B, [13:54])
    • "It’s disconnected them from themselves... and what we’re trying to help our clients to do is to move towards connecting with those things they’ve been avoiding for so long." (B, [15:03])

• Societal Misunderstanding

  • OCD’s impact is minimized in the public eye, but is intensely shame- and grief-laden for those experiencing it.
    • "OCD really does represent a very, you know, intensely felt suffering..." (A, [15:55])

3. Formulation and the Role of Early Life Experiences

• Formulating OCD Compassionately ([17:56])

  • Lisa advocates for curiosity about when and how a person first experienced vulnerability, asking illuminating questions (e.g., "How old does your anxiety make you feel?").
  • Explores attachment dynamics, suppressing emotions, and how safety strategies develop early—and can evolve or compound in adulthood.
    • "We’re really trying to listen to the client’s story, to be curious about how their life experiences were... And are there emotions that they don’t engage with or feel frightened about having?" (B, [19:57])

• Gradual Access to Emotion

  • Noticing sadness or grief emerging midway into treatment is a positive therapeutic sign.
    • "People start to get very sad... and they go, 'Oh, the treatment’s not working.' And I’m like, 'No, no, no, this is the treatment.' This is what you’ve been running away from." (B, [22:08])

4. Compassionate Language and De-shaming Strategies

• Reframing Safety Behaviors ([26:23]–[30:04])

  • Rather than “just stopping behaviors,” acknowledging them as best attempts at safety during vulnerability.
    • "You don’t remove armor... unless you’ve built up a compassionate shield." (B, [29:09])
    • "These were your best efforts at keeping yourself safe, that it’s not your fault." (B, [30:04])

• Wisdom in Transitioning Strategies

  • Change must be wise and gentle, integrating compassion to avoid retraumatization.

5. Evolutionary Psychology and the Three Circles Model

• Normalizing “Tricky Brains” ([31:19])

  • Using the three-circle model (threat, drive, and soothing systems) to visually conceptualize a client’s inner world, helping to de-shame their experiences.
    • "Our minds were built for us, not by us, and they've got these inherently tricky loops that we're all trying to work out and we all struggle with." (B, [31:23])

• Practical Group and Individual Work

  • Pre/post self-assessment using the circle model illustrates change and fosters team connectedness.
  • Drive behaviors often mask threat; compassionate inquiry asks, "If I weren't engaged in [drive behavior], what do I fear underneath that?" ([35:36])

6. Flows of Compassion and Community

• Three Flows of Compassion ([38:15]–[45:40])

  • Early introduction of the three flows: giving compassion, receiving compassion from others, and self-compassion.
  • Residents often find it easier to offer compassion to others, but struggle to receive it themselves.
    • "It’s near impossible in those [high threat] states to then think, 'Oh, there’s somebody else suffering to my left or right.'... But the capacity to do that definitely increases over time." (B, [43:19])

• Therapeutic Community

  • Morning meetings and group gratitude foster both skill-building and “exposure” to compassion in action.
  • Supporting family involvement is crucial, as home environment influences recovery.

7. Compassion-Focused Techniques and “Set Pieces”

• CFT “Smorgasbord” ([47:24])

  • Embodiment through method acting and drama; reconnection via yoga, music, cooking, and pottery.
  • Core techniques: soothing rhythm breathing, compassionate imagery, working with the self-critic, grounding, and diffusion.
    • "It’s a smorgasbord of CFT approaches... but all with compassionate intentions." (B, [47:24])

• Compassionate Imagery Challenges ([51:16])

  • Imagery can be difficult for some—adapting to focus on felt sense or nonhuman sources of warmth (e.g., a pet) is encouraged.
  • "It’s not like, 'Oh, we do a session on that and then you’re all set and ready to go.' These things take time and there may be moments where it’s easier and sometimes when it’s harder." (B, [52:24])

• Evoking Compassion Through Memory and Qualities ([54:17])

  • Focusing on moments of felt warmth or safeness—however subtle—builds the foundation for compassionate self-imagery.

8. Integrating CFT with CBT and Exposure/Response Prevention (ERP)

• Integration, Not Separation ([57:48])

  • CFT is infused throughout CBT and ERP, not a bolt-on.
    • "Everything is through... a lens of compassion focused therapy." (B, [57:48])

• Bringing Compassion to ERP

  • Exploring the client’s mindset during ERP—curiosity vs. gritting teeth, self-criticism vs. compassionate intent.
  • Encouraging understanding of ERP as moving toward valued life, not simply symptom reduction.
    • "If you can go into [ERP] and say, 'I’m making a towards move right now... and I’m taking my compassionate self with me on that journey.'" (B, [61:13])
    • "I'm here because my ancestors survived... I'm taking their strength and their courage and their wisdom along with me too." (B, [63:18])

Notable Quotes & Memorable Moments

• “The suffering of OCD is enormous; there’s a grief for a life not lived.”
  Lisa Williams, [13:54]

• “You don’t take off the armor and leave someone exposed underneath unless you’ve built up a compassionate shield.”
  Lisa Williams, [29:09]

• “Our minds were built for us, not by us, and they've got these inherently tricky loops that we're all trying to work out and we all struggle with.”
  Lisa Williams, [31:23]

• "I'm here because my ancestors survived... I'm taking their strength and their courage and their wisdom along with me too."
  Lisa Williams, [63:18]

• “It’s the courage to feel it all, you know. And that’s not easy.”
  Lisa Williams, quoting Nick Mulvey, [65:35]

Timestamps for Key Segments

• Lisa’s Introduction & Path to CFT: 02:22–07:58
• Defining OCD & Its Suffering: 10:51–15:55
• CFT Formulation in Practice: 17:56–24:43
• Reframing Safety Behaviors, De-shaming: 26:23–30:04
• The Three Circles and Evolutionary Context: 31:19–35:36
• Community Compassion & Flows: 38:15–46:25
• CFT Strategies & Compassionate Imagery: 47:24–54:17
• Working with Memories of Warmth/Safeness: 54:17–57:14
• Integrating CFT with ERP: 57:48–63:18
• Ancestry and Courage: 63:18–65:12
• Resource Recommendations: 66:08

Suggested Resources (from Lisa’s Recommendations) ([66:08])

• Books:

  • “The Compassionate Mind” by Paul Gilbert
  • “The Compassionate Mind Workbook” by Chris Irons & Elaine Beaumont
  • “Living with the Inner Critic and Compassion Focused Therapy” by Deborah Lee
  • “Working with Anger” by Russell Kolts
  • “Mindful Compassion” by Paul Gilbert & Choden
  • “Compassion-Focused Therapy: Working with Shame, Self-Criticism, and Difficult Emotions” by Tobyn Bell
  • “Inside Out: A Compassion-Focused Therapy Approach to Difficult Emotions” by Tobyn Bell

• Websites/Apps:

  • Compassionate Mind Foundation
  • Compassionate Mind Foundation App

• Training:

  • Diploma in CFT with Paul Gilbert and colleagues

Tone and Final Reflections

The discussion is warm, gentle, and practical, modeling the compassion it seeks to teach. Lisa and Stan advocate for patient, wise, and de-shaming therapeutic approaches. They emphasize the importance of community, the value of embodied and creative methods, and the courage inherent in facing and feeling all our emotions.

“It’s not about symptom reduction; it’s about reconnecting with the self—with courage, wisdom, and an understanding that we all have tricky brains.”

For listeners:
This episode is valuable for therapists, those living with OCD, and anyone interested in cultivating compassion—showing that, with patience and courage, compassion can become the shield that makes healing possible.