Using Structured Compassion Focused Formulations Towards Change in Couples and Organisations

Tammy Lennox ¹, Angela Kennedy ^2,*

1. Clinical Psychologist in private practice, North Tyneside, UK

2. Clinical Psychologist and Director of Innovating for Wellbeing, Durham, UK

* Correspondence: Angela Kennedy

Academic Editor: Chris Irons

Special Issue: Compassion Focused Therapy (CFT) - New Insights and Outcomes

Received: May 04, 2023 | Accepted: May 26, 2023 | Published: July 20, 2023

OBM Integrative and Complementary Medicine 2023, Volume 8, Issue 3, doi:10.21926/obm.icm.2303030

Recommended citation: Lennox T, Kennedy A. Using Structured Compassion Focused Formulations Towards Change in Couples and Organisations. OBM Integrative and Complementary Medicine 2023; 8(3): 030; doi:10.21926/obm.icm.2303030.

© 2023 by the authors. This is an open access article distributed under the conditions of the Creative Commons by Attribution License, which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is correctly cited.

1. Introduction

• Understanding an individual’s response is enhanced by understanding the interaction between their survival strategies and those of their partner or the system that they are in.
• Compassion-focused formulations can be usefully adapted to work with couples or systems so that causality is more circular and more emphasis on the intersubjective creation of difficulties rather than the intersubjective experience alone.

2. The Nature of Formulation

A formulation is a way of framing a psychological problem within an evidence-based theoretical framework. A formulation framework seeks to provide clarity and understanding so that a way of addressing the person’s goals can be found. It is often done at the endpoint of an assessment to summarise the information about a person’s difficulties in an organised way. Different theoretical lenses create different perspectives and hence, can indicate different ways forward for the person. As well as describing difficulties, formulation should enable hypotheses to be developed about the links between a person’s vulnerabilities and history, to current difficulties, plus why certain maintaining factors are present and what function they might have for the person or group. Generating hypotheses in this way allows for testing out, examining and redefining, if necessary aspects of the formulation to see what factors might influence change. Psychologists and therapists use formulations to enable people to change their status quo for the better. Formulation highlights each person’s resources and strengths and clarifies the survival value of some problems in the context of their life [2] and points to the meaningful, adaptive and functional nature of “symptoms” in illness models of distress and mental ill health. Meaningful formulations often evolve as new insights come to light. They are therefore not definitive but represent a kind of truth and utility. In this way, different formulation frameworks can be useful at different time points or present different opportunities for change. The subjective truth in a formulation is important and as such be co-produced with the person. Engagement with the formulation is what motivates change. This engagement sometimes requires pragmatism and the humility of negative capability or ‘not knowing’. Insight and awareness can be both reassuring and provocative. Developing understandings that are within someone’s window of tolerance is critical. They need to present people with a new perspective but one that they recognise and can engage with. Finding ways of doing that with compassion, recognising the challenges that being faced with a mirror to one’s problems can present, is a skill. Therefore, the process of constructing the formulation is as useful as the content.

3. An Outline of a Compassion-Focused Formulation Framework and Its Comparison to Systemic Thinking

Compassion focussed formulations are one such theoretical lens and derive from the Compassionate Mind theory developed by Gilbert ([1,3] see Figure 1), where compassion is conceived as a motivation characterised by sensitivity and awareness of suffering or need followed by some wise action to address, alleviate or prevent the issue. This theory stems from concepts related to evolutionary psychology, attachment theory, Buddhist principles and neuroscience. It suggests that we can harness our innate capacity for affiliation and compassion and direct this courageously towards suffering to alleviate it. Gilbert [3,4] developed a compassion-focused formulation model for understanding problematic cycles that are driven by conditioning and shame within the individual. Such fears and impulses generate both automatic and planned safety behaviours with consequences for the person and those around them. The process of collaborative formulation seeks to bring awareness, de-shame these reactions and demonstrate what course of action would help alleviate the problem.

Figure 1 A basic compassion-focused formulation framework.

Compassion Focused Formulations are most usually used with individuals and hold to a psychological framework that is essentially intrapsychic. It deals with the workings of the person’s mind and the external influences on it. The CF formulation does consider the origins of each party’s thoughts, beliefs and behaviours, facilitating mentalising and empathy for the other. It also offers a means to enhance communication between parties, offering a language with which to discuss each person’s viewpoint, enlightening them to their communication cycle and highlighting their fears about how other parties might respond should they act differently to the norm. It does not explicitly illustrate cyclical patterns of interpersonal interaction from both perspectives that inadvertently reinforce difficulties in the way that some other formulations do [5]. Such interpersonal dynamics and intersubjectivity may add a dual perspective to the understanding of relational patterns that may be useful when working with someone in a context.

Systemic frameworks, for example, remove linear causality. They minimise the personal sense of failure by focusing on facilitating contexts that allow for growth. In this way, they are aligned with the values of CFT, where formulations also attempt to reduce shame and blame but increase personal responsibility for change. Where CF formulations highlight internal feedback loops, systemic formulations highlight the feedback loops that occur between parties. These maintain communication or relational difficulties that fuel distress: “over time members of a family come to form predictions, not only of each other’s actions, but also of each other’s thoughts, beliefs and feelings…. they come to form a web of mutual anticipation” [5,6]. This means that although each party may be presumed to be acting and thinking autonomously, in fact, they become caught in repetitive patterns of action. Importantly, what each person decides to do is understood to be shaped and constrained by others. Systemic therapies aim to facilitate communication and develop shared stories of people’s pasts and how this informs the way they interpret actions in the present [7]. Life scripts help to explain how previous experiences of relationships can impact the interpretation of events in current relationships e.g. one couple might differently view what one party calls “teasing” and perceives as “fun”, whereas the other party perceives this as “bullying” and “upsetting”.

4. The Application of Formulation to Work with Systems and Teams

In many psychological formulations there is space for the consideration of systemic factors, often understood as maintaining factors impacting individuals’ difficulties [8]. For example, a lack of family support may mean that it is difficult for the person to feel a sense of belonging, therefore maintaining a low mood and hopelessness. Another example might be the understanding that an individual depends on the service and noticing that the service has been drawn into this dynamic. In the latter example, it would be beneficial to understand why both the individual and the service is responding in the way that they are to be able to compassionately and appropriately respond to this for the benefit of both parties. It was these kinds of dilemmas that prompted a new application of a compassion-focused formulation to reflect its potential utility to describe what happens between people from both perspectives rather than just one. Johnstone and Dallos [2] do refer to the interaction over time between the client and the service as an important factor in team formulations. They highlight the important role formulation has in developing a psychosocial narrative and understanding more about the role of trauma and attachment drives brought by long-term patients. This helps the service to appreciate their contribution to the maintaining factors contributing to a person’s ongoing mental health issues. Gumley [9] too, notes that poor service engagement is not solely down to the avoidance of the client but that the way the service responds may be triggering the client to disengage.

Kennedy [10] used the Compassion Focused formulation to understand staff fears and survival responses to the task they have been appointed to while working in mental health. Such a formulation is based on the idea of social defences that supposes groups of people to behave en masse with characteristics prompted by the group anxieties. The compassion element presents the formulation in such a way as not to attach blame and accepts behaviours as efforts to survive the underlying fears presented by the situation. (For example, staff who have had a patient die through suicide may become risk averse, particularly if the review process raised fears that they were perceived to be failing in their duty in some way. The impact of this might be that responsibility is taken away from clients who then become disempowered and less able to protect themselves from their impulses).

5. An Interactive CF Formulation

In applying the CF formulation in practice onwards, it was noticed that sometimes, the ‘space between’ two parties often seemed to be a key maintaining factor. A systemic version of the CF formulation would appreciate the cyclical and interpersonal nature of our responses to threats and the interaction between our attempts to deal with this and that of the context. It could present the interface between two intrapsychic experiences simultaneously and the unique ways that difficulties are maintained by each other’s perceptions. Instead of simply examining the unintended consequences for the self, survival strategies may also prompt unintended consequences for the other and reinforce the other's key fears too. In this way, the feedback loop is not internal but rather fueled by the reactions of the other. This more interactive explanation could be applied to staff groups within a system, couples, families or individuals within their social context (see Figure 2). An Interactive and Intersubjective CF formulation model may expand the applicability of the Compassionate Mind theory by enabling each individual in a dyad to understand that their behaviours, stemming from their relationship themes, are understandable human survival reactions, based on the activation of attachment-related threats. This may enhance the alleviation of any external shame (i.e. the worry that others would globally condemn them) and promote compassion-based care-related motivations towards the other person by becoming aware of the impact of one’s reactions on the other person.

Figure 2 Intersubjective Compassion Focused Formulation: core circular maintenance cycle.

If the ‘self’ is a social construction and we are social animals, then our behaviours do not, therefore, exist in a vacuum. Our behaviour only makes sense in terms of our relationship with those around us. We come to experience ourselves through our experience of others. As such, an understanding of social systems can more accurately reflect the nature of our interconnectedness. Such an interpersonal (systemic) understanding can contribute to de-shaming through contextualising individual reactions so that responsibility is shared. Perhaps if we miss the interactive aspect of well-being, we risk causing further harm. An example might be a person diagnosed with depression, who reports feeling insecure in their relationship. The insecurity may be formulated as cognitions, locating the problem inside the individual. There may be a risk to the relationship by empowering the person to solve their problem alone or by leaving. Locating the ‘problem’ within themselves may fuel further self-criticism and low mood or blame and anger towards the partner. Working together with the partner on the impact of the partner’s behaviour e.g. distance, which may have a role in the person’s low mood, may define the problem differently. The problem may be located ‘between’ rather than ‘within’ them, that is, co-created as something intersubjective. The partner may also be reacting to something. By resolving the relationship dynamic together, both the person’s mood and their relationship may improve leaving them stronger.

6. Building the Formulation

Collaboration and co-production are at the core of Compassionate Mind work so that formulation building becomes a therapeutic process in itself. The process builds new connections in the mind, which help to calm and regulate us. New information comes to light that challenges old assumptions and beliefs. It illustrates how functional survival reactions can be. Realising the typical ways that our brains and bodies respond to situations engenders common humanity. Patterns emerge from the chaos. It names emotions and brings them into a space where they can be processed. It provides distance to enable an overview and clarity of a problem. It engenders trust in someone else as they bear witness to your dilemma with kindness. The formulation offers the potential discovery of different ways forward. All of this is healing in itself.

When building a formulation, a spirit of curiosity is required. Prompting thinking by using a coaching style can be useful. Perhaps some of the following questions could act as prompts for the four sections:

1. History: What adverse experiences have I had in my life? What themes are in my culture? What did I not have experience of that might have helped me develop differently? What characteristics do I have that may make me different from most other people? How has my physical ill health been challenged? What scared me or upset me the most?
2. Key fears and impulses: What is the worst thing that may happen if I don’t make this better? What does my self-critic say about me? What is the worst thing others may think about me? What does my body want to do when feeling at its worst? 
3. Survival strategies: What behaviour is causing me or other people problems? How did I react at the time of a trauma that is similar to now? How am I trying to cope?
4. Unintended consequences for self: What risks occur as a result of my reacting in this way? How are others reacting to me? In what way is this reinforcing my fears? In what way is this impacting on others?
5. Unintended consequences of my survival strategies for others: What have I assumed about the person? What does their reaction make me feel or think or want to do? What do I fear most about this situation? What does my critical mind say about their reaction?
6. Unintended consequences on me of the survival strategies of the other side of the dyad: What have I assumed about the other person’s behaviour? What did I think this meant for our relationship? What has this triggered in me?

Having the capacity to mentalise the mind and intentions of another is important in navigating the social world. Mentalising is “the process by which we make sense of each other and ourselves, implicitly and explicitly. It is a profoundly social construct in the sense that we are attentive to the mental states of those we are with,” [11]. Along with compassion, the ability to mentalise is closely linked to close and safe attachment experiences. Abusive early relationships have been shown to reduce a person’s capacity for trust and impact their ability to appreciate the motives of others. Therefore having a structure to understand the interplay between people, particularly if this is in vivo and co-created, can lessen tension and hence prompt motivation towards appreciating the other. It may also motivate people toward one’s responsibilities for others’ welfare as well as their own. Such mindfulness of mind and compassion for the other may be prompted by:

What do you notice in yourself now that you have a different understanding of the cause of the other person’s reactions? How does it feel to you to hear this? How does this new realisation change the way you are motivated to react? What might you at your most compassionate say about this situation between you both?

One example might be a young person who uses self-harm to numb insecurities, triggered by parents arguing. The arguments may be experienced by the child as dangerous. Maybe the child notices that the parents stop arguing with each other to focus on them instead after they self-harm. However, the arguing may be perceived by the parents as them resolving their differences without appreciating the worries this generates in the child. The child who uses self-harm to cope may be pathologised or blamed for increasing parental stress. The resulting focus on the child as the ‘problem’ does nothing to prompt reflection on their relationship. An alternative interactive CF understanding may lead to increased awareness and a sense of responsibility and so motivate a different way of dealing with parental disagreements.

Two examples of the application of the model follow. The examples were from clinical practice within an adult mental health inpatient setting.

7. Applying the Model

7.1 Two Individuals in a Relationship

An example of using the formulation with two people in a romantic relationship was chosen. “If a formulation “works” it will be a helpful and organizing concept for the couple, one that the partners will integrate into their understanding of the relationship and will help to diminish blame and criticism and increase their readiness for acceptance and change” [12].

7.1.1 Case Example 1

In this first example, the Intersubjective Compassion Focused Formulation was built with a couple, one of whom was an inpatient on a psychiatric ward and the other was their partner (see Figure 3).

Figure 3 Example of interaction between a two people.

Person 1 was admitted to an acute ward following increased violence towards his partner, due to “delusional jealousy”. Person 2, his partner was also a service user with a diagnosis of ‘emotionally unstable borderline personality’ disorder being supported in a community setting. The Psychologist met with the couple together and separately to build the formulation.

In this example, Person 2’s key fears may be being maintained by the coping strategies that she has learnt through experiencing violence and abuse from a young age. Such powerlessness, submission and avoidance are common reactions to abuse. This was elicited by asking “How would X coping strategy have helped you to survive when you were a child?” In this instance, the client replied “It was safer not to make any waves” and, “It helped me to block out the pain”. Such questions allow the client to make connections between their life experiences and their behavioural survival-based responses. Person 2’s key fears and self-blame (which developed through the experience of childhood abuse) are also perpetuated by her partner’s violence. She continues to believe and experience other people as frightening and controlling and she experiences guilt after arguments with her partner maintaining her sense of responsibility. She continues to believe that she is the reason why she has repeated experiences of violence in relationships, absolving her partner of any responsibility for his behaviour.

Person 1’s key fears of abandonment are perpetuated by the coping behaviours that he adopted throughout a violent and unstable childhood. As a child, violence was taught as a means of obtaining power and respect. The consequences of this, however, mean that he can frighten his partner and she often leaves him after he has been violent towards her. As a child too, he experienced frequent changes in caregiver, leading to him learning to expect that people will abandon him or reject him. This feeling is maintained when his behaviour results in his partner leaving him. He has learned to be very rank focused and he ends up feeling that he has lost power and is being manipulated by his partner by the frequent separations.

This compassion-based formulation was developed over two sessions with the couple after the assessment and enabled an honest, open discussion between them about the difficulties in their relationship. They stated that the formulation helped them to understand more about the origins of both their own and the other’s behaviour i.e. as survival responses to events in childhood. In this way, the process of formulation helped them to mentalise each other’s behaviours.

Following formulation, the couple were able to commit to each other to find ways to prevent the cycle from continuing. Such mentalising facilitated regulation and grounding in concern for each other. Importantly person 1 needed to commit to refrain from violence and recommendations were made for him to receive further therapy and support around managing his angry impulses. Another priority was to build activities that they could do together and individually. The formulation went some way to enabling person 2 to notice self-blame and instead, responsibility for the violence was placed back on her partner. At the same time, recommendations were made that she receive individual therapy regarding the trauma-related difficulties that she experiences. They were supported to develop a plan to reduce the physical violence including de-escalating the situation and giving each other space. This reduced conflict thereby reducing the likelihood of crises where person 2 would leave, further adding anxiety to her partner’s insecurity.

7.2 One Individual Within a System

The Intersubjective CF formulation can be especially useful when consulting with a team about a person receiving mental health treatment whose needs are considered complex by the team. Often Psychologists are called upon to formulate and reflect on cases where the treating team feels stuck. The formulation can also help leadership teams within NHS trusts to identify sources of threat among staff and consequential difficulties e.g. burnout, stress and sickness. Psychologists are recommended to be available where risk is an issue, such as in acute inpatient wards [13] and increasingly in liaison psychiatry [14]. The formulation is a Psychologist’s core skill and arguably one of the most time-efficient uses of the scarce psychological resource. The Intersubjective CF formulation could help psychologists in such contexts to focus care on psychosocial factors.

7.2.1 Case Example 2: Intersubjective CFT Formulation Applied to One Individual and the Health Care System

In this example, the person has health anxiety and multiple unexplained symptoms. She repeatedly presents to services, which have been drawn into doing further assessments and examinations, which is not having a reassuring effect on this lady (see figure 4).

Figure 4 Example of systemic interaction.

Here the service user frequently seeks reassurance from health professionals regarding multiple unexplained symptoms. She has been admitted to the hospital and frequently asks nursing staff to explain test results, noticing benign anomalies in her results. This lady’s anxieties may stem from the early loss of her mother due to illness, which may have shaped her fears about her health and mortality, as well as struggling to deal with bereavement. This may have led to an emphasis on the physical (which there is often a perceived solution for) as opposed to managing overwhelming emotions of loss. This is being maintained by her denial of the emotional issues but also services striving to find a physical explanation for her ailments. Unable to find any physical cause, services may inadvertently be reinforcing her fears that she cannot be helped and that there is something seriously wrong with her that just hasn’t been discovered yet. This too may be the key fear of the service and additionally avoiding a complaint of negligence against them (as has happened in the past). Therefore, they continue to refer her to more senior specialists to find the root of the problem, even though the cause of her physical symptoms seems to be somatisation and hypervigilance.

Such a formulation can enable an understanding of the complexities in the interaction of each party’s protective strategies and key fears. It can help to create a shift in an otherwise stalemate situation. It can de-shame the service’s attempts to help the person, offering explanations and ways forward. In this example, it would be wise to reduce the number of referrals and tests done, although each presentation would need to be assessed on its own merits, but within the context of this formulation. Then a risk assessment exercise could be performed which could help the service to determine whether the benefits of further tests and intervention outweigh the costs. Referral for psychological input may help develop a biopsychosocial formulation of the individual’s multiple unexplained symptoms and the links to early life factors. The formulation may enable the service user to understand that further tests may be reinforcing her anxiety and find new ways to cope when she experiences concerns about her health. The formulation offers a framework within which other more specific treatment models can be incorporated. For example, with this service user, the cognitive behavioural model helped the lady to progress forward using different behavioural methods of tolerating anxiety and self-soothing.

8. Conclusion

Looking at the interaction between two individual Compassion Focussed formulations is described in this article using a visual framework. It may be useful when seeking to understand the dynamics between and within systems whether individual to individual, or within wider contexts. By its very nature, the formulation is compassionate allowing individuals and groups to de-shame their problems, developing compassion for each party and therefore seeking to alleviate any unnecessary suffering created by such interactions. This then offers the starting point for compassionate affiliation building. By highlighting the coping strategies that are maintaining both the individual’s own, and the other party’s key fears and distress, insight can lead to change motivated by compassion for self and the other. There is increasing evidence that compassion-focused approaches hold significant promise as key therapeutic tools for individuals [15].

In Compassion Focussed Therapy, emphasis is placed on developing compassion in three directions or flows:

• Receiving compassion from others (other to self)
• Giving compassion to others (self to other)
• Relating compassionately towards the self (self to self)

This interactive framework can provide direction around how each party might achieve these flows. This would need to occur through showing compassionate behaviour towards each other and through developing the individuals’ own compassionate thinking and attention, to develop clearer mentalisation of the situation.

The formulation is limited, however, in that it lacks the scope for more than two parties or perspectives. Further exploration of how to include the perspectives of several parties, such as in families, could be beneficial. There is also further work to be done to test out how this model could map onto compassion focussed therapy and whether this could be achieved within the framework of couple therapy, as suggested. The benefit of the model is that recommendations for intervention can be made within several bio-psychosocial domains including medication, social engagement, marriage or staff counselling, or other types of psychological therapy. Often recommendations involve stopping a certain type of intervention, which may be maintaining the problem (as in the instance of the health-anxious patient in case example 2). Crucially the framework removes blame on any one party. Instead, the responsibility of learning and developing wiser ways of relating and responding to distress is shared and this is the cornerstone of this formulation.

Acknowledgments

We would like to acknowledge the work of Paul Gilbert and the lively discussions in the Compassionate Mind Foundations northeast supervision group.

Author Contributions

Both authors worked on the paper.

Funding

No sources of funding was gained for this paper. The paper reflects the clinical work at the time of employment which was with Tees, Esk and Wear Valleys, NHS Foundation Trust.

Competing Interests

The authors have declared that no competing interests exist.