This is a naturalistic study, reporting basic data obtained in the clinic as routine procedure. The patients have given their consent to participate in group treatment based on CFT principles. As a standard procedure, treatment was evaluated using standard measures. Prior to start patients received oral and written information. This study was a register study using data obtained as part of the standard treatment.
The group size was 10–12 participants. This size was selected to ensure the group’s viability and to create the best conditions for the therapeutic process. The reason for being two therapists throughout the programme was the possibility of discussing group processes and creating dynamic sessions by switching therapist during sessions. Additionally one therapist would be able to leave the group for a short while if a participant felt unwell and had to withdraw.
Each group had 10 weekly sessions plus a follow-up session.
The inventories used are standard measures in CBT treatment.
Beck depression inventory
The BDI is a familiar, 21-item scale for measuring depression in clinical populations. Beck et al. [27,28,29] provided a major review of the psychometric properties, and outlined various recommendations and guidelines regarding the use of the BDI.
Beck anxiety inventory
Beck Anxiety Inventory (BAI)  is a 21-question self-report inventory. It measures the severity of physical anxiety symptoms. Final scores can fall into the Normal, Borderline, Clinical, Mild, Moderate, Severe, Extreme range for anxiety.
Rosenberg self-esteem scale (RSE)
The RSE  is a widely used 10-item measure of self-esteem (e.g., “I take a positive attitude towards myself”). It has high test–retest reliability and good internal consistency .
The psychiatrist assessed and diagnosed every participant, using ICD10 criteria, prior to treatment. The assessment consisted of a thorough examination of the course of illness together with a specific focus on early life events; and specifically self- critical statements and shame- based memories. If the psychiatrist noted high levels of shame and self-critic, the patient was found suitable for the CFT-group and received an oral introduction of the CFT treatment paradigm. If the patient accepted, she referred him or her to group therapy after one or more consultations. A large proportion of the participants had previously received various forms of psychiatric and/or psychological treatment.
The exclusion criteria coincided with the more traditional, general criteria often used for group therapy. Examples of such criteria were active abuse, active psychosis and acting out behaviour.
The patients consecutively signed up for group therapy. Therapy was launched when a group-size of 10–12 participants was reached.
In the first and last session, patients rated themselves using Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI) and Rosenberg Self-Esteem Scale (RSE).
Each group course consisted of 10 weekly two-hour sessions with a break halfway through, and after one or two months an additional follow-up session.
The treatment protocol
The overall structure of sessions two to ten is as follows:
Discussion/review of previous session
Discussion/review of homework
Theme of the day
Discussion/review of new homework
Content of individual sessions
The group settles and there is a mutual introduction, including presentation, group purpose, and group rules. After exploring peoples’ hopes, fears and motivation for being in the group, the therapists present the fundamental ideas of CFT. This includes the new brain/old brain problem, common humanity, the importance of attachment, and the fulfilment of basic needs from the perspective of psychological development. The therapists outline The three affect regulation systems , highlighting the importance of anxiety-reducing safety strategies. Lastly, grounding is established through mindfulness meditation in the form of Soothing Breathing Rhythm. . The participants discuss, in pairs, possible obstacles to doing the homework, which consists of a daily soothing breathing exercise guided by audio file. It is important to acknowledge Fears, Blocks and Resistance arising in the meeting with compassion and address these emotions /reactions already from the early stages of treatment.
The group settles. There is a grounding exercise using Soothing Breathing Rhythm. The group discusses anxiety, fears, and worries from a psychological and biological perspective. Illustrations outline the mechanisms of anxiety. There is a focus on the prefrontal cortex, the limbic system and the role of different brain structures (i.e. the amygdala and hippocampus). The therapists highlight the similarity between the physical reactions associated with experienced threats, and imagined threats. Conditioning is mentioned as one possible psychological factor in the development of anxiety. After a break, a new exercise – Safe Place  is introduced. The aim is to give the people the sense that inner images of a soothing nature can have an immediate physical and emotional effect. Some might find it challenging or impossible to create such images. Therefore, it is important to adopt a ‘playful’ rather than performance-oriented approach to the exercise.
Finally, the group reflects on the human motivation system, distinguishing between motives and emotions categorized as threat-focused, drive / reward-focused and soothing/contentment-focused. The affect systems constitutes a preliminary case formulation. People reflect on how they experience the balance between the affect systems. They present specific situations that influence the individual systems. Homework is to meditate doing the soothing breathing rhythm and safe place exercises and to make a note of situations where the threat protection system, the drive system and the soothing system, respectively, is predominating.
After settling, the session is set about with the exercise Safe Place with Stone. The stone is a conditioning object. The aim is to enable people, over time, to get into contact with their safe place by touching the stone. They share experiences of visualising their safe places and of overcoming the obstacles that some may encounter during the exercise. There is a focus on the participants’ experiences from their homework dealing with the affect systems. They reflect on their discoveries and experiences, outlining specific factors that affects the balance between the systems. Besides situations associated with the drive and safeness systems participants identify trigger situations affecting the threat system. The Compassion model  is introduced during the second part of the session, firstly by running through the theory in dialogue with the group, emphasising the complexity of the concept of compassion, both attributes and skills. Secondly, the exercise – The Compassionate Self  is presented. The purpose is to encourage an experience-based understanding, using techniques from method acting. During this exercise, the participants create an image of themselves at their compassionate best. The focus is on developing a compassionate attention, thinking, feeling and behaviour linked to the affiliative soothing system. Finally, participants use their own examples of trigger situations as a basis for working compassionately with their negative and self-critical appraisals. Exercising the compassionate self and working compassionately with trigger situations are the participants’ homework.
After settling and Compassionate Self Meditation, the focus is mainly on peoples’ work with trigger situations. Using personal experiences, the group rehearse compassionate reappraisal  of negative thoughts associated with trigger situations. They do not engage in challenging self-criticism directly. During this exercise, it is vital to demonstrate the difference between a compassionate approach and for instance a more rational and reserved response. Some participants may not find their reappraisals soothing or helpful, perhaps because these are self-critical in content and tone. Some may experience fears and blocks towards compassion. It is very vital to notice and address these issues in the group. The homework assignment is to identify trigger situation and rehearsing a compassionate approach to negative thoughts and emotions.
Besides the regular elements of settling, meditation and homework, the emphasis is exercising compassionate letter-writing . The group splits up into smaller groups, and people are asked to read a not particularly compassionate letter. Using their experience from the previous sessions, they draw up a more compassionate draft. They share their drafts with the whole group. Again, vital elements of compassion are highlighted, not least the compassionate tone of voice. As well as meditation, the participants’ homework consists of writing a compassionate letter to themselves.
After settling and meditation, the group summarises homework, i.e. the compassionate letter writing. People are encouraged to read their compassionate letters to themselves aloud to the group. In some cases, one of the therapists may read the letter at the participant’s request. Again, the tone of the letter, both in writing and reading is clearly crucial to the emotional and physical reactions experienced . The therapists invite people to express their emotional reactions to the letters read aloud, and call explicitly for their compassionate feedback. After the break, people try to identify external sources of self-critical thoughts, and in this connection, the idea / concept of the critical self/ the inner critic is introduced . The fundamental assumption is that no one is born self-critical and that self-criticism will always come from external, experience-based sources. People share their individual reflections on the external sources that shaped their inner critics, for example parents, siblings, teachers, and classmates. During the last part of the session, the group considers the function of the inner critic, it’s advantages, as well as it’s disadvantages. They all engage in the exercise The Good Teacher and the Bad Teacher, by giving examples of qualities associated with a good and a bad teacher respectively. The aim is to make out whether the self-critical stance is helpful or not. In addition to meditation, the participants’ homework is to continue working with the sources of self-critical thoughts.
Following the regular elements, including settling, meditation, and review of homework, the group is introduced to the Threat/Safety Strategies Formulation . Using a pre-printed example of a woman with a rather traumatic background, the group discusses how the past has affected her, with regard to her schemes and key fears. The group identifies her possible safety strategies and discusses the subsequent positive and negative consequences. A case formulation can only embody part of a person’s story, and no-one’s story can fit in a sheet of A4 paper. It is important to point this out. The goal of creating a case formulation is to give people a chance to gain greater insight into the background for and the possible unintentional consequences of their safety behaviour. This includes viewing safety behaviour as an entirely natural and probable response to traumatic childhood experiences and the subsequent fear of rejection and exclusion. In the last part of the session, the participants work individually on their own case formulation and complete it as part of their homework. During case formulation work, participants may experience an entirely understandable grief at the conditions to which they have been exposed and the consequences of these conditions. It is important to see, acknowledge, and handle these reactions appropriately and compassionately.
After settling, meditation and homework review, the focus is on reviewing peoples’ experiences with their case formulation homework. Some will be willing to share their formulation with the group. Again, the other participants’ compassionate responses to the person presenting a case formulation are of very great importance. Some may identify with the case- story; others may react emotionally to the often very harsh and austere life stories. Working with case formulation proves to be a highly effective illustration of the fact that the common human condition entails a life with challenges and suffering, albeit to various degrees. Using Paul Gilbert’s expression ‘it’s not your fault but it’s your responsibility to change it’ and the personal case formulations as a basis, people are encouraged to articulate a more compassionate mind set: “How would I like my interpersonal relations to be?”, “What would be a more compassionate view of myself, others and the world?” “Can I hold an image of this in my mind’s eye?” “What new rules for living and strategies would be most appropriate in that connection?” “How can I build up my motivation and my strength in order to pursue the new goals?” In addition to meditation, homework is to focus on and practise the new strategies.
Following settling, meditation and homework review, the main theme of the session is the construction of a Compassionate Image . As well as people can have inner mental images of a threatening nature, they can also create mental images of a compassionate nature. People acknowledge that the qualities of the new brain – the ability to create soothing mental images, for instance – will reinforce the safeness-soothing system, thereby reducing anxiety and worry. Firstly, people reflect on which traits and sensory qualities they individually associate with soothing and safety. They then describe in writing their own Compassionate image, which could be, for example, a person or animal that has these sensory qualities (i.e. a specific scent, colour, appearance, texture and voice). The compassionate image should also possess strength, wisdom and courage together with a deep commitment to enhance the person’s wellbeing. The session closes with a meditation during which the Compassionate Image is visualised. Some may find it hard to imagine a compassionate image during the first try. It is therefore important to stress that this is a process fostered by a playful approach.
The homework consists of meditation incorporating a Compassionate Image. The participants are also encouraged to use the Compassionate Image as a discussion partner for tasks such as compassionate letter-writing and compassionate reappraisal when in trigger situations.
After meditation and homework review, the participants work with Fears, Blocs and Resistance to compassion . Therapists have addressed this topic on an ad-hoc basis in the other sessions, but this session focuses explicitly on this issue. As well as working together in a group, the participants reflect in pairs on potential barriers and possible ways of overcoming them. The group then makes up a list of behavioural initiatives people could launch in the future to stimulate their safeness system, as well as discusses the possible barriers and ways of overcoming these.
Exercise using a compassionate Image follows the break, and the participants then reflect on f their take home messages from the group sessions and share them in plenum. Loving-kindness meditation (metta)  and final statements about the group course from all group members conclude the last session.
Follow-up (11th session)
The follow-up session begins with a meditation, after which the group engages in a plenary discussion; each group member describes his or her experience of working with compassion during the relatively long period since last session. People point out specific barriers and obstacles. The group has an opportunity to repeat exercises and meditations from various sessions. At the end of the session, participants individually reflect on how they could each hold onto a compassionate perspective in the future.