ACT With Compassion

Acceptance and Commitment Therapy and its related theory of language and cognition, Relational Frame Theory (RFT), outline three ways of thinking about the self.  Self as process refers to the ongoing awareness of one’s experience and the description of thinking, behaving, feeling, and sensing. Self as content (i.e., the conceptualized self) involves describing and evaluating yourself, in the same way one might describe and evaluate an object--as something that has qualities. Self as context refers to the coming together of a set of the perspective taking (i.e., deictic) frames that relate to the ability to observe and describe from a perspective or point of view. Self as context refers to the ability to flexibly shift perspective as needed by the situation. It enables or facilitates many different experiences including empathy, compassion, and self-compassion. In a more traditional ACT viewpoint, this process was often referred to as the “observing self” and can involve contact with a stable, ongoing sense of self that transcends the content of one’s experience.

From an ACT perspective, the self is not a thing, but rather a process of behaving or framing our experience in terms of a perspective from which it is experienced. To use an awkward (but hopefully illuminating) turn of phrase, people are constantly “selfing.” Perspective-taking or deictic relations (I-YOU, HERE-THERE and NOW-THEN) have received considerable empirical attention in RFT research (e.g. McHugh, Barnes-Holmes, & Barnes-Holmes, 2004). Three types of perspective taking frames have been posited, personal (I/YOU), spatial (HERE/THERE), and TEMPORAL (NOW/THEN).

Because of the way that relational frames work, each frame entails another perspective. Less technically, in order for there be an I, there must be a you. As such, each type of psychological self entails a corresponding type of psychological other. Other as process refers to the ongoing awareness of another’s experience and the description of their thinking, feeling, behaving, and sensing. Other as content involves describing and evaluating another person, in the same way one might describe and evaluate an object. Other as context, refers to the ability to flexibly shift perspective to include those of others in one’s social context. This can include behavior such as empathy for another’s situation or the awareness of others’ as conscious beings.

This document focuses on the flexible use of personal frames in therapy with highly self-critical and shame prone clients and is meant to provide a few examples of how to use this type of framing in therapy.

During moments of heightened shame or self-criticism, people tend to get fused with either a conceptualized self, a conceptualized other, or both. Shame can be evoked by either viewing oneself negatively or by imagining the perspective of another who is viewing oneself negatively. If we are with another person when this happens, we often lose contact with an accurate sense of what that person is experiencing, but instead respond in terms of this verbally created other that is linked to shame (e.g., “You don’t like me”). In the literature around shame, this has been termed internalized shame versus external shame. For people who are highly self-critical and shame prone, this happens frequently.

Shame focuses attention toward a conceptualized self and one’s own perceived flaws and inadequacies, and away from the rest of the immediate environment including the people in it. Even in those clients, who have well developed repertoires of warmth and caregiving responses, this tendency to fuse with a conceptualized self during shame and self-criticism impedes them from taking a warm and caring perspective on themselves, being flexible in their response to current stimuli, or accessing the views of warm or caring others (such as the therapist). Instead, they may only be able to imagine a harsh and critical other, or they may not be able to imagine another’s perspective at all, but simply be fused with their own shame-infused conceptualized self.

When to use perspective taking using personal frames: These strategies may be particularly useful when the client is experiencing shame and/or self-criticism and has lost contact with the present moment/is not responding to stimuli in the room. In particular, this can be a useful exercise if the therapist is feeling warm or caring toward the client, but the client is unaware of this experience or otherwise seeing the therapist as neglectful, harmful, or otherwise malevolent or unsafe.

Functions served by this exercise: In addition to bringing the client into contact with the present moment, these exercises are intended to build up the experience of accurate other-as-process (e.g., thoughts like, “You seem to be feeling warmth toward me right now”) rather than other-as-content (e.g., “You have it all together”). This, in turn, helps to move the client into self-as-process (e.g.,” I’m feeling sadness and noticing my therapist’s warmth at the same time”) and out of self-as-content (e.g., “I’m weak”). There may even be an experience of we-as-process (e.g., we are noticing both sadness and warmth). The present-moment, self-, other- and we- as process perspective can help foster a more self-compassionate way of responding to oneself, particularly when the client is able to accurately notice and respond to the therapist’s genuine care and warmth toward his suffering.

Examples of using personal frames in therapy

Example. Focusing on helping client to contact other-as-process (i.e., the therapist’s ongoing perspective) as a means to elicit self as context:

C: I’m such an idiot. I hate myself.[client verbalizes self as content]

T: There are some harsh thoughts coming up for you right now. [demonstrates other-as-process] How would you feel in this chair if you were to see Greg [using client’s name in third person to elicit shift to YOU perspective] getting bullied by those thoughts while he is feeling so hurt and lonely? [directly invites I/You perspective taking].

C: I don’t know. That’s really hard to imagine. [possible deficit in perspective taking skill, or possible sign that client is out of touch with present-moment stimuli]

T: Greg is sitting right there, across from you, and you can see that he’s just getting pummeled. And it’s a bit heart-breaking maybe because you know he’s been hurt so many times before and here he is being punched in the gut right in front of your eyes. [Elaborates on therapist perspective in order help client with perspective-taking] What would you feel from over here?

C: That feels sad to me. I would maybe feel sadder from over there. I would want him to know that he’s okay and would want him to have a friend.

Example: Building self as context through use of spatial and person frames:

C: You must think I’m pathetic.[client verbalizes other-as-content]

T: You imagine me over here looking at you and thinking, “How pathetic?” [moving from other-as-content to other-as-process] That must hurt [active empathy].

C: Yeah I guess.

T: Could you come over here [invites client to sit in therapist’s chair as a means of facilitating spatial perspective taking]. How would you feel if you were in this chair and you could see [client’s name], who has been hurt so much before [give specific examples of client’s life experiences], wincing and fearing that even her therapist, who she thought would be the one person she could be safe with, thinks she’s pathetic?

C: I could feel for her a little bit. She doesn’t want to be afraid of her own therapist.

Example: Using self-disclosure to facilitate a sense of shared humanity in shame:

In this example, the client is not verbalizing any self as content but is showing nonverbal signs of shame such as averted gaze, slumped shoulders, monotone voice, or appearing small and meek.

This strategy generally would depend upon having a stronger therapeutic alliance with your client and familiarity with his/her shame displays if you want to attempt this exercise based solely on nonverbal signs of shame. Unlike the examples involving verbal self-criticism, in this situation your client has not directly shared his internal experience with you. It’s important to never force your client to tell you about his internal experience, but you can gently ask questions and stop if the client is not willing or if it seems like the exercise is causing the client’s behavior to become even more rigid, frozen, or if the therapeutic alliance is being threatened.

T: Did you notice what happened right there? You seemed to go into your shame place.

C: Oh? I don’t know.

T: I wonder if when I asked you about your phone call with your sister, if that might have brought up some feelings of shame for you. I noticed that you looked away and got really quiet. Did you notice that? [offers educated guess about what might have triggered it – facilitating self as process].

C: I guess maybe.

T: From that shame place, sometimes we feel like we want to hide because it’s scary to think about how another person might see us. [This may be a good time to skillfully self-disclose a shame memory that the therapist has good flexibility around… e.g…. “like the other day I was talking to my supervisor, and because I was feeling shame about a mistake I had made, I imagined that she saw me as stupid.] Do you think that might be happening for you right now? That you are imagining what I might think of you?

C: Oh, well no, I know you are a kind person. But I guess I could relate to what you were saying about feeling like other people see you as stupid.

T: [notices slight increase in client’s behavioral flexibility] I appreciate your sharing that with me [reinforces client’s disclosure] Do you feel like other people see you as stupid right now? Which in this case, I guess I am “other people” because there’s nobody else in the room with us. [keeping the focus on the present-moment relationship].

C: Well, I guess I feel seen as stupid, so sort of it feels like you think I’m stupid.

T: [Pauses, allowing experience of sadness and warmth for the client to deepen.] How would you feel in this chair looking at [client’s name] looking away, wincing, and disconnecting for fear that his therapist and lots of other people think he is stupid?

C: I would want him to open up and trust more so he’s not alone.

These are quite abbreviated examples. Most clients are unlikely to arrive at a warmer self-to-self relation so quickly. This process could even take up to several sessions or longer, especially when they have had few or no prior experiences of being viewed with warmth and compassion by another person.

During the first few times the therapist engages in this kind of perspective taking, the therapist can fairly heavily coach the client to take the perspective of the therapist. In general, the goal is to match the client where he is at while simultaneously maintaining a stance that is much warmer and more flexible than the client’s. To do this, you may draw upon details you have learned during the case conceptualization and functional analysis in order to validate the client’s experience and access genuine compassion for it. You might practice active empathy, bringing the hurt parts of the client’s emotional experience into focus in order to access your own compassion for the client.

As you engage in these strategies, pay attention to signs that the client’s shame is increasing or decreasing. If the client’s behavior becomes narrower and more withdrawn in response to your coaching, it may be more beneficial to focus on validating the difficulty of working with such painful affect by asking something like, “It’s hard to be giving this so much attention, isn’t it?” Alternately, it may be helpful to “take the heat off” by turning attention elsewhere for a bit, looking away from the client instead of staring directly at him, or shifting to more comfortable topics before returning to the cues that elicit shame. This may also be a good time to skillfully use self-disclosure to willingly share some of the hot seat with client and demonstrate flexibly responding to your own shame.

Once the client has demonstrated some amount of ability to take the therapist’s perspective, the therapist can then guide the client toward a deeper experience of an affiliative and warmer response to himself.

Example:

T: Now that we have noticed some of the pain that you are feeling and some of the fear about what you must look like from my perspective, and now that there is a bit of a change in perspective happening, I’d like you to sit over here [invites client to sit in therapist’s chair].

[client sits in therapist’s chair. Therapist sits or kneels next to client looking toward the now empty chair]

T: Let’s imagine you are me now, looking at [name of client.] You see his fear and you know how long he has been struggling with it… [remind client of everything he noticed during the first part of the exercise about his pain] and you see that he’s quite afraid of what you must think of him [getting client in touch with his pain from therapist’s perspective]. You also are starting to feel like you wish she didn’t have to be afraid of her own therapist [getting client in touch with desire to alleviate suffering that arose in first part of exercise]. Can you talk to him about that? What would you say if you were feeling that way toward [name of client]… What else do you feel looking at [client’s name]?

The exercise may continue from the switched chairs for as long as it appears to be aiding the person in developing a more affiliative and compassionate perspective on himself.

Time should be set aside after this type of work for debriefing ork. Possible questions to ask during the debriefing include:

What did you notice during this exercise?

What is it like now that we have switched back into our original chairs?

Would you like any feedback on how I actually see you? [see self-disclosure handout for ideas for skillful use of self-disclosure].

How do you want to relate to yourself the next time you feel shame?

Do you think there will be an opportunity for you to practice seeing yourself this way before our next session? [leave some time to brainstorm together how to apply this for homework].