Compassion-focused therapy

1. Introduction

Version followed: Paul Gilbert's compassion-focused therapy (CFT) and its core skill-building component, compassionate mind training (CMT), as set out in Gilbert (2009, Advances in Psychiatric Treatment) and sequenced in the module order of Kolts, Bell, Bennett-Levy & Irons (2018, Experiencing CFT from the Inside Out). Chairwork follows Bell, Montague, Elander & Gilbert (2021). The current definitive clinical text, Gilbert & Simos (2022, Compassion Focused Therapy: Clinical Practice and Applications), is not drawn on here [uncertain where it updates the details below].

CFT is an integrative, process-based therapy that adds evolutionary psychology, attachment theory, Buddhist-derived compassion practice and affective neuroscience to CBT. Gilbert developed it in the 1990s–2000s with clients high in shame and self-criticism, often from neglectful, abusive or cold backgrounds. These clients could produce logical alternative thoughts but did not feel reassured by them ("Logic is not enough"). [source: Gilbert 2009; Bell 2021 thesis]

Core idea of change: human minds run three emotion-regulation systems: threat/protection, drive/resource-seeking, and soothing/contentment/social safeness. In shame and self-criticism the threat and drive systems are overactive and the soothing/affiliative system is under-developed or feared. Change happens when the client:

understands their difficulties as understandable safety strategies of an evolved "tricky" brain shaped by experience (de-shaming: "not their fault", but now their responsibility); and
deliberately trains the soothing/affiliative system through the body, attention, imagery, reasoning and behaviour, so they can meet their own suffering with warmth, strength and wisdom instead of threat-based self-attack. [source: Gilbert 2009; Gilbert 2020]

Gilbert defines compassion as sensitivity to suffering in self and others, with a commitment to try to alleviate and prevent it. It flows three ways: to others, from others (being open to receiving it) and to the self. [source: Gilbert 2020]

CFT is a therapy that can stand alone or be added to other work, especially CBT. CMT is also delivered on its own as a group course, a public-health course, guided audio or an app. Adaptations include CFT-E for eating disorders (Goss), psychosis groups, acute inpatient groups, acquired brain injury, and school or teacher courses. [source: Wikipedia, CFT; Gilbert 2009]

2. Framework

Gilbert (2009) does not set a fixed sequence of stages. He describes three interlocking components: (a) formulation, (b) psychoeducation, and (c) compassionate mind training delivered through a warm, de-shaming relationship. The phases below follow the module order Kolts et al. (2018) use to teach CFT to therapists. Using the same order with clients is a common clinical practice, but in this guide it counts as [synthesis]. [source: Gilbert 2009; Kolts et al. 2018 contents]

Phase 1: Developing compassionate understanding (engagement, psychoeducation, formulation)

Goals: build safeness in the relationship; agree on a problem focus; teach the three systems and the tricky brain; introduce soothing rhythm breathing and mindfulness early; build a threat-focused formulation; name fears of compassion; map self-criticism.
Typical content in order: assessment and identifying a challenge → three systems → soothing rhythm breathing → tricky brain → old brain/new brain loops → mindful breathing → shaped by our experiences → compassionate functional analysis → safe-place imagery → attachment style → fears of compassion → threat-focused formulation (historical influences and key fears; safety strategies and unintended consequences) → mindful check-in → unpacking compassion → self-criticism diary → mid-point review. [source: Kolts et al. 2018 contents]
Move on when the client can describe their difficulties in three-systems terms with less self-blame, has a shared written formulation, and practises a body-based soothing skill (even briefly) between sessions [synthesis].

Phase 2: Cultivating the compassionate self

Goals: build the compassionate self as an identity the client can step into, then use it in real situations and behavioural experiments.
Content: threat-based self versus compassionate self → cultivating the compassionate self → compassionate self in action → deepening → behavioural experiments. [source: Kolts et al. 2018 contents; Gilbert 2009]
Move on when the client can bring up the compassionate self, even if only partly or briefly, and use it at least once on a real difficulty [synthesis].

Phase 3: Developing the flows of compassion

Goals: strengthen compassion to others, from others and to self, using memory, imagery, behaviour and writing (including the compassionate letter). [source: Kolts et al. 2018 contents]
Move on when the client can direct compassion toward their own distress without a large rise in threat, or when fears of receiving compassion have been worked with directly [synthesis].

Phase 4: Working with multiple selves and self-criticism

Goals: tell apart the threat emotions (angry, anxious, sad selves) and the self-critic; let the compassionate self relate to each of them; use chairwork. In Bell et al.'s study, multiple-selves chairwork came after psychoeducation, formulation and compassionate-self practice, at sessions 7–17 (mean about 13). [source: Bell et al. 2021; Kolts et al. 2018]

Phase 5: Maintenance

Goals: review progress, build a practice plan, and anticipate setbacks as moments for compassion rather than self-attack. [source: Kolts et al. 2018 contents]

Session count and format

There is no single number. Reported formats include:

individual CFT running past 17 sessions (Bell et al. 2021);
8-week CMT groups for the general public (Irons & Heriot-Maitland 2021, via Wikipedia);
a 6-session trial adaptation combined with breathing retraining (Trials 2023 protocol table);
longer groups in psychosis and eating disorders.

Individual sessions are typically weekly and about 50–60 minutes; groups are often 1.5–2 hours [uncertain: typical lengths are not given in the sources]. Sessions blend Socratic discussion, experiential practice (breathing, imagery, chairwork) and agreed between-session practice. [source: Bell et al. 2021; Wikipedia; Trials 2023 table]

3. Guiding principles

Three-systems map as a heuristic. Read every problem as a balance between threat, drive and soothing. Practical meaning: ask "which system is running this?" rather than "what is wrong with you?" [source: Gilbert 2009]
Threat system: "better safe than sorry". Threat responses are easily conditioned and biased towards false alarms. Practical meaning: normalise over-reaction as design, not defect. [source: Gilbert 2009]
Not your fault, but your responsibility. Symptoms are safety strategies that grew out of genes and early experiences the client never chose. Practical meaning: de-shame first; then invite responsibility for training the mind now. [source: Gilbert 2009]
De-shaming stance. The therapist aims to be experienced as safe, compassionate and non-shaming. Practical meaning: validate every safety strategy's function before targeting it. [source: Gilbert 2009]
Logic is not enough; feel the alternative. Alternative thoughts must feel supportive, not just correct. Practical meaning: check the emotional tone in which a client "says" a new thought, not only its content. [source: Gilbert 2009]
Safeness differs from safety and from relaxation. Safety means threat has been removed. Safeness means affiliative signals are present, which allow exploration, play and connection. Practical meaning: aim for a warm, open, engaged state, not just calm. Expect early soothing attempts to make some clients more anxious. [source: Gilbert 2020]
Compassion as courage and strength, not softness. Compassion means turning towards suffering and acting to help; "encouraging means giving courage". Practical meaning: frame self-compassion as a stance of strength and wisdom, which also counters the client's fear that it is self-indulgent. [source: Gilbert 2009]
Safe haven and secure base. Compassion includes both soothing (safe haven) and encouraging and guiding with boundaries (secure base). Practical meaning: help clients tell soothing apart from encouraging and use each when it fits. [source: Gilbert 2020]
Six attributes, six skills (the compassion circle). The attributes are care for well-being, sensitivity, sympathy, empathy, distress tolerance and non-judgement. The skills are attention, reasoning, behaviour, imagery, feeling and sensation, each practised with warmth. Practical meaning: diagnose which attribute or skill is missing and train that. [source: Gilbert 2009]
Self-compassion is the main target, not self-esteem. Self-warmth is most needed when things go badly. Practical meaning: practise especially around failure, setbacks and shame. [source: Gilbert 2009]
Process-focused rather than task-focused. Value the effort and the warmth of the attempt more than the result. Practical meaning: praise practising, not "getting it right". [source: Gilbert 2009]
Fears, blocks and resistances are central work, not obstacles. Fears of compassion are expected, especially in high self-criticism. Practical meaning: assess them early and treat a block as assessment information. [source: Gilbert 2009; Gilbert 2020; Bell et al. 2021]
Multiplicity of mind. The mind holds competing motives and emotions ("multi-mind"). Practical meaning: separate the angry, anxious, sad and critical selves, then relate to each from the compassionate self. [source: Bell et al. 2021]
Functional, not pathologising. Ask what self-criticism and other strategies are trying to achieve or prevent. Practical meaning: explore what the client fears would happen if they gave up self-criticism. [source: Gilbert 2009]
Compassionate self-correction rather than self-attack. Change is pursued through encouragement, not bullying. Practical meaning: when the client "forces" change with a cold or harsh inner tone, explore an encouraging tone instead. [source: Gilbert 2009]
Therapist warmth is the medium, and the therapist practises too. Therapists build CFT skill partly by practising on themselves. Practical meaning: do the exercises yourself before teaching them. [source: Gilbert 2009; Kolts et al. 2018]
Guided discovery and collaboration. CFT keeps the CBT stance of Socratic questioning and collaborative experiments. Practical meaning: build formulations and experiments with the client, not for them. [source: Gilbert 2009; Kolts et al. 2018; exact wording [uncertain]]

4. Intervention inventory

The intervention list combines the techniques Gilbert (2009) describes, the module titles in Kolts et al. (2018), and the chairwork procedures in Bell et al. (2021). Kolts et al. (2018) was seen only as a table of contents. Wherever a step-by-step procedure comes from secondary knowledge of the CFT literature, it is tagged [uncertain]. All example language is illustrative wording written for this guide.

A. Engagement, psychoeducation and formulation

4.1 Building safeness in the relationship (therapist modelling, de-shaming validation)

Purpose / when: Use from the first session and throughout. The therapist's warmth is how compassion is first experienced and modelled. This matters most for clients who expect shaming. [source: Gilbert 2009]
Steps: (1) Pace slowly and use a warm voice tone. (2) Validate the function of each symptom when it comes up ("that makes sense as a way to protect yourself"). (3) Name shame directly and without alarm. (4) Stay steady with strong emotion; this is distress tolerance modelled. (5) Check in regularly about how the client experiences you. [source: Gilbert 2009; steps 1, 5 [synthesis]]
Example language (illustrative): "I'm not here to judge what you've done to survive. I'm interested in what it was trying to protect you from."
Watch for: Warmth can itself trigger grief or a sense of threat ("distress calling"; attachment pain). If the client looks uneasy, slow down and ask how the warmth lands. It is working when the client discloses shame-laden material with less hiding. [source: Gilbert 2009]

4.2 Psychoeducation: the tricky brain and old-brain/new-brain loops

Purpose / when: Use in early sessions to de-shame. It explains that humans have old emotional and motivational systems that interact with new-brain abilities (imagining, ruminating, self-monitoring), which can trap us in loops. [source: Kolts et al. 2018 contents; Gilbert 2009]
Steps: (1) Explain that we all "find ourselves here" with a brain shaped by evolution, which none of us designed [uncertain: phrasing used widely in CFT teaching; verbatim source]. (2) Give a loop example: a threat thought → body alarm → more threat thoughts → rumination. (3) Ask the client for their own loop. (4) Draw it. (5) Link it to "not your fault" (4.4).
Example language (illustrative): "A zebra runs from a lion and then goes back to grazing. We can replay the lion in our heads all night. That isn't a personal failing; it's how our brains are built."
Watch for: The client using the model to excuse change ("so I can't help it"). Pair it with responsibility. It is working when the client describes their own reactions as understandable rather than shameful. [synthesis]

4.3 Psychoeducation: the three systems (three-circles map)

Purpose / when: Use early; this is the core map for every later intervention. [source: Gilbert 2009; Wikipedia]
Steps: (1) Draw three circles: threat (anxiety, anger, disgust; fight, flight, submit), drive (wanting, achieving, excitement) and soothing (contentment, safeness, connection). (2) Explain each system's function. Stress that soothing is not just the absence of threat, and that it regulates the other two. (3) Ask the client to estimate how large each circle is in their life now, and draw them to scale. (4) Ask what fed each circle in their history. (5) Note how drive can be hijacked by threat (striving to avoid rejection or failure). (6) Set the goal: build the soothing system. [source: Gilbert 2009; step 3 widely used [uncertain]]
Example language (illustrative): "If you drew these circles for your life right now, how big would each one be?"
Watch for: Clients who equate soothing with laziness or giving up. It is working when the client spontaneously labels states ("that was my threat system").

4.4 Psychoeducation: thoughts and images stimulate the body; self-criticism as an internal bully

Purpose / when: Explains why self-criticism keeps threat going and why imagery practice can work. [source: Gilbert 2009]
Steps: (1) Ask the client to imagine a favourite meal and notice salivation: an image alone triggers the body. (2) Ask how they would feel if someone followed them around criticising them all day. (3) Draw the parallel with self-criticism activating threat. (4) Draw the parallel the other way: warm signals from others soothe, and the same signals can be generated internally. [source: Gilbert 2009]
Example language (illustrative): "If a colleague spoke to you all day the way you speak to yourself, what would happen to your body?"
Watch for: "But I deserve it". Note it as a fear or belief for 4.17–4.18. It is working when the client links self-attack with low mood and anxiety.

4.5 Shaped by our experiences: "not your fault" and responsibility

Purpose / when: Early de-shaming. Use it after the history has been gathered. [source: Gilbert 2009; Kolts et al. 2018 contents]
Steps: (1) Review genes, temperament and early environment the client did not choose. (2) Ask who they would be if they had been raised by different people (for example, in a violent gang versus a caring family) [uncertain: illustration commonly used in CFT]. (3) Draw out that their strategies made sense given what they faced. (4) Separate blame from responsibility: it is not your fault, and you can now take responsibility for training your mind.
Example language (illustrative): "None of us chose the brain or the childhood we got. What we can choose is what we practise from here."
Watch for: Anger at caregivers or grief may surface; make room for them. The client may also reject "not your fault" because self-blame feels protective; explore this in 4.18. [synthesis]

4.6 Threat-focused formulation

Purpose / when: Builds a shared, non-blaming, written understanding of how problems developed and are maintained. Use it after psychoeducation, and revise it as therapy goes on. [source: Gilbert 2009; Kolts et al. 2018 contents]
Steps: Build four columns together. (1) Historical influences: key early and background experiences. (2) Key threats and fears: external (what others might do to me) and internal (what I might find inside or feel about myself). (3) Safety strategies: external (for example submission, appeasing, avoidance, aggression) and internal (for example self-criticism, rumination, suppression). Validate each one as protective. (4) Unintended consequences: how the strategies keep problems going or create new ones, including how the client then judges these consequences, often with more self-criticism. Also examine drive: what happens when a goal is not reached (disappointment, self-attack or attacking others)? [source: Gilbert 2009; four-element structure from Kolts et al. 2018 module titles; the internal/external split [uncertain]]
Example language (illustrative): "Given what you went through, keeping your head down and criticising yourself first made a lot of sense. Let's look at what it costs you now."
Watch for: The formulation turning into a list of faults. Keep the protective function visible. It is working when the client feels understood and shows less shame.

4.7 Compassionate functional analysis

Purpose / when: Use when a specific problem behaviour or reaction needs understanding without blame. [source: Kolts et al. 2018 module 8 title; content [uncertain]]
Steps (reconstructed): (1) Pick a recent episode. (2) Map the trigger, the threat emotion, the thoughts and images, and the behaviour. (3) Ask what the behaviour achieved in the short term (relief, protection) and what it cost in the longer term. (4) Ask which of the three systems was driving it. (5) Ask what a compassionate response might have looked like. [synthesis]
Example language (illustrative): "What was that reaction trying to do for you in that moment?"
Watch for: Analysis delivered in a prosecuting tone. Model curiosity.

4.8 Exploring attachment history and style

Purpose / when: Links current difficulty with giving and receiving care to early attachment experiences. It is useful before working on the flows of compassion. [source: Kolts et al. 2018 module 10 title; Gilbert 2020 on internalised secure base]
Steps: (1) Explore who soothed and who encouraged the client as a child, and how. (2) Ask what happened when they were distressed. (3) Ask how they now seek or avoid comfort. (4) Link this to which flow of compassion is hardest. [synthesis]
Example language (illustrative): "When you were upset as a child, what usually happened next?"
Watch for: Grief and idealisation of caregivers. Pace the work.

4.9 Unpacking compassion: definition, attributes, skills and flows

Purpose / when: Corrects the misconception that compassion is softness or indulgence. Use before compassionate-self work. [source: Gilbert 2009; Gilbert 2020; Kolts et al. 2018]
Steps: (1) Offer the definition: sensitivity to suffering plus a commitment to alleviate and prevent it. (2) Show the compassion circle: six attributes (care for well-being, sensitivity, sympathy, empathy, distress tolerance, non-judgement) and six skills (attention, reasoning, behaviour, imagery, feeling, sensation). (3) Contrast compassion with submissiveness, pity and self-indulgence. (4) Introduce the three flows (to others, from others, to self). (5) Ask which feels easiest and which hardest.
Example language (illustrative): "Compassion here means having the courage to turn towards pain and the wisdom to do something helpful about it. Think of a firefighter, not a fluffy blanket."
Watch for: Nodding agreement while fears remain. Revisit 4.18.

B. Body, attention and soothing practices

4.10 Soothing rhythm breathing (SRB)

Purpose / when: The basic body-based practice for slowing the body and engaging the soothing/parasympathetic system. Use it early (module 3), and as the opening for most other exercises. [source: Kolts et al. 2018 contents; Bell et al. 2021; Trials 2023 table]
Steps: (1) Sit upright and grounded, feet on the floor, shoulders slightly open, eyes closed or gaze lowered. (2) Notice the breath without changing it. (3) Let the breath become a little slower and deeper, finding an even rhythm that feels soothing to the client. Some find a gentle count helps. (4) Notice the body slowing; let the out-breath feel like settling. (5) Add a slight friendly facial expression (4.11). (6) Continue for one to a few minutes, then return attention to the room. (7) Agree on brief, frequent practice between sessions. [source: steps 1–5 [uncertain]; slowing the breath to access the compassionate self is confirmed in Bell et al. 2021]
Example language (illustrative): "Let the breath find a rhythm that's a little slower than usual, a rhythm that feels like it's settling you rather than pushing you."
Watch for: Over-control of the breath, lightheadedness, and anxiety rising with attention on the body (common in panic and trauma). If so, keep eyes open, shorten the practice, or shift focus to the feet or hands. It is working when the client reports even a slight slowing or settling; perfection is not the aim.

4.11 Body posture, friendly facial expression and voice tone

Purpose / when: These are used as direct routes into the compassionate state. Use them with SRB and in compassionate-self and chair work. [source: Gilbert 2009; Bell et al. 2021]
Steps: (1) Adopt an upright, open, grounded posture. (2) Soften the face into a gentle half-smile. (3) Practise saying a phrase in a warm, slower voice. (4) Compare this with a slumped, threat posture to feel the difference.
Example language (illustrative): "See whether you can let a small, friendly expression come onto your face, as if you're greeting someone you like."
Watch for: The client feeling fake. Normalise this as the method-acting stage (4.21).

4.12 Mindful breathing and mindfulness of the mind

Purpose / when: Builds the attention skills needed to notice threat activity and choose where to place attention. [source: Kolts et al. 2018 module 6; Trials 2023 table ("monkey mind" practice)]
Steps: (1) Rest attention on the breath. (2) When the mind wanders, note where it went without judgement. (3) Kindly return to the breath. (4) Treat each return as the practice itself, not as failure. [source: standard mindfulness procedure [synthesis]]
Example language (illustrative): "Noticing that you've wandered off is the moment of mindfulness. Just gently come back."
Watch for: Self-criticism about "doing it wrong" is itself material for the work.

4.13 The mindful check-in

Purpose / when: A brief, repeatable scan of which system is active right now. Use at the start of sessions and several times a day. [source: Kolts et al. 2018 module 14 title; content [uncertain]]
Steps: (1) Pause. (2) Notice body sensations, emotion, thoughts and urges. (3) Ask which circle is active (threat, drive or soothing). (4) Decide whether to shift, for example with a few soothing breaths. [synthesis]
Example language (illustrative): "Right now, which circle is running the show?"
Watch for: The check-in becoming a monitoring ritual that feeds threat. Keep it brief and curious.

4.14 Safe-place imagery

Purpose / when: Imagery of a place that feels safe and welcoming, used to access soothing. Often an early imagery exercise. [source: Kolts et al. 2018 module 9 title]
Steps: (1) Begin with SRB. (2) Imagine a place, real or invented, using sights, sounds, smells and touch. (3) Add the sense that the place itself welcomes the client and is glad they are there. (4) Notice facial expression and body. (5) End by returning to the room. Images are often fleeting; that is normal. [source: welcome element [uncertain]; fleeting images normal [source: Gilbert 2009]]
Example language (illustrative): "Imagine that this place is pleased you're here, as if it takes joy in your being there."
Watch for: No safe place comes to mind, or a trauma memory intrudes. Allow invented places, and allow opening the eyes.

4.15 Compassionate colour (imagery)

Purpose / when: A low-demand imagery entry point for clients who struggle with images of people. [uncertain: script not in the Gilbert sources]
Steps (as commonly taught): (1) SRB. (2) Imagine a colour associated with warmth and kindness. (3) Imagine it surrounding the client or flowing through the body, carrying wisdom, strength and kindness. (4) Notice its effect. [uncertain]
Example language (illustrative): "Imagine the colour moving around you with the intention of helping you."
Watch for: Forced or busy imagery. Keep it simple.

4.16 Compassionate attention (memories of kindness, strengths, savouring, gratitude)

Purpose / when: Retrains attention away from threat-focused scanning. [source: Gilbert 2009]
Steps: (1) Recall a time the client was kind to someone, or someone was kind to them. (2) List strengths such as courage, kindness and past coping. (3) Revisit positive memories and dwell on their details. (4) Daily, savour ordinary pleasures (food, sky, music) and notice gratitude and appreciation. [source: Gilbert 2009]
Example language (illustrative): "Let's slow that memory right down. What did their face look like when they helped you?"
Watch for: Positive memories triggering grief or "yes, but". Validate the sadness; positive emotion itself can feel threatening (see 4.24).

C. Working with self-criticism and fears of compassion

4.17 Mindfulness of self-criticism diary

Purpose / when: Builds awareness of when, how and in what tone self-criticism shows up. Use it before changing anything. [source: Kolts et al. 2018 module 16 title; diary format [synthesis]]
Steps: (1) Each day, note the situation, the self-critical words or images, their emotional tone (contempt, anger, disappointment), body sensations, and the effect on mood and behaviour. (2) Notice without arguing with the criticism. (3) Review the diary in session for patterns and functions.
Example language (illustrative): "Just be a curious observer of your inner critic this week. Notice the words, and especially the tone of voice."
Watch for: The diary itself becoming another stick to beat oneself with. Frame noticing as a skill.

4.18 Functional analysis of self-criticism: its fears, functions and forms

Purpose / when: Self-criticism often protects against feared outcomes, so a client will not give it up until its function is understood and honoured. [source: Gilbert 2009; Bell 2021 thesis]
Steps: (1) Ask what the client fears would happen if they stopped criticising themselves (becoming lazy or arrogant, being rejected, being punished later). (2) Identify the functions: self-improvement, pre-emptively avoiding others' criticism, keeping safe through submission. (3) Explore the form: a self-correcting, disappointed critic versus a hostile, contemptuous critic that persecutes. Clinical research suggests self-persecution is the more harmful form. (4) Contrast shame-based self-attack, which looks backward, punishes and condemns, with compassionate self-correction, which looks forward, encourages growth and targets specific behaviour. (5) Agree to keep the function (wanting to do well, wanting to be safe) while changing the method. [source: steps 1–3 Gilbert 2009 and Bell 2021 thesis (forms); step 4 widely taught in CFT [uncertain]]
Example language (illustrative): "If your critic took a week off, what are you afraid would happen?" "Would you coach a child you love by shouting that they're useless?"
Watch for: Strong attachment to the critic ("it's what got me through"). It is working when the client can see the critic as a frightened protector rather than the truth.

4.19 Imagining the self-critic (externalising)

Purpose / when: Gives emotional distance from the critic and reveals its emotional tone and its relationship to the self. [uncertain: commonly described CFT exercise. Externalisation itself is supported by Bell 2021 thesis]
Steps: (1) Ask the client to imagine their self-critical part as if it were outside them. (2) Explore what it looks like, its facial expression, and what emotions it directs at them. (3) Ask what it wants and what it fears. (4) Notice how the client feels in response; usually a threat response. (5) Shift to SRB, then look at the critic from the compassionate self (4.21), seeing its fear or pain.
Example language (illustrative): "If that critical voice had a face, what would its expression be? And what is it really afraid of?"
Watch for: The image resembling an abuser. Slow down, ground the client, and do not prolong the image. Move to the compassionate self quickly.

4.20 Exploring fears, blocks and resistances (FBRs) to compassion

Purpose / when: Use when compassion practice triggers threat, grief, numbness or dismissal. Assess early, especially when self-criticism is high. [source: Gilbert 2009; Gilbert 2020; Bell 2021 thesis]
Steps: (1) Assess all three flows: fear of giving compassion, fear of receiving it from others, and fear of self-compassion. Gilbert and colleagues' Fears of Compassion Scales can be used; this is a published measure, so do not reproduce its items. (2) Distinguish fears (it is dangerous or will be exploited, or I will be overwhelmed by grief), blocks (lack of opportunity or skill) and resistances (it costs too much or seems pointless) [the three-way distinction is from Gilbert's work, but its definitions were [uncertain]]. (3) Link fears to the function of self-criticism (4.18) and to history (4.5, 4.8). (4) Normalise grief: warmth can reactivate unmet attachment needs ("distress calling"). (5) Work up a graded approach to the feared flow, as with any exposure (see 4.24). [source: Gilbert 2009 for grief, dissociation, beliefs that self-kindness is weak, undeserved or will lead to punishment]
Example language (illustrative): "It's really common for kindness to feel uncomfortable at first, especially if it was rare growing up. Let's go at a pace that works."
Watch for: Dissociation, sudden sadness, or physiological stress during imagery (documented). Treat a block as assessment information rather than failure. [source: Gilbert 2009; Bell et al. 2021]

D. The compassionate self and compassionate skills

4.21 Cultivating the compassionate self (method-acting approach)

Purpose / when: The central CMT practice: building an identity, the compassionate self, from which to relate to self and others. Use it in Phase 2 and as the base for later work. [source: Gilbert 2009; Kolts et al. 2018 modules 18–21]
Steps: (1) Begin with SRB, upright posture and a friendly face. (2) Ask the client to imagine being a deeply compassionate person, regardless of whether they feel it; like an actor taking on a role. (3) Build up the qualities one at a time: wisdom (understanding the tricky brain and that suffering is not one's fault), strength/confidence (a grounded, steady authority), and commitment (a caring motivation to help) [the specific triad is [uncertain]; Gilbert 2009 lists wisdom, strength, warmth and non-judgement for the ideal compassionate image]. (4) Imagine the voice tone, facial expression and posture of this self. (5) Imagine how this self would move, speak and act during the day. (6) Practise daily, briefly. (7) Contrast with the threat-based self (module 18): notice how each one thinks, feels and acts. [source: Gilbert 2009 for method acting, posture, expression, voice and daily practice]
Example language (illustrative): "You don't have to feel compassionate to do this. Just imagine what it would be like to be someone wise, strong and caring. How would you sit? How would you breathe?"
Watch for: "I'm not like that." Remind the client that it is a role being practised, and that the intention to be compassionate counts. It is working when posture and voice shift visibly and the client can call on the self briefly when distressed.

4.22 The compassionate self in action and deepening practice

Purpose / when: Transfers the compassionate self to real difficulties. Use it after 4.21 takes hold. [source: Kolts et al. 2018 modules 20–21]
Steps: (1) Pick a moderately difficult upcoming situation. (2) Bring up the compassionate self. (3) Imagine it handling the situation: what would it notice, say and do? (4) Plan a brief cue (a breath, a posture shift) for use in the situation. (5) Debrief afterwards from the compassionate self, not the critic. [synthesis]
Example language (illustrative): "Before the meeting, take three soothing breaths, sit as your compassionate self, and ask: what would be the wise, kind thing to do here?"
Watch for: All-or-nothing judgement of performance. Stay process-focused.

4.23 Compassionate reasoning (compassionate thinking and thought balancing)

Purpose / when: Builds on CBT and mentalising techniques. Use it when a client can generate alternatives that do not feel reassuring. [source: Gilbert 2009]
Steps: (1) Identify a self-critical or threat thought. (2) Generate alternatives as in CBT. (3) Ask the client to step into the compassionate self, then re-read or say the alternatives in a warm, supportive tone. (4) Check whether they feel supportive, not just logical. (5) Spot rumination and redirect attention compassionately rather than arguing with every thought. (6) Draw on common humanity ("many people would feel this") and on the tricky brain. [source: Gilbert 2009 for steps 2–5; step 6 [synthesis]]
Example language (illustrative): "Say that alternative again, but this time in the voice of someone who really cares about you. What changes?"
Watch for: Cold, bullying "rational" self-talk ("just get over it"). It is working when the client reports feeling, not only knowing, the alternative.

4.24 Compassionate behaviour, compassionate exposure and behavioural experiments

Purpose / when: Uses compassion as the motive and tone for courageous action: exposure to feared situations, approaching positive emotion, self-care, and tests of fears of compassion. [source: Gilbert 2009; Kolts et al. 2018 module 22]
Steps: (1) Agree on the behaviour together as a compassionate act ("what would help you flourish?"). (2) For exposure, agree on a gradual hierarchy and informed consent. Check for contraindications (unmanaged dissociation, acute risk, very low affect tolerance) and establish SRB first. (3) During the task, use a warm, encouraging inner tone, modelled on an encouraging parent or coach. (4) Value effort over result. (5) Include approach to positive emotions and to receiving kindness, which may feel threatening. (6) Behavioural experiments: test predictions such as "if I'm kind to myself I'll stop working" by trying self-compassion for a set period and recording the outcome. [source: Gilbert 2009 for steps 1, 3–5; consent and contraindications [synthesis]; experiment example [synthesis]]
Example language (illustrative): "Encouraging literally means giving courage. What would you say to a friend standing at the edge of this?"
Watch for: Safety behaviours being relabelled as "self-care". Compassion includes doing hard things. It is working when the client attempts avoided tasks and appraises them with encouragement rather than self-attack.

E. Developing the flows of compassion

4.25 Compassion from self to others: memory

Purpose / when: The easiest entry point for many self-critical clients. Feeling compassion for others uses the same machinery that self-compassion will later use. [source: Kolts et al. 2018 module 23; Wikipedia (third-person compassion first); Gilbert 2020 (flows share a psychophysiology)]
Steps: (1) SRB. (2) Recall a time the client felt kindness towards someone in distress (not an overwhelming event). (3) Recall their own facial expression, voice and wish for that person. (4) Notice where warmth is felt in the body. (5) Name the qualities they showed. [source: Gilbert 2009 (feeling compassion for others; noticing bodily warmth)]
Example language (illustrative): "Remember a time you wanted to help someone who was struggling. What did you feel in your chest, your face, your hands?"
Watch for: Choosing a traumatic memory; steer to a moderate one.

4.26 Compassion from self to others: imagery and behaviour

Purpose / when: Extends the outward flow through imagery and real acts. [source: Kolts et al. 2018 modules 24–25]
Steps: (1) From the compassionate self, imagine someone you care about. (2) Direct wishes for their well-being and freedom from suffering towards them, in the client's own words (a loving-kindness-type practice; such practices appear in the Trials 2023 programme) [source: Trials 2023 table]. (3) Then extend to a neutral person [uncertain]. (4) Plan one small compassionate act towards another person this week, and notice what happens in the three systems.
Example language (illustrative): "Picture them, and from your compassionate self wish them well, in whatever words feel natural."
Watch for: Over-giving and appeasing (submissive caring). Check that the motive is care, not fear of rejection. [synthesis]

4.27 Compassion from others to self: memory, and opening to kindness

Purpose / when: Works on the receiving flow, which is often the most feared. [source: Kolts et al. 2018 modules 26–27; Gilbert 2009; Gilbert 2020]
Steps: (1) Recall a time someone was kind or helpful to the client. (2) Slow down on the person's face, voice and intention. (3) Notice the feelings that come, including discomfort. (4) Between sessions, practise noticing and allowing small kindnesses (thanks, help) instead of deflecting them. (5) Track the fears that arise for 4.20. [source: steps 1–2 Gilbert 2009 (recalling being treated kindly); steps 4–5 [synthesis]]
Example language (illustrative): "When someone thanked you, what did you do with it? Could you let it land for two seconds longer?"
Watch for: Grief, suspicion ("they want something") and unworthiness. These are central data for the work, not failures.

4.28 Compassionate ideal other (compassionate image)

Purpose / when: Creates an imagined being who is unconditionally compassionate towards the client. It is useful when self-directed warmth is too hard. [source: Gilbert 2009]
Steps: (1) SRB and safe place, if helpful. (2) Ask the client to build their own ideal compassionate image: its face, voice, manner, age and appearance. It may be non-human (an animal, a tree, a mountain, light), as long as it has a mind with wisdom, strength, warmth and non-judgement. (3) Suggest that it has been through difficult things too, rather than being a distant, perfect being. (4) Imagine it wanting the client to be free of suffering and to flourish, understanding the tricky brain, and not judging. (5) Notice the felt response in the body. (6) Tell the client that images are fleeting and incomplete; this is normal. [source: Gilbert 2009 for all of these elements; the "one's own creation" framing is [uncertain]]
Example language (illustrative): "This image is your creation. It knows what you've been through, and its whole wish is for you to be OK. What does its voice sound like?"
Watch for: Using a real person, especially an ambivalent caregiver, can bring loss or threat; suggest an imagined being. The client may feel the image's compassion is undeserved; work this as a fear (4.20).

4.29 Compassionate feeling and sensation

Purpose / when: Links compassion to bodily experience so that it becomes felt rather than conceptual. Weave it into 4.25–4.28. [source: Gilbert 2009]
Steps: (1) During any compassion practice, pause. (2) Ask where in the body warmth, kindness or support is felt. (3) Ask the client to stay with it for a few breaths. (4) Note its quality (warmth, expansion, softening).
Example language (illustrative): "Where do you notice that, even slightly?"
Watch for: Numbness. Accept "nothing yet" without pushing.

4.30 Compassionate letter writing

Purpose / when: Self-compassion in written form about a current difficulty. It is useful between sessions and in Phase 3. [source: Kolts et al. 2018 module 28; Trials 2023 table (letter to self, read aloud with the breath)]
Steps: (1) SRB and bring up the compassionate self (or the ideal other). (2) Write to oneself about a current struggle, from that perspective. (3) Show understanding of the distress and why it makes sense (tricky brain, history). (4) Validate feelings and recognise that others struggle similarly. (5) Avoid condemning, and avoid empty reassurance. (6) Encourage specific, helpful next steps with warmth and strength. (7) Read it back, ideally aloud and slowly in a warm voice, and check the tone. Rewrite any line that sounds like a critic in disguise. [source: steps 1–2, 7 supported by Trials 2023 table and Kolts et al. 2018; steps 3–6 commonly taught letter guidance [uncertain]]
Example language (illustrative): "Write as if from someone who really understands and wants the best for you. Afterwards we'll check together whether any 'shoulds' crept in."
Watch for: Letters that are logical but cold, or that contain hidden criticism ("you need to stop being pathetic"). It is working when the client reads it back and feels some easing.

F. Multiple selves and chairwork

4.31 Getting to know the multiple selves (imagery and writing)

Purpose / when: Differentiates the threat emotions (the angry, anxious and sad selves) that are often fused or avoided, especially in depression. It reduces self-blame by treating emotions as understandable parts. [source: Bell et al. 2021; Kolts et al. 2018 modules 29–30]
Steps: (1) Choose a recent conflict with someone the client cares about. (2) Take each threat self in turn (angry, anxious, sad). For each, explore: its thoughts and focus, its body sensations, what it wants to do (urges), memories linked to it, and what it needs in order to settle. (3) Ask how each self views the others (for example, what the angry self thinks of the anxious self) and which one blocks which. (4) In writing variants, the client writes a paragraph from each self in turn. (5) Finally, step into the compassionate self and consider the situation and each self. [source: Bell et al. 2021 for steps 1–3 and 5; step 4 from Kolts et al. 2018 module 30 title, detail [uncertain]]
Example language (illustrative): "Let's just give the angry part of you the floor for a moment. What is it thinking? What does it want to do? And what does it need to calm down?"
Watch for: Some emotions that are hard to access or leave. Use this as information about which emotions are feared or dominant. [source: Bell et al. 2021]

4.32 Multiple-selves chairwork

Purpose / when: The embodied, chair-based form of 4.31. Place it after psychoeducation, formulation and established compassionate-self practice (sessions 7–17 in Bell et al.'s study). Therapists need intervention-specific training and supervision. [source: Bell et al. 2021]
Steps: (1) Agree on the rationale and consent, and set chairs for angry, anxious and sad selves plus a compassionate-self chair. (2) The client sits in each threat-self chair in turn and speaks from that emotion: thoughts, body, urges, memories, needs. (3) Between chairs, they "shake off" the previous emotion with breath and a physical gesture. (4) Explore the relationships between selves from each chair. (5) The client moves to the compassionate-self chair and accesses it with posture, SRB and a friendly expression (in the study, clients were prompted to smile). (6) From there they reflect on the conflict, mentalise both parties, and speak compassionately to each threat self in turn, recognising its triggers and origins. (7) Close by integrating: the selves are understood as parts of a whole, held by the compassionate self. Then ground the client and debrief. [source: Bell et al. 2021; the published step table was not read, so the exact order and wording are [uncertain]; debrief and grounding [synthesis]]
Example language (illustrative): "Now come over to this chair. Take a moment to settle your breath, sit tall, let a soft expression come. Looking back at your anxious self over there, what do you understand about it?"
Watch for: Getting stuck or fused in one chair (move chairs); a feeling of "jumble" (separating helps); fear of being overwhelmed by sadness (titrate); the client wanting to hug or soothe a self, which is a sign it is working. Chair distance can be adjusted to show relationships. [source: Bell et al. 2021]

4.33 Self-critic two-chair work

Purpose / when: Enacts the self-critical dialogue, then brings compassion to both the criticised self and the critic. Use when self-criticism is entrenched and the compassionate self is available. [source: Bell 2021 thesis (described as a core CFT set piece)]
Steps: (1) The critic speaks from one chair to the criticised self in an empty chair. (2) The client moves to the criticised chair and says how the criticism affects them. (3) The client steps into the compassionate self (third position or chair) via posture and SRB. (4) The compassionate self speaks to the criticised self with understanding and support. (5) The compassionate self speaks to the critic, recognising its fear and protective function and offering another way to meet the need it serves. (6) Debrief, and note what shifted. [source: two-chair structure and compassion to both sides from Bell 2021 thesis; sequence detail [uncertain]]
Example language (illustrative): "From this compassionate place, what do you see the critic trying to protect you from? What would you like to say to it?"
Watch for: Intense shame or overwhelm (documented risks of chairwork). Keep the critic's turn short, ground between chairs, and stop if dissociation appears.

G. Maintenance

4.34 Maintaining and enhancing compassionate growth

Purpose / when: For the final sessions, and the boosters that follow. [source: Kolts et al. 2018 module 34 title]
Steps: (1) Review the formulation and the changes in the three circles. (2) Choose a sustainable daily practice (for example, brief SRB and a compassionate-self check-in). (3) Write a setback plan in which lapses become cues for compassion, not self-attack. (4) Write a compassionate letter to the future self. (5) Plan boosters. [synthesis]
Example language (illustrative): "When old patterns come back, and they will, what will your compassionate self say to you?"
Watch for: All-or-nothing "I've failed" after a lapse.

5. Handling problems

Compassion practice makes the client more anxious or distressed. Expect this; it is documented. Some participants find compassion imagery physiologically stressful, and early efforts to help clients feel safe can raise anxiety. (1) Name it as a fear or block, not a failure. (2) Shorten the practice and keep eyes open. (3) Move from receiving or self-compassion to the easier flow, compassion to others. (4) Explore the fear (4.20). [source: Gilbert 2009; Gilbert 2020]
Grief floods in ("distress calling"). Warmth can reactivate unmet attachment longing. Normalise it, validate it, and contain it. Slow the pace, ground the client, and treat the grief as meaningful rather than a sign to stop. [source: Gilbert 2009]
Dissociation during imagery or chairwork. Stop the exercise, orient to the room (eyes open, feet, naming objects), and return to SRB or the safe place with eyes open. Next time, titrate exposure to the feared emotion more gradually. Clients with trauma histories may need trauma-focused work, which can become more tolerable after some compassion work. [source: Gilbert 2009 (dissociation, trauma sequencing); grounding steps [synthesis]]
"I understand it but I don't feel it." This is the original problem CFT was built for. Move from content to tone: work on voice, posture and the compassionate self (4.21, 4.23). Check for a bullying tone in the alternative thoughts. [source: Gilbert 2009]
"Self-compassion is weak, self-indulgent or undeserved; I'll get lazy." Do a functional analysis of the critic (4.18). Reframe compassion as courage and strength. Contrast self-attack with compassionate self-correction. Test the prediction with a time-limited behavioural experiment (4.24). [source: Gilbert 2009; experiment [synthesis]]
Strong attachment to the critic. Do not fight the critic. Thank it for its protective intent and look at what it is afraid of. Chair or imagery work can help the client see it as frightened rather than authoritative (4.19, 4.33). [synthesis, consistent with Gilbert 2009]
No images, or fleeting images. Gilbert states that images are usually fleeting. The felt intention matters more than vividness. Offer non-visual routes: voice, posture, sensation, colour, or memory. [source: Gilbert 2009]
Stuck in one emotion during multiple-selves work; emotions feel like a jumble. Physically move chairs, and use breath and a gesture to shake off the emotion between chairs. Treat difficulty accessing or leaving an emotion as diagnostic information about avoided emotions. [source: Bell et al. 2021]
Non-practice between sessions. (1) Be curious, not corrective: avoidance may reflect fear of compassion, perfectionism, or chaotic circumstances. (2) Shrink the practice (for example, three breaths at a daily cue). (3) Link it to existing routines. (4) Use audio guidance. (5) Value any attempt (process-focused). [synthesis; process focus from Gilbert 2009; audio formats noted on Wikipedia]
Ruptures and therapist warmth as threat. Warmth can feel manipulative or intrusive to clients who learned that care was dangerous. (1) Ask directly how your warmth lands, and adjust the dose. (2) Own your part in any rupture without excessive self-blame; this models compassionate self-correction. (3) Link the rupture to the formulation, without blaming the client. [source: Gilbert 2009 (therapist warmth activating attachment pain); repair steps [synthesis]]
Submissive or appeasing compliance (agreeing in order to please). This is a safety strategy the formulation predicts. Invite disagreement explicitly, and check meaning behind "yes". [synthesis]
Using "not your fault" to avoid change. Bring back the second half: responsibility for training the mind now. [source: Gilbert 2009]
"Compassion" used to justify avoidance or safety behaviour. Compassion includes the courage to approach difficulty. Ask what a wise, strong compassionate self would do for long-term well-being. [synthesis consistent with Gilbert 2009]
Over-reliance on others for safeness, or on the therapist. This is noted as a risk in dependency difficulties. Build the internal compassionate self and a range of supports, and plan the ending early. [source: Gilbert 2020 (over-reliance); responses [synthesis]]
Anger towards caregivers or others emerges. This is a valid threat-self emotion. Give the angry self a voice (4.31–4.32), and help the compassionate self hold it without acting it out. [synthesis]
Suicidal ideation or self-harm. Conduct standard risk assessment and safety planning, including lethal-means counselling on safe storage or removal. Coordinate care as needed. Compassion work can be framed as supporting the part of the client that wants to live, without minimising the risk. A compassion-focused CBT group for self-harm has been evaluated (Rayner et al. 2022, cited on Wikipedia). [synthesis; uncertain on specific protocol]
Psychosis, eating disorders and other adaptations. Use the specialised adaptations (CFT for psychosis, as in Braehler et al. 2012; CFT-E for eating disorders, Goss) rather than improvising. Do not set weight or calorie targets within compassion work. Coordinate with medical monitoring. [source: Wikipedia; details [uncertain: adaptations]]
Group delivery problems (comparison and shame in a group, uneven practice). Normalise difficulty by voicing common fears early. Let members pass on sharing. Use the group to practise receiving compassion from others. [synthesis]
Therapist's own blocks (cold or anxious delivery). Use self-practice and self-reflection, and supervision; Kolts et al. (2018) frame this as an internal compassionate supervisor. [source: Kolts et al. 2018 contents]

Sources

Sources:

Introducing compassion-focused therapy (Gilbert 2009, Advances in Psychiatric Treatment, PDF)
Compassion: From its evolution to a psychotherapy (Gilbert 2020, Frontiers in Psychology). Only the theoretical sections (safety versus safeness, secure base) were readable; the clinical sections were not retrieved [uncertain].
Experiencing Compassion-Focused Therapy from the Inside Out: table of contents (Guilford)
Multiple emotions, multiple selves: compassion focused therapy chairwork (Bell, Montague, Elander & Gilbert 2021, The Cognitive Behaviour Therapist). The step table (Table 2) was not visible.
Tobyn Bell PhD thesis: CFT chairwork, University of Derby repository (opening chapters only)
Compassion-focused therapy (Wikipedia)
Summary of sessions table, CFT/CMT trial protocol (Trials, 2023)