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Psychology and Psychotherapy: Theory, Research and Practice (2015), 88, 143–162 © 2014 The British Psychological Society www.wileyonlinelibrary.com

An exploration of compassion focused therapy following acquired brain injury Fiona Ashworth1,2,3*, Alexis Clarke4, Lisa Jones5, Caroline Jennings6 and Catherine Longworth2 1

Department of Psychology, Anglia Ruskin University, Cambridge, UK Oliver Zangwill Centre, Cambridgeshire Community Services, Cambridgeshire, UK 3 Evelyn Community Head Injury Service, Cambridgeshire Community Services, Cambridgeshire, UK 4 Plym Neurorehabilitation Unit, Mount Gould Hospital, Plymouth, UK 5 Neurorehabilitation Unit, Rookwood Hospital, Cardiff, UK 6 Oxford Institute for Clinical Psychology Training, University of Oxford, UK 2

Background. People with acquired brain injuries (ABI) frequently experience psychological difficulties such as anxiety and depression, which may be underpinned and maintained by high self-criticism and shame alongside an inability to self-soothe. Compassionate focused therapy (CFT) was developed to address shame and self-criticism and foster the ability to self-soothe. Objectives. This is a naturalistic evaluation with the aim of assessing the feasibility, safety, and potential value of CFT for ABI patients with emotional difficulties receiving neuropsychological rehabilitation. Methods. This study employed a mixed methods design combining self-report measures and qualitative interviews. Twelve patients received a combination of CFT group and individual intervention. Self-report measures of self-criticism, self-reassurance, and symptoms of anxiety and depression were collected pre and post programme and analysed using Wilcoxon signed rank test (N = 12; five female, seven males). Follow-up data were analysed in the same manner (N = 9). Interviews were conducted with six patients and analysed using interpretative phenomenological analysis. Results. CFT was associated with significant reductions in measures of selfcriticism, anxiety, and depression and an increase in the ability to reassure the self. No adverse effects were reported. Three superordinate themes emerged from the interviews: psychological difficulties; developing trust and finding safeness; and a new approach. Conclusions. This study suggests that CFT is well accepted in ABI survivors within the context of neuropsychological rehabilitation. Furthermore, the results indicate that further research into CFT for psychological problems after ABI is needed and that there may be key aspects, which are specific to CFT intervention, which could reduce psychological difficulties after ABI.

*Correspondence should be addressed to Fiona Ashworth, Department of Psychology, Anglia Ruskin University, East Road, Cambridge CB1 1PT, UK (email: [email protected]). DOI:10.1111/papt.12037

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Practitioner points  CFT appears to be a feasible intervention for psychological problems after ABI.  CFT was associated with a reduction in symptoms of anxiety and depression and associated selfcriticism, as well as enhanced self-reassurance for ABI survivors.  These ABI survivors reported that CFT provided them with tools to manage continued psychological difficulties.

It is estimated that 135,000 people suffer an acquired brain injury (ABI) each year in the United Kingdom (Department of Health, 2005). ABI survivors face huge every day challenges as a result of the complex consequences of their injuries. Soo and Tate (2007) estimate that anywhere between 30% and 70% of people who experience a traumatic brain injury are likely to suffer with significant psychological difficulties. ABI survivors are considerably more likely to suffer from depression, anxiety, post-traumatic stress disorder (PTSD) and are at a higher risk of committing suicide than those in the general population (Hesdorffer, Rauch, & Tamminga, 2009). For ABI survivors, psychological problems can further exacerbate physical, cognitive, and social difficulties experienced after the injury, often leading to a significantly reduced quality of life; furthermore, compromised cognitive abilities can substantially reduce their psychological coping capacities, making them susceptible to further deterioration. The management of psychological difficulties after ABI has traditionally involved transferring evidence-based approaches from mainstream mental health practice. Research into the effectiveness of psychotherapy after brain injury, although growing, is still in its infancy. Research in this area is dominated by studies on cognitive behavioural therapy (CBT). Randomized control trials (RCTs) in CBT indicate some positive results for CBT as a standalone intervention (e.g., Bradbury et al., 2008) and more recently combining CBT with motivational interviewing (e.g., Hsieh et al., 2012). In a recent review of the evidence base of CBT for depression and anxiety in adults with ABI, Waldron, Casserly, and O’Sullivan (2013) conclude that CBT treatment is more effective when specifically targeting depression or anxiety, finding larger treatment effect sizes (for depression 1.15 and for anxiety 1.04) than when intervention is more generalized. However, they also note that often studies indicated only partial reduction in symptoms of anxiety and depression and will not be suitable for all patients or difficulties (Waldron et al., 2013). Although limited in its generalization, there is a report of adverse outcome of using CBT after ABI in the treatment of PTSD in the context of executive dysfunction (King, 2002). Within mental health treatment approaches, there has been a shift in the direction of ‘third wave therapies’, which have moved away from targeting interventions for psychological events (e.g., thoughts), towards aiming to change the function of these events and the individual’s relationship with their psychological and contextual experiences (Hayes, Luoma, Bond, Masuda, & Lillis, 2006). Examples of such approaches include mindfulness based cognitive therapy, acceptance and commitment therapy, and compassion focused therapy (CFT). Recently, this shift has been advocated for in the literature on psychotherapy for survivors of brain injury (Ashworth, Gracey, & Gilbert, 2011; Kangas & McDonald, 2011). Compassion focused therapy (Gilbert, 2000, 2010a, 2010b) hypothesizes that key underlying processes are present across mental health difficulties (particularly shame and self-criticism) and these are central to maintaining psychological problems, such as depression and anxiety. This model draws on social, evolutionary (especially attachment theory), and neurophysiological approaches to affect regulation (Gilbert, 2000, 2005,

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2009, 2010a, 2010b). This model highlights the role of developing compassion to activate our affiliative/soothing system, which aids in balancing our affect regulating systems, particularly in response to the threat system. CFT distinguishes between the therapy itself that involves the therapeutic relationship and the basic paradigms and formulation processes, and the specific training in compassion with the client. The specific training exercises of CFT, compassionate attending, thinking, behaviour, and imagery are part of what is called compassion mind training (CMT). There is a growing body of research highlighting the role of compassion in mental health; a recent meta-analysis by MacBeth and Gumley (2012) concluded that increased self-compassion is linked to lower levels of mental ill health, while lower levels of selfcompassion are associated with higher levels of psychopathology. Notably, the studies informing this meta-analysis were primarily from non-clinical populations. However, more recently, several studies have provided support for the theoretical model of CFT in clinical populations, for example, associations have been found between high shame and low self-reassurance in eating disorders (Kelly, Carter, Zuroff, & Borairi, 2013) and selfcriticism is associated with increased levels of distress in women with cancer (Campos, Besser, Ferreira, & Blatt, 2012). There are also a number of naturalistic evaluation studies indicating CFT’s feasibility and preliminary effectiveness, including evidence for group CFT for eating disorders (Gale, Gilbert, Read, & Goss, 2012); CFT as an adjunct to CBT for trauma (Judge, Cleghorn, McEwan, & Gilbert, 2012), and group-based CFT interventions within community mental health settings (e.g., Gilbert & Irons, 2004; Laithwaite et al., 2009; Lucre & Corten, 2012; Mayhew & Gilbert, 2008). Recently, the first RCT of CFT has been published indicating the feasibility and positive impact of group CFT for people with psychosis (Braehler et al., 2012). At the very least, these studies show that CFT has promised within clinical settings across a range of disorders where there are shared transdiagnostic processes of shame and self-criticism. Research into the emotional experiences of ABI survivors has indicated that both internal and external shame and self-criticism form part of their emotional experience and is related to significant distress (Freeman, Adams, & Ashworth, 2015; Hagger, 2011; Jones & Morris, 2013). Therefore, like other clinical populations, it is possible that these processes have a role in the development and maintenance of common psychological difficulties, such as anxiety and depression, in survivors of brain injury. Apart from three clinical case studies, one which outlines the theoretical foundations of the suitability of this intervention for this population and its effectiveness (Ashworth et al., 2011), a second which focuses on building the rationale for CFT following ABI (Ashworth, 2014) and a further case integrating CBT, mindfulness, and elements of CFT for emotional difficulties after stroke (Shields & Ownsworth, 2013), there is relatively little understanding of whether this intervention may in fact be feasible and helpful for ABI survivors. An experimental study by O’Neill and McMillan (2012) examined the impact of a single session of compassionate imagery on empathy deficits in severe head injury with non-significant results. However, it is difficult to draw strong conclusions about the effectiveness of CMT from this study as only one CMT exercise was used in isolation and the literature suggests that CFT and CMT need to be provided as a full treatment when working with a clinical population. Further evaluation, outcome, and process research could offer greater insights into the feasibility, safety, and suitability of CFT and the factors associated with positive change. Given the current lack of consistent evidence for treatment of psychological difficulties after ABI and the suggestion that underlying transdiagnostic processes (i.e., self-criticism, shame, and the reduced ability to self-soothe) may play key roles in psychological

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problems after ABI, it seems crucial to investigate the feasibility and potential benefit of CFT for people with psychological problems after ABI. It is not known whether the treatment-specific factors in CFT, which are associated with positive change in mental health populations, are experienced similarly by survivors of brain injury. Therefore, the clinical application of CFT, with individuals with ABI, could be enhanced by gaining an understanding of the factors associated with the psychological change process within this approach. Understanding the process, ingredients, and outcome of psychological change can be difficult (Higginson & Mansell, 2008). To support the understanding of the effectiveness of this approach we choose to use a mixed methodological approach that would allow for expansion beyond the quantitative, self-report measures, and captures the richness of human experience (see Greene, Caracelli, & Graham, 1989 for an overview). In this study, we have taken an inductive approach, interested in understanding both the quantitative change on self-report measures, and the survivors’ experiences of CFT.

Aims This investigation is a naturalistic study of a combination of group-based and one-to-one CFT with ABI patients presenting an 18-week neuropsychological rehabilitation programme with mental health problems including anxiety and depression. In addition, we aimed to explore any psychological change associated with CFT and its nature.

Methods A mixed methods design was employed using qualitative and quantitative methods to evaluate CFT (Robson, 2002). The quantitative analysis using self-report measures provided key descriptors of group characteristics, population sample, and outcomes with regards to the aims of therapy (i.e., to reduce self-criticism and general symptoms of anxiety and depression as well as to build the capacity to reassure and soothe the self). Interpretative phenomenological analysis (IPA) of interview data was used to explore emerging themes relating to patients’ experience of psychological difficulties, psychological change, and the experience of CFT.

Patients The study involved patients with an ABI who were attending the neuropsychological rehabilitation outpatient programme. Each had complex interacting difficulties as a consequence of their ABI, including cognitive and psychological difficulties, however, patients – with a diagnosis of a personality disorder or who were currently abusing drugs or alcohol – were excluded from the service. Within this National Health Service (NHS), patients are not separated according to the nature or type of ABI, however, initial interdisciplinary assessment enables professionals to formulate which patients will most likely benefit from the programme and particularly cognitive assessment informs the best way to support patients to learn and benefit from rehabilitation. A total of 12 patients consented to take part in the evaluation and both pre, post, and follow-up questionnaire measures were completed. Out of the 12 patients, seven were men, and five were women; all subjects were white British aged between 21 and 55 (men: M = 46.1, SD = 9.64; women: M = 33.5, SD = 8.36). Participant demographics are

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Table 1. Participant demographics Study ID 1 2 3 4 5 6 7 8 9 10 11 12

Type of injury

Age (years)

Stroke Stroke Tumour Traumatic brain injury Traumatic brain injury Anoxic damage (overdose) Traumatic brain injury Traumatic brain injury Traumatic brain injury Traumatic brain injury Traumatic brain injury Stroke

32.4 38.4 42.9 49.5 49.5 27.7 50.0 54.5 21.4 31.1 39.7 53.3

Gender F M F M M M M M F F F M

illustrated in Table 1. At the time of intervention, all patients were not receiving rehabilitation or psychological intervention from another source.

Measures All measures were administered by an Assistant Psychologist prior to and at the end of the CFT intervention. Follow-up measures were sent via post. All measures were an integral part of the participant’s therapeutic process and were fed back to the patients as part of their outcome meetings.

Hospital Depression and Anxiety Scale The Hospital Anxiety and Depression Scale (HADS) was developed by Zigmond and Snaith (1983) and is commonly used to determine the levels of anxiety and depression. The HADS is a 14-item scale that generates ordinal data; seven of the items relate to anxiety, and seven relate to depression.

Forms of Self-Criticism/Self-Attacking and Self-Reassuring Scale The Forms of Self-Criticism/Self-Attacking and Self-Reassuring Scale (FSCRS) was developed by Gilbert, Clark, Hempel, Miles, and Irons (2004). It was developed to measure self-criticism and the ability to self-reassure. It is a 22-item scale, which measures the different ways people think and feel about themselves when things go wrong for them. The items make up three components, there are two forms of self-criticism; inadequate self, which focuses on a sense of personal inadequacy (e.g., I am easily disappointed with myself), and hated self, this measures the desire to hurt or persecute the self (e.g., I have become so angry with myself that I want to hurt or injury myself), the final aspect, the reassured self, measures the propensity to provide self-reassurance (e.g., I am able to remind myself of positive things about myself). Patients are asked to estimate how like them each statement is on a Likert scale, ranging from 0 (not at all like me) to 4 (extremely like me).

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Procedure The evaluation of this intervention was provided as part of the routine clinical evaluation of neuropsychological rehabilitation within the NHS. Prior to publication, the authors sought advice from the Chair of the NHS Research Ethics Committee who confirmed that the study conformed to evaluation of routine treatment, and therefore did not require ethical review. Although CFT was a novel intervention, it had previously been integrated into the existing rehabilitation programme after initial cases highlighted its potential benefits (e.g., see Ashworth et al., 2011). Clients, accepted to the neuropsychological rehabilitation programme, were asked whether they consented for their data to be used for evaluation purposes; twelve patients consented and then completed the measures both pre- and post-intervention. In accordance with IPA, purposive sampling (Smith, Flowers, & Larkin, 2009) was used to recruit seven patients for semi-structured interview with AC. Interviews were conducted after the self-report measures were collected and analysed. To reduce interviewer and interviewee bias (Robson, 2002), none of the participants interviewed had engaged in an individual therapeutic relationship with AC. One participant declined to take part due to a recent bereavement. Four interviews were conducted in the centre and two in the patients’ homes. Patients gave consent to be interviewed and audiorecorded. The interviews typically lasted between 40 and 60 min and were audiorecorded for transcription. The interview was adapted to incorporate recommendations by Paterson and Scott-Findlay (2002) for interviewing ABI survivors. The interview questions were developed by reviewing the published literature on psychological change (Elliott, Slatick, & Urman, 2001; Higginson & Mansell, 2008). An outline of the semistructured interview questions is given in Table 2.

Service delivery and CFT intervention The CFT intervention consisted of a ‘mood group’ and individual CFT sessions, embedded within a holistic neuropsychological rehabilitation programme run by a Cambridgeshire Community NHS Centre. The programme offers an interdisciplinary team (IDT) approach to support the patients to reach their rehabilitation goals, which includes clinical psychology, cognitive neuropsychological rehabilitation, occupational therapy, and Table 2. Semi-structured interview questions You have volunteered today to discuss your experiences of compassion focused therapy used at the centre 1. What were the emotional difficulties you were experiencing when you started the programme? 2. How did they affect your life? Prompt: Can you tell me a story about how they affected you? 3. Have you had any therapy or psychological help in the past? 4. Did you have any knowledge or expectations of the compassion focused therapy when you entered the programme? 5. What were your experiences of mood group? Prompt: Can you tell me a story about the group? Prompt: what usually happened in the group? 6. What were your experiences of psychotherapy? Prompt: Can you tell me a story about the therapy? 7. What changes have you noticed since the programme in relation to your emotional wellbeing? What are the best changes? Are there any changes for the worse? 8. How likely do you think these changes might have been if it wasn’t for mood group or the one-to-one sessions? 9. How do you feel about your difficulties now?

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speech and language therapy. CFT was introduced by FA, a Clinical Psychologist (CP), who had attended a 3-day workshop training in CFT and received monthly supervision from Paul Gilbert (PG; founder of CFT) during the initial development of the intervention within the neurorehabilitation programme. Three CPs delivered the CFT intervention (FA, AC, and CL), all received supervision from a qualified CP and had attended PG’s 3-day training in CFT. Since the introduction of CFT within the programme in 2010, it has developed further with the support and feedback from both the IDT and from service users. The holistic neurorehabilitation programme runs for 18 weeks with a maximum cohort of five patients. The first 6 weeks of the programme which is primarily group based, focus on (1) psycho-education about the biopsychosocial consequences of ABI and (2) introduction to ‘taster’ examples of tools or strategies to help manage these consequences. For each of these 6 weeks (apart from week 1), the group education focuses on a specific component of the consequences of ABI which runs for four full days. The 6 weeks of the programme for the groups are as follows (1) induction, (2) understanding brain injury and the physical consequences, (3) cognitive consequences: memory and attention, (4) cognitive consequences: executive functioning, (5) communication and (6) mood group. Mood group is the last group in week 6 to enable cohesion to form within the group to facilitate the discussion of sensitive issues and benefit from peer support.

Brief overview of mood group The mood group aims to help survivors of ABI to make sense of the emotional difficulties that they experience following ABI alongside beginning to develop tools to manage these difficulties. This was based within the CFT approach and consisted of three main components; socialization to the CFT model, CMT, and planning for practice, all in the context of the consequences of the ABI. Each of the 4 days consisted of a mixture of each of these components. The group was a combination of psycho-education and group skills training. The group was semi-structured and the group facilitators encouraged discussion, feedback, and reflection from the participants. The socialization to the CFT model involved the presentation and discussion of core components of the compassionate mind approach (see Gilbert, 2009, 2010a). Two core components of CFT guided the group and were explicitly discussed with the patients; these were definitions of compassion and the common humanity principle. Compassion was explained using Gilbert’s (2009) definition; to approach, engage, and understand the suffering and to work to alleviate and prevent it. Gilbert’s (2009) fundamental common humanity principle was described as the ability to see one’s experiences as an understandable part of being human, rather than individual and shameful (i.e., human susceptibility to injury and disease). Drawing from CFT’s evolutionary routes, affect was explored with reference to the three systems model of affect regulation. This model consists of a threat and protection system, a drive, resource-seeking and excitement system, and a contentment/soothing and safeness systems. We provided a description of Gilbert’s (2009) ‘tricky brain’ and introduced the concept of the brain injury leading to a ‘trickier brain’, explaining that damaged neuro-circuitry following brain injury may disrupt emotional systems. Strategies to approach and alleviate suffering were discussed including reflection on behavioural patterns (e.g., avoidances) that may lead to and/or maintain distress. Exercises from CMT were tried within the group to develop the propensity for selfsoothing, including soothing rhythm breathing and safe place imagery.

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At the end of each mood group day, the participants were supported to practise compassionate skills in their own time and this included exercises to raise awareness of their own affective systems, for example, ‘this evening we would like you to notice when your threat system is activated’ and planning to practise the CMT exercises.

Brief overview of individual sessions All patients received individual weekly CFT psychotherapy sessions for the duration of 18week programme (a maximum of 18 sessions, with a mean uptake of 16). The one-to-one sessions involved interventions related to content (i.e., formulation, CMT, addressing blocks, and barriers to self-compassion) and specific attention was paid to the process (i.e., therapeutic relationship). Please see Gilbert (2010a) for more details. Within the first group phase of the rehabilitation programme (weeks 1–6), the individual CFT sessions delivered alongside the groups primarily focused on assessment, formulation, and goal setting. As the patient moved into the second phase (weeks 7–18), having had the mood group, the individual CFT sessions focused primarily on the development of compassionate practice to engage and deal with the challenges as well as addressing barriers to compassion. Therefore, there was significant overlap in the content of the mood group and individual sessions. A number of adaptations were made to ameliorate the patient’s cognitive difficulties within both mood group and individual CFT sessions (e.g., see Ashworth et al., 2011). This is a core consideration in the provision of psychotherapy for individuals with ABI (Ashworth, 2014; Block & West, 2013). For clarity, a brief outline of the interventions and adaptations are given in Table 3.

Table 3. Description of CFT Compassionate mind mood group  Introducing CFT – the underpinning theories (including effects of ABI on tricky brain and threat system activation after ABI)  Understanding the origins and functions of self-criticism and shame after ABI  Explore the basic concepts of compassion and what compassion entails (including how compassion might be expressed in the group and towards the self)  Understand how compassion can be used to engage with difficulties  Introduce and practise CMT exercises (soothing rhythm breathing and safe place)  Focus on development of affiliative motivation and emotion directed at self and others  Use group process to foster caregiving mentality (compassionate ‘group’ mind)

One-to-one CFT  Development of CFT formulation, understanding symptoms as related to safety and emotion regulation strategies  Focus on therapeutic relationship  Compassion skills practice in relation to internal, external threats, and related individual difficulties (e.g., shame)  Reflection on practice and developing the compassionate mind  Working with fears, barriers to compassion  Focus on development of affiliative motivation, emotion directed at self, others  CMT exercises (e.g., soothing rhythm breathing, safe place, and compassionate self)  Focus on the importance of practice  Relapse prevention and planning  All undertaken with a compassion focus

Note. Supports and adaptations after ABI – including compassionate texts reminders and alerts, images on mobile phone; shorter sessions; focus on planning practice into weekly schedule. ABI = acquired brain injury; CMT = compassion mind training; CFT = compassion focused therapy.

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Analysis Quantitative data analyses Descriptive statistics (mean, standard deviation) were generated using SPSS statistics software version 20 (IBM). Statistical tests were also conducted using SPSS software. Due to the small sample size and nature of the data, the non-parametric Wilcoxon signed rank test was used to analyse the pre-, post-, and 3-month follow-up measures, the HADS, and FSCRS. Data regarding effect size were calculated using Cohen d estimations for with-in group changes. Effect size conventions are based on Cohen’s (1988) d estimations: small = 0.20, medium = 0.50, large = 0.80. Effect sizes reported pertain to anxiety, depression, self-criticism, and self-reassurance.

Qualitative data analyses All interviews were transcribed verbatim and analysed guided by a six-step IPA process as described by Smith et al. (2009). The analysis was initially in paper form and the organization of emergent themes was later supported by Inspiration software (version 8). The analysis was guided by recommended validation guidelines for qualitative research (Elliott, Fischer, & Rennie, 1999). Data were analysed by AC under the supervision of LJ, who is experienced in this methodology. Emergent themes were discussed between AC, LJ, and FA systematically and regularly to ensure a good fit between the text and the final superordinate and master themes.

Results Quantitative data analysis Data analysis for all the measures at pre-, post-, and 3-month follow-up evaluation is presented in Table 4. With regard to the self-criticism measure, there was a significant reduction in hated self and inadequate self pre- to post-intervention, and pre- to 3-month follow-up. At these same time points, there was also a significant increase in reassured self that taps into ways of being more positive and compassionate to oneself. With regard to the symptom measures, there were significant reductions in both depression and anxiety pre- to post-intervention and pre- to follow-up. Analysis conducted on all the outcome measures between post- and 3-month follow-up indicated no significant difference highlighting that gains were maintained during this period. Follow-up analysis could only be conducted on nine of the patients, as three did not return the 3-month follow-up questionnaires. In terms of Cohen d, effect sizes for with-in group comparisons pre to postintervention, there was a large effect size with regards to reductions in anxiety (r = .52), depression (r = .58, d = 1.43), and self-criticism (inadequate r = .67, d = 1.81; hated r = .60, d = 1.5). There was also a large effect size with regards to the increase in reassured self from pre- to post-intervention (r = .56, d = 1.38).

Qualitative data analysis Figure 1 represents a visual depiction and relationship between the master and superordinate themes. Master themes are clustered under three broad superordinate themes, which are:

6.33 (4.01) 4.33 (2.93) 13.08 (6.11) 1.00 (1.28) 23.08 (5.84)

24.42 (6.37) 7.17 (5.64) 15.50 (5.09)

Post-intervention 12 M (SD)

12.33 (5.69) 9.75 (4.48)

Pre-intervention 12 M (SD)

13.11 (5.69) 2.78 (3.11) 21.99 (3.38)

6.22 (4.09) 4.44 (2.46)

3-Month follow-up 9 M (SD)

2.81** 2.91** 2.67*

2.81** 2.68*

Pre-Post 12 z score

ns ns ns

ns ns

Post-follow-up 9 z score

2.67* 2.44* 2.39*

2.14* 2.39*

Pre-follow-up 9 z score

Note. M = mean; SD = standard deviation, shown in parentheses; HADS = Hospital Anxiety and Depression Scale; FSCRS = Forms of Self-Criticism/Self-Attacking and Self-Reassuring Scale; ns = not significant. *p < .05; **p < .005.

HADS Anxiety Depression FSCRS Inadequate Hated Reassure

N

Table 4. Number of patients (N), mean scores with SD, Wilcoxon signed rank z scores for HADS-anxiety, and depression and FSCRS subscales – inadequate, hated, and reassure self

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Figure 1. Visual description of emergent themes.

1. Psychological difficulties. 2. Developing trust and safeness. 3. A new approach.

Psychological difficulties The brain injury presented psychological difficulties for the survivors. For some it was a new experience, for others it exacerbated pre-existing difficulties. Many described their emotional difficulties as relating to or resulting from life changes.

Self and world as unsafe. All patients described their emotional experience following brain injury as unsafe; they experienced both themselves and their external world in this way. Survivors described panic, fear, and confusion: I felt sick with anxiety and I was coming into work shaking and. . .it was just hell, it was an awful time. I’ll never forget it. Sarah The stress. . . I was finding it really hard to think properly and think clearly and it would take me ages to think about what I wanted. I don’t know, it was a lot of confusion. Lucy

Life changes. All survivors describe how their brain injury brought major life changes including relationship, employment, and role changes: I was going through a separation, redundancy, movement, less time with my son, the strokes. . .the list goes on. So it was a bad time really. Sam I was off sick, my self-worth went to the floor, my wife was earning for us, she was having to take care of the children. My role in the family had changed from being the leader of the family to being an invalid, a burden on the family. Paul

Self-criticism. All patients described experiencing self-criticism and associated depression and anxiety in response to the experience/consequences of the ABI. Notably, the

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patients used aggressive and image-inducing language, such as beating and flogging, as they expressed their experience of self-criticism: I had a very low mood, I was quite depressive, self-hatred, self-criticism, no confidence and I was a failure in my own eyes, that is how I would sum it up. Jill I was very angry, this was right after the head injury and I was beating myself up. Lucy I would be very self-critical in myself saying ‘look, you just cannot do this, what the hell is wrong with you’. Paul

Continuity versus discontinuity. For two patients, distress was experienced as being congruent with prior emotional experience, and for the others it was experienced as unfamiliar and abnormal. Similarly, there was a difference between how patients described their ongoing relationship with their emotional difficulties. For four patients, there was acceptance that emotional difficulties will continue to be a part of their lives: When I am talking about all the {difficulties sic}, about how it was, it brings back all those bad feelings. . .because obviously I am not miracle worker – those well worn paths are hard to change. Jill I was just very stable, I didn’t have any problems with my temper, nothing really would rock me so it was like the opposite of how I had been before-hand and that scared me because I didn’t know what was happening. Paul

For two patients, their experience of emotional difficulties was positioned wholly in the past: I feel like a completely different person, it is completely separate, it feels like a lifetime ago. . .like before the head injury was a completely different life to after the head injury and now it’s completely different to before I came here. Lucy

Developing trust and finding safeness Patients described finding security in their relationships with members of staff, their therapist, and within the group. They also describe finding a sense of safeness within the environment at the neurorehabiliation centre. They describe the development of affiliative relationships between themselves and others, which were reported as important in approaching change.

Consistent caregiver. All patients describe developing relationships with the staff at the neurorehabiliation centre and feeling understood by them. For many, their therapist was a primary source of care and comfort, however, affiliative relationships were developed with all of the staff team: I think of all my friends from rehab and all the lovely people I met there and that helps me, in a way that I can’t really explain, but that helps me a lot, just knowing I have you guys and my friends, just knowing that I have you caring people there for me helps me. Nicola

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It was everything that I needed; it was people who really understood me. Sarah

In it together-security in the group. Five of the patients described finding safeness in the group which allowed group members to draw strength from each other, and feel as though they were in it together: We had a lot of these groups between us. . .that was a real help because it can be very isolating, well, always had been for me, very isolating. Jill Our group was really strong, it was really nice to get together. Lucy

Environmental security. The centre itself was described by all as a safe environment which helped place patients at ease and facilitate learning: I just felt like I was in an environment where I was understood and I could relax. It was just comfortable and easy and I could learn about what had happened to me and it was lovely. Sarah

A new approach The patients described how CFT gave them a new way to relate to themselves, helped them to revaluate their sense of worth, and provided tools to manage their difficulties. A key part of this process was of understanding and developing empathy for their own situation. They described that this allowed them to make changes to how they relate to others as well as themselves.

It’s not my fault-sense making. All patients described their experience of formulation as a powerful and helpful one. They described the importance of drawing from neuropsychology along with other psychologies to establish a non-blaming understanding: Then it started to make sense that I could make the connections between what was unexplained in my own reactions, when I lost my temper and the accident.So I could say ‘well, that is reasonable I can see the connection there’, and that helped. Paul For the first time I could actually look at it and really mean it when I say ‘I am not stupid’, because for so long I thought I was really stupid and really thick. Jill

New tools. All patients described how the CFT model allowed them to develop a toolkit/ repertoire, which included soothing rhythm breathing and compassionate self-focusing and allowed patients to develop a more personal sense of control: With the compassionate mind training, it’s much easier to cope. Because I can face a problem head on and go from there. I don’t see many problems really, now. Now I’m able to sort them out now and concentrate and focus. Sam

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Fiona Ashworth et al. Without being compassionate to myself, I would still not have had the tools to be able to stop myself going into the deep depression stages. I would have perhaps had tools to not get into the situations so much but, like I said earlier, there are times where you are still going to muck it up and it’s how you respond to that, that is where the compassionate mind really comes into its own. Paul

Revaluing self. All patients described how CFT prompted them to show care towards themselves. They explained that they were now much more able to engage in other activities that helped them manage other consequences of their brain injury, such as fatigue management: I have started caring more about myself and what I want out of life and not thinking so much about others – not saying that I don’t care about others, because I do, but I have started to put myself first now, not others. Nicola

New way to relate to others. Two survivors described how CFT allowed them to develop a better understanding of others’ behaviours and alter their response to their actions or perceived judgments: For example, if I am driving to work when I get in the car, I have to clear my head and say ‘Paul, there is going to be someone today who is going to do something stupid who is going to take your right of way, who is going to do something dangerous’. So I expect it, and in that way I am taking over some of the actions of my frontal lobes because that is what it is doing, it reasons with the old brain. Paul

Discussion This naturalistic evaluation explored the feasibility and impact of CFT set within a neuropsychological rehabilitation programme for people with psychological problems after brain injury. The results show a significant improvement on all measures after the programme, which is supported by the emergent themes in the clients’ narratives. The questionnaire data indicated that, at the start of the programme, clients experienced self-criticism both in the form of inadequacy and hatred towards the self. The qualitative data support this finding and provide a rich description of the experience of self-criticism and how this may relate to depression and anxiety. As well as reflecting the authors’ clinical experience, this response of being self-critical when things go wrong after brain injury is described in other studies (e.g., Freeman et al., 2015). However, it should be noted that baseline means on the inadequate and hated subscale for this group were not as high as those found in studies with mental health populations (see Gilbert & Procter, 2006; Judge et al., 2012), but they were higher than those found in the general population (Kupeli, Chilcot, Schmidt, Campbell, & Troop, 2013). Furthermore, baseline means for this group on the reassure subscale were higher than those found in the aforementioned mental health studies, but were lower than those found in the general population (Kupeli et al., 2013). The significant reduction in inadequate self on the FSCRS found in this study is not consistent with other studies of CFT in clinical populations that found inadequacy scores

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that did not significantly change (Gilbert & Procter, 2006; Lucre & Corten, 2012). Within the qualitative data, we see a continuous thread that might elucidate this finding; within the theme, ‘It’s not my fault-sense making’, patients described how CFT helped them to develop empathy for themselves and an understanding of the ABI and its consequences by recognizing and putting into practice the ‘it’s not my fault’ compassionate mentality. This ‘new approach’ of having a compassionate approach to one’s self and the ‘tricky brain’ is associated with a significant reduction in self-criticism and significant increase in reassured self as evidenced by the quantitative data. Consistent with previous CFT evaluation studies, is the reduction in the more pathological ‘hated self’ measure in response to the CFT; highlighting patients’ experience of moving from a ‘self-hatred’ threat based mentality to a more secure and compassionate ‘it’s not my fault’ mentality. The significant increase in self-reassurance at the end of the programme is also positive and corroborates with the patients’ narratives, explored within the theme ‘revaluing self’, describing learning to have a different relationship with the self in being able to show more care. The general mental health measures of anxiety and depression also showed a significant reduction at the end of the programme, with ratings shifting from mild and moderate symptoms to symptoms within the normal range. This finding could be due to the reduction in self-criticism and the increase in self-reassurance. Indeed, patients described developing ‘new tools’, which allowed them to approach and manage challenging situations and develop a sense of mastery in how they responded psychologically. In interpreting these data, it is helpful to compare the effect size data with that from other studies where rigorous trials have been conducted with control treatments for depression and anxiety for those with ABI. When compared with effect size for HADSanxiety in the control group in Hsieh et al. (2012; r = .24), which is medium, the current results are larger (r = .52). When compared with the HADS-anxiety pre treatment to post treatment for the treatment group in Hsieh et al. (2012; CBT plus MI; r = .49) this study results are comparable, both estimated as large effect sizes. As the Hsieh et al. (2012) study was specifically aimed at treating anxiety, the HADS-depression is not compared here. One clearly different and interesting aspect of the findings is the patients’ positive experiences of being able to draw from neuropsychology in making sense of their ‘trickier brains’ and seeing this as ‘not their fault’. The ‘tricky brain’ concept is a key principle of CFT and is particularly salient for ABI populations where the tricky brain becomes even ‘trickier’ given the impact that frontal lobe and other damage can have on executive control of emotions and rational thinking abilities. This added neuropsychological dimension to the ‘tricky brain’ was a key part of the CFT psycho-education group. Group membership, as described in the master theme of ‘In it together – security in the group’, was described by the majority of patients interviewed as facilitating change propagating feelings of being understood. Research has indicated that living with an ABI can lead to social isolation and social stigma (Boden-Albala, Litwak, Elkind, Rundek, & Sacco, 2005; Hagger, 2011; Morton & Wehman, 1995). Our patients reported that belonging was a fundamental part of the change process. Further studies also highlight the positive effects of group membership for ABI survivors (Haslam et al., 2008). This links to the CFT theoretical foundations, where the development and experience of understanding empathic validating and affiliative relationships, specifically in relation to one’s difficulty, is thought to be the key to the development of an affiliative compassionate approach to oneself (Bates, 2005).

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Given that CFT is a novel intervention with this group, safety of the intervention was paramount, and therefore all patients were carefully monitored during the intervention. This was important, given that there have been reports of adverse effects of other psychological therapies such as CBT in ABI (e.g., King, 2002). In this group, no patients reported adverse psychological effects. However, given the novelty of the intervention and the lack of rigorous research of its application in this population, the authors advocate due caution and considerable monitoring particularly with individuals who have complex pre-injury mental health histories, especially when combined with emotion dysregulation as a result of frontal lobe damage. In this study, three patients were deemed to fall under this category but no adverse psychological effects were observed or reported by these or any of the other patients.

Limitations Limitations of this study need to be acknowledged. Firstly, this is a naturalistic evaluation and secondly it is limited by its sample size. Therefore, caution needs to be taken in interpreting the results of the outcome data. Specifically, the small sample size means that the data presented are likely to be prone to problems with Type I and Type II errors (Button et al., 2013). In order to investigate the effectiveness of this intervention with this population, a rater-blind, randomized, well-controlled trial is required before any conclusions regarding efficacy and harms can be made. We also acknowledge that our interpretation of the qualitative data is shaped by our training in psychology and we recognize that the themes identified in this study are open to support or refutation by other researchers. In addition, measures were taken in the first week of the programme and given that the first 5 weeks of the programme primarily consisted of education on brain injury and only limited CFT intervention was conducted prior to this stage, which means that baseline measures are limited in terms of extrapolating if changes are attributable to CFT or some other factors of neurorehabilitation, including in particular the psycho-education prior to the CFT group intervention, as this was not evaluated. Furthermore, we did not monitor the frequency and duration of CMT practised by the individual patients, additional research is needed to explore the contribution of CMT practice on positive change in this group. Finally, although the group selected struggled with significant self-criticism and problems soothing the self, their mental health symptomatology was relatively moderate and, therefore, it is difficult to generalize these findings to those with severe mental ill health after ABI.

Future research The concepts and clinical application of CFT have yet to be explored in depth with people with ABI. It would be useful to investigate further the experience of shame and self-criticism in this population to understand the nature of these emotional experiences and responses in relation to the ABI. One key area to consider is the development of formal measures of shame and self-criticism. In addition, investigating the fear of compassion in this group would be helpful, as it has been suggested that the fear of compassion may affect a patient’s engagement and response to treatment (Gilbert, McEwan, Matos, & Rivis, 2011). In relation to the efficacy of CFT with this population, RCTs are required.

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Clinical implications This study provides some key insights into the practice of psychotherapy with survivors with ABI facing psychological difficulties. Our patients described feelings of anger, disappointment, a sense of loss, and self-criticism (threat system focused) but, with CFT, they are able to focus on kindness, validation, and support (soothing system focused), which could offer a different means for affect regulation. Our patients reported that this approach gave them a sense of mastery over their emotions and that the formulation, which included neurological implications of the injury was important in facilitating their understanding and empathy of their struggles. This study provides further evidence that key underlying processes such as shame and self-criticism are present for ABI survivors and they need to be explored in clinical assessment and where evident, need to be targeted for psychological intervention. Furthermore, as highlighted by Ashworth et al. (2011), within the assessment and formulation process, CFT offers a novel and compelling way of conceptualizing psychological difficulties after brain injury. In particular, given that CFT incorporates neuroscientific and neurophysiological factors into its model of affect regulation, it translates usefully for those with ABI where neurological damage is likely to affect such systems. As one participant stated, ‘I had a tricky brain before my brain injury, but now I have an even trickier one’. Thus, CFT with its understanding of neurobiological aspects of emotion regulation can facilitate the process of making sense of the link between emotional difficulties and the consequences of the ABI, which can be lacking in other psychotherapeutic approaches. From an intervention perspective, there are a number of points we wish to draw attention to. The first is that, by its very nature, experiences of shame and self-criticism are threatening. This means that, within the psychotherapeutic process, an individual’s threat system may be activated and self-protection strategies employed, leading to resistance. Working with this resistance in psychotherapy is key, as is addressing barriers to reducing self-criticism and shame. Secondly, our experience of working with clients using CFT has highlighted how important the philosophy of ‘it’s not my fault’ and the ‘tricky brain’ is for them to move through a therapeutic process. Furthermore, the training in building the soothing system using CMT offers a structured and contained approach which is ever important in working with clients’ where cognitive abilities such as executive functioning can be compromised (Ashworth, 2014). Therefore, it is vital that therapists working with people with ABI give due consideration to cognitive adaptations to support the psychotherapeutic process. Finally, it is important to draw emphasis to ABI as a long-term condition as survivors are constantly faced with challenges and, with this in mind, it is easy to see how developing compassion can be a key tool in coping with such challenges across their life span. Conclusions This study of CFT in a naturalistic setting with a heterogeneous group of brain injury survivors provides some preliminary evidence for the feasibility, value, benefits, and suitability of CFT for those with brain injury. However, further research is needed before any firm conclusions can be drawn about the efficacy of the approach.

Acknowledgements The authors are grateful to the two reviewers for their comments on the manuscript. The authors would also like to acknowledge and thank all the staff and service users involved.

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