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Understanding Depression and Compassion Focused Therapy | Gregoris Simos

Compassion in a T-Shirt

Wed Feb 12 2025

Summary

Podcast Summary: Compassion in a T-Shirt

Episode: Understanding Depression and Compassion Focused Therapy
Guest: Professor Gregoris Simos
Host: Dr. Stan Steindl
Date: February 12, 2025

Overview

In this engaging episode, Dr. Stan Steindl interviews Professor Gregoris Simos, an internationally renowned psychiatrist and expert in psychotherapy from the University of Macedonia, Greece. Their discussion centers on Professor Simos’s work in Compassion Focused Therapy (CFT), his co-edited landmark book "Compassion Focused Therapy: Clinical Practice and Applications," and, most importantly, his integration of CFT in understanding and treating depression. The conversation also delves into the relationship between self-compassion and empathy, conceptual models of depression, the interplay of shame, and the fascinating synthesis of CFT with schema therapy.

Key Discussion Points and Insights

1. The Making of “Compassion Focused Therapy: Clinical Practice and Applications”

[01:49–08:06]

Genesis of the Book: The idea emerged after a successful symposium on self-compassion in 2018. A publisher’s invitation led Professor Simos to partner with Paul Gilbert, the originator of CFT.
Collaborative Effort: The project blossomed into a major compendium, featuring foundational theory by Gilbert (ten chapters) and practical/clinical chapters from numerous international experts.
Notable Quote:

"I could have never done this book without Paul Gilbert. He is the master. He's the one." — Prof. Simos [02:49]
Purpose: The book fills a gap by serving as a “reference book” for at least the next decade, synthesizing theory and practice.

2. Self-Compassion, Empathy, and Emotion Regulation

[08:53–14:10]

Research Findings: Professor Simos’s symposium work revealed significant correlations between self-compassion and empathy, as well as self-compassion and emotion regulation.
Understanding the Link: Self-compassion is seen as "self-empathy," and emotional regulation is harder for those lacking self-compassion.
Quote:

"Self compassion actually equals self empathic for oneself... To be empathic with others but also to want to help and prevent their suffering." — Prof. Simos [10:54]

3. CFT’s Three Circles Model and Depression

[14:10–22:20]

Model Explanation: Depression, in CFT terms, is characterized by:
- Overactive Threat System: “A civil war inside.” Heightened self-criticism leads to internal strife and pain ([14:10], [20:55]).
- Inhibited Drive System: Marked by low motivation and energy.
- Exhausted Soothing System: The capacity for self-comfort is nearly depleted.
Metaphors: Simos likens depression to a “civil war” within, where self-attacking parts do deep harm.
Host Reflection: Dr. Steindl references Kristen Neff’s “enemy or ally” metaphor and the tragedy of needing, yet being cut off from, soothing and connection ([18:53–20:55]).
Notable Quotes:

"This internalized threat produced by self-criticism—it's actually a civil war. Half of my person fights with the other half. But this is a disaster." — Prof. Simos [14:10]
"The soothing system... is exhausted. It cannot do anything more." — Prof. Simos [16:35]

4. Sadness, Shame, and Depression’s Dynamics

[22:28–28:15 | 40:53–46:57]

Sadness in Depression: Sadness becomes pervasive, disabling the soothing system and feeding learned helplessness. It’s both expected and adaptive in some contexts, but in depression, it can be overwhelming and paralyzing.
Shame’s Role: Shame feeds and feeds off depression, especially via social rank and defeat dynamics. The sense of being fundamentally flawed, withdrawal from others, and the fear of being "found out" sustain depression.
Notable Quotes:

"Shame actually empowers a negative self view... and there's a reciprocal relationship. The more shame I feel, the more depressed I become." — Prof. Simos [44:37]
"If I have so many flaws, I feel very much the same and same actually... triggers the threat circle. And when this is triggered, it causes pain, disaster." — Prof. Simos [44:37]

5. Evolutionary and Psychological Models of Depression

[28:15–38:18]

Three Key Models:
1. Control and Learned Helplessness: Depression arises when one loses the belief in their ability to affect their environment or outcomes.
2. Attachment and Relational Loss: Insecure/failed relationships breed loneliness, which increases depression.
3. Social Rank, Defeat, and Entrapment: Drawing on primate hierarchies, Simos notes how defeat and withdrawal mirror depressive states to avoid greater threat.
Evolutionary Utility: Depression may once have been adaptive—a period of withdrawal and recuperation—but is maladaptive in the modern context ([34:47–36:23]).
Notable Example: Reference to Seligman’s learned helplessness experiments ([37:55–38:18]).

6. Fear, Blocks, and Resistance to Self-Compassion in Depression

[48:23–52:47]

Misunderstandings: Self-compassion is often misconstrued as weakness or passivity.
Resistance: People may resist changing their identity, fearing the unfamiliarity of self-compassion or happiness itself (“the calm before the storm”).
Quotes:

"People sometimes fear compassion... because they think they might become weak" — Prof. Simos [48:33]
"There are people who actually are fearful of being calm, of feeling happy because they say, ‘okay... the disaster is coming now.’" — Prof. Simos [51:08]

7. Integrating CFT and Schema Therapy

[53:58–67:48]

Rationale for Integration: Both approaches address deep-rooted, long-standing patterns, especially where compassion has been missing (e.g., emotional deprivation, abuse).
Key CFT Elements: Simos highlights the powerful refrain "it’s not your fault," using personal examples to illustrate how circumstances beyond our control shape us.
Therapist’s Role: Compassionate presence and “limited reparenting” in schema therapy mirror the compassionate stance of CFT.
Endpoint vs. Means: Healthy Adult (schema therapy) is an endpoint; the Compassionate Self (CFT) is both a means and an end.
Experiential Techniques: Both therapies use “chair work” and other experiential interventions to evoke and nurture healthier self-states.
Notable Quotes:

"There are things that are inevitable... It’s not my fault that I was born in that family... But I didn’t choose to have this father and this mother anyway." — Prof. Simos [56:31]
"The most hearting schemas are the ones where compassion was missing... I think compassion, self-compassion training, is probably quite good for those humans." — Prof. Simos [60:43]
"Helping someone, the compassionate self, is not the endpoint — it's the means." — Prof. Simos [60:43]
"The way schema therapists provide limited reparenting is like what the CFT therapist provides…with compassion." — Prof. Simos [64:56]

Memorable Moments and Quotes

On Self-Criticism as Civil War: "It's very painful... you might be fighting your brother, might be fighting someone that used to be your friend. So this is very painful to have a civil war instead of having a war with an enemy outside." — Prof. Simos [20:55]
On the Tragedy of Disconnection: "The person who's very, very depressed really needs and yearns for social connection... and yet is feeling so disconnected, so detached from others..." — Dr. Steindl [18:53]
CFT Accessibility: "Compassion Focus Therapy, our book, has been translated into Italian, Portuguese, Turkish, and Korean... I think it's a great success..." — Prof. Simos [70:26]
On the Therapist’s Compassion: "In any treatment... we need compassion, self-compassion. This is something that can fit everywhere." — Prof. Simos [62:45]

Important Segment Timestamps

Book Development and Purpose: [01:49–08:06]
Empathy and Self-Compassion Research: [09:02–14:10]
CFT Depression Formulation (Three Circles): [14:10–22:20]
Sadness, Shame and Social Rank in Depression: [22:28–28:15]; [40:53–46:57]
Psychological Models and Evolutionary Perspective: [28:15–38:18]
Fear and Resistance to Compassion (in Depression): [48:23–52:47]
CFT x Schema Therapy Integration: [53:58–67:48]
Translations and CFT’s International Reach: [70:26–71:21]

Tone and Style Notes

Warm, Compassionate, and Thoughtful: Both Dr. Steindl and Prof. Simos maintain an empathic, humble, and personally relatable tone throughout.
Anecdotal and Practical: Simos frequently grounds abstract concepts in personal or clinical anecdotes.
Accessible Language: Complex psychological models are clearly explained with concrete metaphors and simple analogies.

This episode is essential listening for clinicians, researchers, and anyone interested in the deep psychological roots and treatment of depression through compassion-focused approaches. Prof. Simos offers practical insights and moving metaphors that illuminate both the challenges and the hope within compassionate clinical care.

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Transcript

A (0:01)

Hi, I'm Dr. Stan Steindl. Welcome to Compassion in a T shirt. Gregoris Simos, MD is Professor of Psychopathology, University of Macedonia, Thessaloniki, Greece. He's an internationally respected psychiatrist and a recognized authority on contemporary psychotherapies including cognitive behaviour therapy and compassion focused therapy. In 2022 he and Professor Paul Gilbert edited and contributed to Compassion Focused Clinical Practice and Applications, which really is the big book of all things cft. Many wonderful CFT researchers and practitioners offer their insights into how and why compassion and self compassion are so important for psychological well being. Highly recommended in our conversation today.

B (0:53)

Great.

A (0:53)

Grigoras speaks about an area of particular interest to him which is compassion focused therapy for depression. He offers a number of very helpful ideas about how to conceptualise and work with depression from an evolutionary biopsychosocial compassion focused approach. I'm very grateful to Gregoris for speaking with me in English, especially given it's not his primary language. Oh, and keep an eye out towards the end to to hear his thoughts on integrating CFT and schema therapy. This is an integration. I'm feeling very interested in myself and so I bring you Professor Gregoris Simos. Today I have with me Professor Gregoris Simos. Welcome to Compassion in a T shirt.

B (1:49)

Thank you very much. Thank you.

A (1:51)

It's wonderful to have you and to get to speak to you all the way from Greece. Now I was just going to dive into some questions. You edited the book Compassion Focused Therapy, Clinical Practice and Applications along with Professor Paul Gilbert of course. And this really is such a wonderful and important resource for CFT therapists, but also researchers. What was the whole process like, you know, creating such a well comprehensive piece of work, collecting the chapters of course from Paul, but also all of the other authors. There's a couple of Aussie authors on there which I noticed. James Bennett Levy and Tara Hickey and my close colleague James Kirby. So yeah, what was, what was that all like to bring that, that book together?

B (2:49)

Yes, I would say that I could have never done this book without Paul Gilbert.

A (2:56)

Yes.

B (2:58)

Allow me to say that the story starts in September 2018 and we actually published it in 2022. It took us three years and a half to have it. So in September 19 to 2018 we had had the EABCITY Congress in Sofia, Bulgaria and my colleagues and I presented a symposium on self compassion and the next day I went to one of those stunts that publishers have and they invited me to write a book on self compassionate compassion. Ah. And they were delighted by our symposium. It was very well attended and it was very interesting. So they, they, they asked me, will you write a book on compassion for us? I said listen, give me some time. And what I thought was that I could have never done a book on CFT without Paul Gilbert. So the first thing I did was to email Paul and say, are we going to write book, to edit a book together? And he said, he said I can write a chapter for that, but I have been doing, or I've been thinking of doing something like this with my publisher. Not this publisher. I said, are you. No, no, I need you as a, as a co editor, not, not for, not the right chapter. And he said, and finally we agreed that we could do such a book together in his publisher. Okay, right. So we started that and at first it was a book Safety for Combustion Focused Therapy by Simos and Gilbert and we started collecting co authors and contributors. I think we owe all, we owe all this to Paul Gilbert. He is the master. He's the one. So he, he was the one who actually suggested, okay, let's email him for anxiety, let's imagine for safety with Sid and resume him for eating disorders and, and so on. So we started inviting people to contribute to, to our book and I would say that it was very welcome. I mean, I cannot remember if anyone said no, no, I cannot, I cannot do that. Probably one or no more than one. So it was a challenge for all those people to visit this book. So I need, this is what we, we needed a big book with all those things inside because there are quite a lot of, of books, of excellent books on cfd, both self health and those for, for clinicians. But we have never had this kind of, this, this is a reference book, I would say. And allow me to say that I think that it must be the book for the next ten years at least. I don't think there's, there's a place for another similar book in the years to come. But anyway, anyway, I think that that was the book that was missing. So we started, we started inviting contributors, signing contracts with the publisher and, and so on. And then Paul had to decide whether he would have a different, a separate book writing on compulsory focus therapy, but not like the one we were doing and he had been a little bit ambivalent or whether it should be a separate book or we should combine that book. Finally, as you know, we combine that. The first 10, 10 chapters are from Paul Gilbert and the, the other 17 samples are from various people around. This was exciting. This was very exciting.

B (14:10)

Yes okay. First allow me to say that I, I, I, I, I choose to, to write this chapter on depression before because I thought that it would be an easy, an easy chapter. It was not because I knew that Paul Gilbert has spent ages in, in depression so studying depression, the writing writing on depression. So I thought I had also attended a workshop by, I can't really remember if it was Topping Bell or Chris Irons CFT for depression. So I thought okay, I have the, the knowledge about that so I can, can Write that. But it was very difficult to conceptualize all this thing. And as you can see my chapter is about 70% conceptualization of depression in terms of CFT and then only a small part on treatment. So I try to make it clear how those things relate depression relates to the evolutionary model introduced by. So I think yes, yes, the question has to do with the three system circles and I would say that if we take a closer look we'll see that first of all the threat system is activated because there is a growing relationship between depression and self criticism. And self criticism in an attacking effect. I quite thinking of what I'm going to present here. I thought that this is a civil war, this internalized, internalized threat that's produced by self criticism. It's actually a civil war. Half of my passion fights with the other half. But this is a disaster. This is a disaster. So I think the, the threat system is activated of there is an over reactivity of the third systems. There are quite a lot of negative thought patterns. I'm a failure, I don't like, I don't count, I'm dead, I'm lost, I'm so and don't count and so on. So this is a very harsh, I would say self criticism. That is a very harsh threat system condition. On the other hand, drive system is rather inhibited because there is a very, very reduced motivation and low energy. We know that from clinical practice that depressed patients or clients lack motivation. They don't want to get out of their bed, that cannot work. They don't feel like meeting friends and so on. So they spent hours inactive, almost completely inactive. That means that the drive system is very, very much inhibited because of the reduced motivation, the low energy it implies. And I must also say that the soothing system is inhibited. I don't think there is any significant part of the soothing system alive. I would say that the soothing system. I was about to, to use the word exhausted. I was thinking of today's speaking and I said that probably the, the soothing system is exhausted. He cannot do anything more than what he usually does. But depression is so powerful and so this is this is this is this. This actually creates difficulties for self compassion. There's lack of comfort, there's increased self criticism that so this deactivated I would say mostly the soothing system. So there's an imbalance on the other hand between those three cycles. I mean the, this is a huge cycle of thread system and a smaller, very small size for drive system and shooting system. Is that right? Does it make sense Well, I really.

B (28:15)

Okay, let's go first to the control and learn helplessness model. According to that, we need to feel a sense of control over our lives and our environment. As far as I feel that I don't have control, I actually withdraw. I actually start fighting for what I think will make my life better. I accept that this is it. I'm unhappy, I'm depressed, I'm weak, I have failed. So if, if actually I cannot, I feel that I cannot control my, my life and my, my circumstances, my, my environment. I actually resigned from life. I mean like they give up. Say that is the learned helplessness that I, I give, I give up. I don't try anymore. So this is something like we feel when we are depressed because loss of control is, is really, really something that is. It's unbearable. I don't think I can stand that. We have also to do with the attachment relational loss models. So we all, we all feel that we need a secure attachment to thrive and feel quite well in relationships. If we have insecure or anxious or avoidant attachment in our childhood, then we are doing not very, very well with our relationships and not doing well with my relationship. Means that I will remain alone. And we know that there's a straight direct relationship between loneliness and depression. Because if I feel alone, I don't have all this social support. I need to thrive and be, be able to compensate for what I'm suffering. So I think attachment and relational loss models also, also correlate to depression because of the bad relationships I have, the failings in my relationship, the loneliness, consequent loneliness and all of those the bad things it it, it replies it implies, I would say not replies it implies. Yes. So social rank is another, another quite quite good theory. Defeat and entrapment model. And when, when I, when I teach my, my, my trainees in, in CBT or psychotherapy anyway, I, I remind them of how it is the kingdom of apes. The, the most powerful two apes have to fight to each other. One will win and he will be the guy of the tribe. Yes. The other one has to knit needle, put his head on the ground and give up. Because if he goes on fighting with the powerful one, he's going to die. If he's not going, if he's not going to start to stop fighting, probably he will be expelled from the tribe. But if you are expelled from the tribe, you lose quite a lot of safeness. You lose quite a lot of safety. Being in a tribe means that we are too many, too many partners around. We can fight any, any enemy. But being alone, I don't have any chance of surviving. So he has to knee, kneel and put his head on the ground and says, here I am, I, I don't, I don't fight anymore. So this is kind of depression. That means someone who, who withdraws in order in order to, to show that he actually acknowledged his, his defeat. And that's it. Sometimes there is a theory about reserving sources probably probably become becoming. I mean depression was supposed to be adaptive some ages ago, but nowadays depression is not, is not adaptive any. Anyway. Although I, I said to my, to my patients that listen, what's depression? Depression is how, how the the tiredness you feel when you fight for your life, when you fight in your job, fight in your relationship. So you, you get time and when you get that, you get depressed. What does it mean? It means that you stop, you kneel and you take some deep breaths, wait to regret your strength. And when you feel okay, then you stand up and go on. That's what I, how I describe depression to my clients and they can really understand that. So depression is a way to, to fuel, but to fuel my, my batteries because I Feel very much tired. I feel that I cannot really deal with all the pressure I feel. So I can go back, go back, sit down and reflect. Try to find a way in, in a peaceful way to, to find some solutions to my problems. So this is an evolutionary way thinking that depression is a way to actually to, to, to. To recharge your batteries, to, to get the strengths you, you need. But if you want to get yourself, you have to rest. It's not rest and digest, but rest being big. In depression you don't have to work, you don't have to. To have a reciprocal relationship with others. You are alone. But okay, you are thinking very, in very, in very disturbed way. But in some way depression could have been some ages ago a way to withdraw and readjust to situation and to new situation. And maybe depression might have been adapted ages ago, but probably it's not adaptive in our nowadays communities where we have very many problems to solve, peace and core. And I have to do a job that I don't like. I have probably a spouse I don't like, I don't love. So I have to quite a lot of things to struggle for. So depression in, in some way is the, and, and is something I cannot, I cannot escape. It's not adaptive, but I cannot escape the depression because we have a little bit, a little bit very different conditions of living in nowadays. Yeah.

B (40:53)

Okay, okay. I would say that if I give. Given a fight and I have lost, that's a fact. So maybe it's producing shame, but this is a fact. Unfortunately, many people who feel same shamed for what they are, what they have done and so on, on is not a fact. It is the way they perceive the reality. So if, if I cannot actually Be, that's not right. So I mean as far as I can, I can say it's reality as, as there are hundreds of ways to perceive the same reality. So people in depression think in a way that actually devaluates the values them and they, they, they make them think that I'm not adequate, I'm not worthy, I'm fundamentally flawed. So it makes them feel shamed. But this is very, a very unhappy feeling and there is a fear of being exposed to others. Okay, no one is perfect. I know what my flaws are, but I do want to show, I don't want to show them to the others. So if they actually understand what my flows are, I will feel really unhappy and very ashamed. So in the role of depression, same actually, actually empowers a negative self view. And there's a reciprocal, reciprocal relationship. The more, the more same I feel, the more depressed depressed I, I become and the more depressed I am. The most shameful I, I, I feel. Because we know from cognitive therapy there that probably people in depression and not only depression actually think in, in, in black and white ways concerning themselves and, and others. So I am others perfect or nothing. So I have so many flaws or I have known. So if I have so many flows, I feel very much the same and same actually. PFSA conscious consequence social withdrawal. If I think that I'm too much flawed, I have to, to say no, I'm not coming if they are inviting me somewhere. I think if, if I uncover myself they will understand how flawed I am. So I'm not going to there. So there is an inevitable withdrawal, social withdrawal when one feels shamed. And this also actually activates the threats, the threat system because it's a little bit again like a civil war because both self criticism and same actually are the ones who trigger the, the threat circle. And when this is triggered, it causes pain, disaster.

B (60:43)

Yes. Stan, allow me to go a little bit back backwards. I think if, if we, if we look carefully at schemas, we can see that the most significant, I mean the most hearting schemas are the ones where compassion was missing. Emotional deprivation, mistrust, abuse, abandonment. No compassion, no compassion, no compassion, no compassion. I think there was humans that predominate, that were predominated by the lack of compassion those humans. So I think compassion, self compassion training, compassionate way of thinking and feeling is probably quite good for those humans. Concerning the healthy adult mode or the compassion itself, I would say that the healthy adult mode is the end point of treatment. Endpoint of treatment means that okay, we have dealt with your schemas, with your moods and you have become a healthy adult. Go away. But I think compassion itself is the means to get there. Helping someone, of helping someone is not the endpoint product of statement, it's the means. The compassionate self, I guess it's the end point of course, but this is a means that will actually imply changes, I mean hopeful changes. So I thought that probably there could be. I mean self compassion is something we can use everywhere. I said I can, I can think in, in any, in any psychotherapy, self compassion in any, in any, in any treatment might it be mental health or, or physiological problems with. Yes, we need compassion in, in any part of our life. But in any part of medicine, in any part of psychology, in any part of psychotherapy, we need compassion, self compassion. So I think this is something that can fit everywhere say. But I, I think that it will be much more meaning may making if we actually introduce self compassion to schema therapy. I don't know how chemotherapists feel about this. Actually. This is nothing. I mean using a little bit of compassion in, in chemotherapy. Actually I'm not a Schema therapist. I mean I have trained in chemotherapy, but I would say I'm too old for a three year treatment. A three year treatment duration treatment. I mean I cannot stand long term, long term treatments now. So, and chemotherapy is a long term treatment so I prefer cognitive behavior therapy instead. But I think that we can, we can use the compassion in, in schema schema therapy because I, I would, I would also say that, I mean it's, it's, it's very important that the CFT therapist is a compassionate one. But I think in, it is something like this when in, in, in schema therapy the therapist actually does the limited rebounding.