Acceptance and Commitment Therapy (ACT), with its core principle of acceptance, has much to offer those who are suffering from a chronic health condition (see this article). One of the core skills used in ACT to help you step out of the negative spiral of dirty distress and shift your attention to meaningful activity is “Mindfulness”. In this article, I will explain how mindfulness is used with compassion to manage negative thoughts, feelings and emotions so that they do not stop you living a life you value.

Mindfulness
While mindfulness has been a part of the Buddhist tradition for over two and a half thousand years, it was only brought to the world of psychotherapy in 1979 by an American medical professor and author - Jon Kabat-Zinn. He integrated mindfulness into a treatment program (Mindfulness Based Stress Reduction) to successfully help people manage chronic intractable pain.

Kabat-Zinn defined mindfulness as “paying attention, on purpose, in the present moment and without judgment.” So, it is a form of meditation that cultivates focused attention on present moment experiences with full acceptance of whatever arises – including awareness of pain. The power of mindfulness is now being realised as more and more studies are finding evidence supporting the effectiveness of mindfulness to help people cope with anxiety, pain, depression, and chronic illness. Scientific research has also found that regular mindfulness practice can enhance immune functioning, decrease reactivity to stress and increase positive states of mind. 

Self-Compassion
One of the more powerful recent developments in therapy for me over the last decade has been Compassion Focused Therapy (CFT), developed by an English psychology professor – Paul Gilbert. Professor Gilbert has highlighted that we are often harshly critical of ourselves for things that are not in our control, in a world that is very challenging with a mind that is often chaotic and easily triggered into distress.

CFT aims to help you cultivate a compassionate resource within yourself to help you manage these realities. Although it has gathered momentum over the last decade, developing compassion for ourselves and others has its roots in the Buddhist teachings, as found in Loving Kindness meditations. Loving kindness practices are now being integrated into psychotherapy because of their power to transform suffering. 

Chronic Health Conditions and Grieving
When managing chronic health issues, it is helpful to be aware of the stages of grief outlined by psychiatrist Elizabeth Kübler-Ross. While she identified these stages in her work with people suffering from a terminal illness, they were later found to be just as relevant for those grieving for the loss of health in a chronic illness. You may have observed in yourself the Denial (“maybe they got it wrong, maybe it will go away”); Bargaining (“maybe I can fix it with this vitamin or that alternative approach”), Anger (“why do I have to have this ...it’s not fair”); Depression (I can’t do X, Y or Z anymore) and finally Acceptance (“It is what it is. I can make room for this, and live a full life around it”).

However, it is important to keep in mind that these stages are not just moved through sequentially and in this order – it is a back and forth movement and the feelings may arise at any time and in any order. Also, as grief is a very personal experience, not everyone experiences all the stages, and each stage can last for minutes to months to years, depending on the individual.

What makes grieving even more difficult is that your ailment may also be progressive, or have additional associated health conditions that may appear further down the track. Consequently, just when you think you have accommodated this illness, the goal posts are moved and there is more you have to find a way to live with. And there you are feeling angry or denying or bargaining again.

Use Self-compassion to Step Back from the Struggle
As mentioned in a previous article, when managing a chronic illness it is very common to find yourself struggling to “get rid of” it or to control it, which only makes matters worse. Knowing that grieving is a normal process of coming to terms with a chronic illness will help you to step back from it and notice the struggle, rather than stay in the struggle. Mindfulness can also assist you with disengaging from the struggle and having compassion for yourself in this process is vital.

This may be most relevant when you find yourself feeling angry and frustrated about your medical condition and your inability to control it. As I have said, anger is part of the normal grieving process in the face of losing health and managing limitations you are confronted with. However, as there are no suitable external targets for this anger, you may turn this anger inwards, feeling angry at yourself, or your body, for letting you down or creating this illness.  You may be criticising yourself for not being able to do more or cope better.

This is where Compassion Focused Therapy (CFT) can be invaluable. Instead of blaming yourself, CFT helps you to cultivate a “compassionate-self” by imagining what you would say to a dear friend if you wanted to be compassionate and caring towards them. Connecting to this compassionate-self can turn on the areas in your brain associated with self-soothing instead of self-criticism. The self-soothing system in your brain can be activated by speaking to yourself in a kind inner voice with caring words and using a loving facial expression with some gentle touching or patting of your face or body (our brains are intrinsically wired to be soothed by these actions). 

This compassionate-self would be like a caring buddy who can be with you 24/7 to support you at difficult times.  A part of you that is committed to your well being and has the wisdom to know and remind you that this is not your fault, and you are doing the best you can in a life that can be very challenging.  

Just imagine for a moment, what it would be like to go through life with a reliable, compassionate and caring companion by your side. That is exactly what CFT offers you. We are all told that you cannot be truly loved until you learn to love yourself. In the same way, I would say you cannot truly come to terms with a chronic illness until you learn to develop compassion – truly, deeply – for yourself. 

Appreciate what you can do
Another key to managing a chronic health condition is being mindful and appreciative of want you can do, rather than focusing on what you can’t do.  So, after kindly acknowledging the difficulties you are dealing with, this compassionate-self could also help you to shift your focus away from what you can’t do, to appreciating your body and the millions of things that you are still able to do. Bringing an attitude of gratitude to your daily life, and ‘counting your blessings’ in the midst of your limitations will help you through. 

This does not mean that you shut out your grief. You still need to allow some time to feel the loss and anger and shed some tears.  But then you will be more able to shift your focus and re-engage with the present and do something that you find meaningful or pleasurable.

I remember once being on a beautiful beach in the Whitsundays, but being unable to walk along it as I had an episode of plantar fasciitis (a painful foot condition). It was such a beautiful cloudless sunny afternoon that I did not want to miss out. So I got down on my knees and crawled along the beach and found the most beautiful tiny shells hidden amongst the washed up seaweed that I would never have seen otherwise. I was able to fully focus (mindfully) on the sand and shoreline, enjoying the colours, and textures, and really savoured this moment in time. I collected the shells in a bag which I keep in my office to remind me of being mindful of the small positive joys that may otherwise be overlooked in the midst of limitations and distress.

Mindfulness, Self-Compassion and Pain
Mindfulness can be used in one of two ways to manage pain or other unpleasant body sensations. Initially you may use it to assist with moving your attention away from the feeling onto more rewarding aspects of your present moment. Using your senses, you may shift your focus from the disagreeable sensations and worries, to more pleasant sensual experiences like tasty food, enthralling music, the smell of a flower, feeling a hug, stroking a pet, or looking at a beautiful sunset. You may also shift your attention to think about what you value and decide how you want to act in the present moment with the discomfort.

With more advanced practice in mindfulness and self-compassion, you will be able to observe your unpleasant sensations with curiosity and kindness. Subsequently, you will notice any thoughts, sensations and emotions as they arise, without trying to change them or condemn them. Rather, you will have the capacity to sit with them, describe them as they are in this present moment, and watch them come and go with compassion for yourself. Repeated practice will enable you to become more open to them and to give up the struggle and judgements that would make them worse.

To allow you to experience this with some guidance, I invite you to go to this website where you will find a range of free downloadable Loving Kindness meditations. One of my favourite meditations is the one by Mary Brantley (under Additional Guided Meditations) and is called Lovingkindness for the Body. This meditation is particularly soothing as it combines mindfulness with an attitude of gratitude and loving kindness. 

Changing your Brain
Psychologists have long known that what you pay attention to will change the way you experience your environment.  Recent studies have revealed that what you focus your attention on repeatedly over time can also ultimately make long lasting changes in brain pathways and structures. Just like building and maintaining muscle strength can be done with repeated weight lifting, repeated activation of certain brain pathways will create, strengthen and maintain them. Thus, regular self-compassion and mindfulness meditation will make changes in your brain. This will mean that what was initially a state of mindful awareness, acceptance and self-compassion, can become more of an enduring way of relating to yourself.

Again, it is similar to training with weights so that you can play a sport better. While you may not notice the benefits at the time (and it may even feel tedious), it is when you are out on the playing field later that you appreciate the time you have put into training to build up that strength.  Thus, I encourage you to put the time into a regular mindfulness and self-compassion practice (even if it is just a few minutes each day pausing to observe your breath and then wishing yourself well). If you put the time into developing this part of your brain, you will then have access to a resource that will allow you to maintain a degree of equanimity in the face of flare-ups and all the other challenges that come with chronic health conditions. 

I have just returned from a three day training in Compassion Focused Therapy (CFT) with Professor Paul Gilbert who founded this ground breaking therapy. CFT uses understandings of the evolution of our brain and how the brain works to harness a powerful resource we all have within us. This resource will allow you to manage negative emotions and transform the way you relate to yourself and others. What is this resource? You guessed it - Compassion.


Three brain systems
In CFT, we learn that our brains have evolved to have three different systems to help us manage our emotions and feel better. They are:
1. The “threat system” which puts us into the mode of threat detection and self protection. It is associated with feelings of anger, anxiety, disgust, blame, shame and sadness. 
2.    The “reward system” which involves excitement and craving and feeling better by pursuing, achieving and consuming.
3.    The “caring soothing” system which involves compassion and kindness and facilitates calming of distress and feeling safe through connecting and relating with nurturing others.

These systems operate in different areas of the brain, and have different neural pathways which involve different neurotransmitters. This leads to particular patterns of feelings, body sensations, thoughts and behaviours associated with each system. They will all feel different in the body and we can all activate them by using our imagination. 

Choice
We all have access to these different systems at any time.  However, our default state is to be in the “threat system”. Our western society gives us the message that the way to solve this and be happy is to shift into the drive system of competing, consuming and achieving. CFT highlights the alternative system we have access to, of caring and kindness to self and others. With practice, we can learn to master the art of choosing which system we activate.

For example, we can learn to shift modes from defensiveness and anger to self soothing with compassion and being kind to ourselves. This will calm us down so we are not so overwhelmed, and can then engage with the world in a way we aspire to be.  If our way of self soothing is to routinely shift into the reward system of compulsive eating or working, we can train ourselves to shift into the mode of compassionate behaviours and thoughts towards ourselves.

In some situations, we do want to be protecting or achieving. The question is, if you could develop the skills, which one would do you choose to activate - which would serve you best in which situations? Which system offers you the most benefit when dealing with the challenges of life? 

How to develop skills so you can choose
We have the capacity for great cruelty, aggression as well as caring and kindness. What we focus on can shape our brain as it will activate certain brain circuits. For those of you who have grown up in a home characterised by criticism, any form of abuse (or absence of nurturing, protection or guidance), the compassionate system may be under-developed, with the threat system being highly developed. For example, you may have become highly self critical as a way of monitoring yourself to avoid stirring the anger of abusive parents. This helped you to survive and is not your fault.

The good news is that because the brain is neuroplastic  you can strengthen the caring, connecting system by practising compassionate and loving kindness meditations. And this is what CFT is all about. 

Wisdom, Strength and Commitment
The compassionate resource of CFT is not wishy washy, weak or self indulgent. It is a powerful presence that combines three attributes - wisdom, strength and a commitment to your well being:

Wisdom
Your compassionate resource has the wisdom to know that our minds are (as Professor Gilbert says) “tricky....complex and chaotic, dangerous and crazy”. We have evolved to crave, to love, to grieve, to fear, to be defensive and aggressive, to compare and strive to be better than others, with a negativity bias to noticing deficiencies and threats. And our brains seek permanence in a world of impermanence where we will ultimately lose everything we care about.

Moreover, we inhabit a fragile body, and are subject to all kinds of random adversities and health issues. And who we are is a function of the genes we inherited and the environment we grew up in – both out of our control and not our fault. Your compassionate resource knows all of this and that we are all trying to do the best we can with what we have in the midst of this challenging life.

Strength
Your compassionate resource comes from a grounded, present centred place in the body which is strong. It is solid, like a mountain. It is a resilient part of you that has been able to tolerate great distress and has persevered in the face of many difficulties.   

Commitment to your well being and happiness
Your compassionate resource is totally committed to be as helpful to you and others as possible. It has a genuine desire for you to have a joyful life and to nurture your personal growth and inner peace. It delights in the idea of you being free from suffering. It understands and validates your feelings.

Compassion Focused Therapy Techniques
CFT involves developing your compassionate resource and then learning (through particular therapeutic exercises) to identify, understand and disengage from the part of us that criticises and puts us down (i.e. the “Inner Critic”). This approach differs from some other therapies which set up a struggle with the Inner Critic by trying to get rid of it or argue with it. 

As the compassionate resource has the powerful combination of wisdom, strength and commitment to your well being, it is the better authority when it comes to running your life. So it is the authority you can trust when it comes to deciding who to believe – the self critical thoughts that deflate you, or the kind thoughts that enable you to engage fully with whatever life throws at you.

CFT and ACT
CFT melds very well with Acceptance and Commitment therapy (ACT) which also aims at detachment from negative thinking so you can do what matters to you. In CFT, compassion is not to soothe away negative feelings, but to help you be with the pain that is inevitable in life. As with ACT, this allows you to engage fully with life in the midst of painful feelings, so that you are not overwhelmed by what is happening at the time, and you can take life affirming actions.

Surprise yourself
The compassionate pathways in the brain can be activated by using your imagination (in guided visualisations), with a loving body posture, tone of voice and facial expression and kind words to get into a state of compassion, the way a “method actor” would.  Repeatedly activating these pathways with daily practice will lead to you developing a resource that may surprise you one day when you hear a loving kind inner voice soothing you at a time of distress.  It will seem like a voice, coming from out of nowhere, that is wise, strong, and committed to helping you and nurturing your personal growth.

What if I can’t do it?
For many of you, allowing yourself to receive compassion will be very challenging. You may feel you do not deserve kindness and compassion.  Do not give up, as repeated practice will eventually over ride old learning. You may have to fake it until you make it - one of the few times it’s appropriate!  As a start, rather than sending yourself peace and happiness, Professor Gilbert suggested the words “May the part of me that resists compassion for myself find peace”.

Try this for a couple of weeks, just three or four minutes a day and then re-evaluate.  A good time is just before sleep and upon awakening – a great way to start your day. You may also consider seeing a therapist to help you with this if you find yourself struggling.

Free audio guides
I invite you to use my free loving kindness meditation mp3 to guide you in developing your own compassionate resource and begin to transform your relationship with yourself and others. For additional free audios to help you develop compassion, see Paul Gibert's , Kristen Neff's or Chris Germer's websites on compassion. For even more  free loving kindness audios by a leading psychology professor who has done ground-breaking research into how love and other positive emotions enhance your life, go to  Dr Barbara Fredrickson's website here.