Topic outline

• Introduction to self-compassion focused work with men who have been sexually abused: A guide for pracititioners
  

  Introduction to self-compassion focused work with men who have been sexually abused: A guide for pracititioners

  “Every moment presents us with an opportunity to bring compassion into our lives and give it to others. Every time we think a compassionate thought, direct kindness towards another person, relate warmly to ourselves and others, or bring to mind something that inspires our compassionate nature, we plant and nurture the seeds in our minds that will eventually grow into a garden of kindness and compassion (Kolts & Chodron, 2013).”

  Men who have been sexually abused as children can find it difficult to offer themselves compassion. They may see it as a weakness, or believe they are not worthy or deserving of compassion. Feelings of shame and perceptions of self-blame can result in self-criticism and self-loathing, and impact the way they relate to themselves and others. While this can offer a potential barrier to compassion, it is also the reason why it is worth doing. Self-compassion is a powerful antidote to shame and self-criticism, and can offer men a new way of understanding and responding to themselves, their experience and their relationships. Self-compassion can interrupt the cycle of shame and provide hope and encouragement for positive change. Practitioners have a valuable opportunity to both model and cultivate compassion for men who have experienced sexual abuse in childhood, and this module will help you know how to get started with this process. It provides information on what self-compassion is (and isn’t), its relevance for men who have experienced sexual abuse, and how to begin the practice of compassion. It will be written primarily from the perspective of Compassion-Focused Therapy (CFT), which views compassion as part of the motivational system towards pro-social and affiliative behaviour (including towards the self). Topics to be discussed include:

  1. How Self-Compassion Can Help
     
  2. What is Self-Compassion?
  • Definitions
  • What self-compassion is not
  • Key concepts
  3. Application
  • Qualities, skills and competencies
  • Fears, blocks, resistances
  • How to begin

  Note:  This eLearning Module is to be read in conjunction with the Living Well web page ‘Introduction to Self Compassion’ which highlights some of the specific struggles experienced by men who have been sexually abused or assaulted.  Both the 'Introduction to Self-Compassion' web page and this module were written and developed with the support of Lisa McLean (Psychologist).
• Section 1: How self-compassion can help
  

  Section 1: How self-compassion can help

  Shame and self-blame

  One of the most important and valuable ways self-compassion can assist men who have been sexually abused is by reducing shame and perceptions of self-blame. Trauma-related shame and stigmatisation are common impacts for people who have experienced sexual abuse, and have been identified as a contributing factor to the ongoing emotional distress and post-traumatic stress symptoms experienced by adult survivors (Finkelhor & Browne, 1985; Whiffen & MacIntosh, 2005).

  Early shame memories that become central to a person’s identity and life story are particularly problematic in terms of post-traumatic stress symptoms and ongoing feelings of shame (Pinto-Gouveia & Matos, 2011). It is therefore important that clinicians utilise interventions that specifically target feelings of shame, and offer clients alternative perspectives and strategies for understanding and responding to their experience. Paul Gilbert (2009) developed compassion-focused therapy specifically for this purpose. Gilbert observed that clients with high levels of shame and self-criticism (which he noted often occurred in the context of abuse histories) found it particularly difficult to develop adaptive affect regulation strategies, and identified the role of compassion in addressing this deficit (Gilbert & Procter, 2006). Preliminary evidence provides support for this observation, specifically within the context of trauma. A recent study utilising a 6-week compassion-focused intervention for trauma survivors (primarily relating to sexual assault), demonstrated significant reductions in feelings of shame and post-traumatic stress symptoms, as well as significant increases in self-compassion (Au et al. 2017).

  Shame can be experienced as external or internal (Gilbert, 1997). External shame relates to a belief that we are perceived negatively in the minds of others, and internal shame relates to negative self-evaluations. In both cases the evaluations are negative. For example, internal shame may develop in a man who has experienced sexual abuse in childhood if they blame themselves, or believe it was something they deserved, encouraged, or even enjoyed (in cases where they may have physically responded, or were coerced and manipulated into participation). External shame may develop if they believe they will be judged as weak and rejected by others if they knew about the sexual abuse. Both internal and external shame can be further reinforced by subsequent life choices and circumstances, such as addictive and risk-taking behaviours, problems with pornography, parenting challenges, and the breakdown of relationships. From an evolutionary perspective, CFT conceptualises shame as something that has evolved to ensure adherence to social norms and values. Shame may therefore maintain threat activation if we believe that we have violated social norms in some way, and may be discovered for doing so.

  This understanding may explain why the response from others following sexual abuse has an impact on post-trauma recovery. Negative responses will reinforce the threat of rejection and devaluation, while positive social support (including from a therapist) can provide reassurance to someone who has been abused that they continue to be accepted and valued. Self-compassion can offer a way for men who have experienced sexual abuse in childhood to provide this positive support to themselves.

  One of the key qualities for cultivating compassion is wisdom. This relates not only to the specific knowledge, skills and practices of compassion cultivation, but an understanding of our tricky human brains (see section 2) and how they have been influenced by factors out of our control. It is important that men are supported to recognise that the abuse and its impact was not their fault, but the result of factors such as evolved neurobiological functions, developmental processes, attachment dynamics, family and social context, and the manipulation of power. While it may be difficult to challenge long-held beliefs that support shame, self-blame, judgement and criticism, compassion-focused therapy works to patiently and gradually address these fears, blocks and resistances (see section 3) and facilitate a motivation towards more compassionate thought, feelings and action. 

  Too often men who have experienced sexual abuse see themselves as responsible for it in some way and the resulting shame can have debilitating and long-term effects. Practitioners therefore have an important role in motivating men not to take responsibility for the abuse they experienced, but responsibility for alleviating the impacts and improving their well-being and quality of life.

  “By habitually being self-critical and feeling shame, we remain trapped in the threat mindset and system. The only feelings we can experience in this state are those of anger, disappointment, anxiety, and disgust. (But) we do not have to live out the legacy of our childhood for the remainder of our adult life. There are steps we can choose to take to help us on our journey of recovery. It’s never too late to be who we want to be, but it requires us taking responsibility for ourselves and developing a deep commitment to reduce and alleviate our suffering and the suffering of others, with compassion.” (Deborah Lee, 2012, pp 110-111)

  Avoidance behaviours

  Cultivating self-compassion may also reduce experiential avoidance, which is a key perpetuating factor in post-traumatic stress (Kaplow, Dodge, Amaya-Jackson, & Saxe, 2005; Shin et al., 2015; Ullman, Townsend, Filipas, & Starzynski, 2007; Ullman, Peter-Hagene, & Relyea, 2014; Thompson, Arnkoff, & Glass, 2011; Palm & Follette, 2011, Polusny & Follette, 1995), and one of the diagnostic symptom clusters for Post-traumatic Stress Disorder (APA, 2013). Avoidance behaviours can include drinking, drug use, social withdrawal, gambling, use of violence, and anything else that actively prevents connection to trauma memories and their sequelae. The severity of avoidance has been shown to be negatively associated with self-compassion (Thompson & Waltz, 2008; Maheux & Price, 2015). In other words, the less self-compassionate someone is, the more likely they are to engage in avoidance behaviours.

  Men who have been sexually abused in childhood may find it too overwhelming to attune to and validate their emotional experience. They may engage in chronic avoidance for fear of becoming overwhelmed. Self-compassion may offer the strength and confidence required to respond to this experience in a positive and skillful way, and to support men to tolerate and respond to trauma-based stimuli with compassion, empathy, non-judgement and acceptance, reducing the need to rely on avoidance-based coping.

  Trauma symptoms

  A meta-analysis of compassion-focused therapy provided support for its potential to reduce symptoms of anxiety, depression, and psychological distress across a range of issues and conditions (Kirby, Tellegan & Steindl, 2017). More specifically, a recent study showed that self-compassion was associated with fewer symptoms of post-traumatic stress (Romano, Lyons, & St John, 2015) in men who have been sexually abused in childhood. Self-compassion may offer men an alternative way to respond to themselves, their experience and its impacts, and reduce negative mediating variables such as shame, self-blame, and avoidance behaviours. The authors of the study with men concluded: 

  The development of self-compassion may help individuals view their childhood sexual abuse experiences through a more helpful perspective, which may then facilitate the development of greater self-kindness and less negative self-perception and ultimately better mental health functioning (Romano, Lyons, and St John, 2015).
• Section 2: What is self-compassion?
  

  Section 2: What is self-compassion?

  Definitions
  

  Paul Gilbert (2014), the founder of compassion-focused therapy, defines compassion as:

  “The sensitivity to suffering in self and others, with a commitment to try and alleviate and prevent it”

  Gilbert also suggests that compassion flows in three directions:

  1. Compassion we offer to others
  2. Compassion we receive from others
  3. Compassion we offer to ourselves (self-compassion)

  Someone else who has made a significant contribution to the research and application of self-compassion is Kristin Neff. Neff (2003) has developed the Mindful Self-Compassion program and defines self-compassion as consisting of three components:

  1. Mindfulness — being able to maintain a balanced awareness of the present-moment experience of suffering without over-identification.
  2. Common humanity — understanding that suffering is part of the human experience, as opposed to feeling isolated and alone.
  3. Self-kindness — being able to respond to awareness of suffering with kindness rather than judgement or criticism.

  While there is some diversity in the definition of compassion offered by various frameworks, Strauss et al. (2016) identified five common elements:

  1. Recognition of suffering
  2. Understanding its universality
  3. Feeling sympathy, empathy, or concern for those who are suffering (including the self)
  4. Tolerating the distress associated with the witnessing of suffering
  5. Motivation to act to alleviate the suffering

  These core components suggest that supporting clients to cultivate compassion for themselves requires recognising and acknowledging their pain as part of the broader human experience, connecting to and be moved by this experience, and being able to tolerate and remain with the resulting emotional distress, at least long enough to utilise helpful and compassionate responses to alleviate it.

  What self-compassion is NOT

  There are a number of myths and misunderstandings relating to self-compassion, particularly for men. Self-compassion is often seen as a weakness, or something 'soft and fluffy' — exclusively belonging in the domain of women, and therefore not applicable to them. Men might question how self-compassion will help them, or believe it is letting themselves off the hook. However, when you consider the definitions of self-compassion, it is not at all a soft or easy option, and the motivation towards compassion takes incredible courage. As Deborah Lee, who specialises in the application of compassion-focused therapy for trauma explains:

  “Giving up blaming ourselves is crucial to our being able to move forward in our lives and to begin to heal ourselves from our trauma. This however, does not mean that we simply let ourselves off the hook or fail to take responsibility for how we treat ourselves and others. It’s quite the opposite, as we need to find a way to stop shaming, blaming, and criticizing ourselves for the things we have done, or the things that have happened to us in the past. This can mean we need to put ourselves ‘on the hook’ and take stock of what we fear, by facing our past, looking at our present, and choosing our future” (2012, p. 110).

  Self-compassion is also frequently confused with concepts such as self-esteem, self-pity, and self-indulgence. Kristin Neff addresses these misunderstandings and clearly explains how self-compassion is different. A summary of her responses can be found in Appendix A.

  Key concepts

  Compassion-focused therapy (CFT) is informed by a number of important therapeutic frameworks, including evolutionary psychology, social and developmental psychology, (especially attachment theory), and neuroscience. An in-depth analysis of the rationale and evidence for the underlying principles of CFT is beyond the scope of this module, (interested readers are referred to The Compassionate Mind by Paul Gilbert as a starting point), however there are a couple of key concepts that are important to understand before commencing compassion-focused work with clients (and yourself). 

  Evolutionary Functional Analysis 

  Evolutionary functional analysis is a way of understanding why and how our brains and bodies have evolved to respond as they do - in other words, how do our emotions, behaviours, and motivations serve our evolutionary imperative for survival and reproduction. This approach means that CFT seeks to understand concepts such as shame, self-criticism, and compassion from the perspective of their evolutionary function – why do these concepts exist in the first place? In an effort to formulate an understanding to this question, Gilbert has incorporated the idea of ‘Tricky Brains’ and ‘3 Circle Emotion Regulation Systems’ into the CFT framework. 

  Understanding our ‘Tricky Brains’

  In very simple terms, our brains consist of both ‘old brain’ and ‘new brain’ functions. In other words, there are parts of our brain which relate to basic survival, emotions, and attachment needs, as well as more highly evolved functions of the uniquely human brain.   

  
  

  While ‘new’ brain functions can facilitate highly complex cognitive tasks, and allow for fantasy, imagination, creativity, forward planning and remembering, they can also make recovery from trauma a lot more difficult for humans than for other animals.

  For example, if a zebra is chased by a lion in the wild, it will respond to this threat using ‘old’ brain functions. It will automatically, without any conscious thought, recognise the threat and its brain will immediately determine the most effective way to survive this threat.  

  Generally speaking, the options are to fight the lion, flee the lion, or freeze if neither of these options are available (and playing dead may cause the lion to lose interest). Once the threat has passed, the zebra’s brain will recognise that it no longer needs to be in threat mode, its body sensations will return to normal (breathing, heart rate, etc), and it will get on with grazing on the grass or whatever it was doing before the lion made its appearance.  

  The new brain functions of the human brain result in a very different experience. While the threat is present, the old brain will respond the same way and determine the most appropriate survival response for the situation. Once the threat has passed, however, humans generally don’t just get on with whatever they were doing prior to the threat. Because their brains can clearly remember and replay the trauma experience, fantasise about how they might have liked it to be different, imagine how it could have been even worse, or interpret and analyse in an effort to make sense of it all, it can keep the threat present in our mind long after it has passed. 

  
  

  It is this interplay of old and new brain functions that can explain many of the trauma symptoms experienced by sexual abuse survivors. The continual re-experiencing (flashbacks, intrusive thoughts and memories, nightmares); body sensations (rapid heart-rate, shallow breathing, butterflies in the stomach, jumpiness); efforts to make sense of the experience through perceptions of self-blame; feelings of anxiety, anger, and shame; and the effort to avoid any reminders of the trauma all occur because of the way our brains have evolved to respond to threat, and the inability of the human brain to switch this off after the threat has passed.

  In other words, IT IS NOT OUR FAULT that we respond in this way. Our brains have been created for us, not by us.  

  Our brains develop from biological processes out of our control, genes we did not choose, and the context we were born into and/or raised from. The evolution of the human brain, and its interplay between old and new brain functions makes it tricky for everyone. However, trauma can offer additional challenges, particularly when experienced in childhood. Understanding and learning how to work with this tricky brain is part of the compassionate wisdom that can guide and support us to reduce suffering.

  Three circles — Emotional regulation systems

  Consistent with an evolutionary understanding of our emotions, behaviours, and motivations, CFT suggests that different parts of our brains function to either support or inhibit compassion. In simplified terms, we have three primary systems for helping us manage and respond to emotions:

  1. The Threat System is responsible for threat monitoring and protection, and relates to feelings of anxiety, anger, and disgust. 
     
  2. The Drive System relates to feelings and behaviours of achievement & pursuing goals. 
     
  3. The Soothing System helps to manage stress, promotes attachment and bonding, and relates to feelings of safeness and contentment. 
     

  
  

  From: Gilbert, P. (2009). The Compassionate Mind. UK: Constable & Robinson

  When these systems are in balance, we are generally more likely to experience wellbeing and positive mental health. However, when these systems are out of balance, difficulties can arise. For many sexual abuse survivors, the threat system remains the most dominant, and the soothing system is often difficult to access. In fact, the soothing system itself may have become associated with threat if the people relied upon for care and comfort were also the people who caused harm. This experience can leave some people quite scared and mistrusting of any effort to seek or provide compassion for themselves. This is completely understandable and is one of the reasons why it is important to cultivate compassion gradually. For some men who have been sexually abused in childhood, chronic activation of the threat system may mean they are in perpetual ‘fight’ mode, ready to respond to any perception of powerlessness through anger and aggression. 

  The primary goal of CFT is to reduce the dominance of the threat system by enhancing the capacity of the soothing system through the cultivation of compassion, and to allow experiences of calm, safeness, soothing, contentment, and for a healthy motivation to achieve and succeed. 
• Section 3: Application
  

  Section 3: Application

  Core compassion-based skills and qualities
  

  CFT aims to cultivate a number of key competencies, all of which contribute to the two components of compassion articulated in the definition provided by Gilbert (see section 2). Specifically, the competencies relevant to the first component – attunement to and acknowledgement of suffering are (with explanations summarised from Kolts, 2016):

  • Sensitivity – Awareness of pain, suffering, struggle and difficulty.
    
  • Non-judgement – Relating to one’s experience with acceptance and without judgement.
    
  • Empathy – Making efforts to understand suffering as it exists from the perspective of the being that suffers.
    
  • Sympathy – A warmth, softening, or feeling moved by pain and suffering.
    
  • Care for well-being – A sincere motivation to prevent and alleviate suffering.
    
  • Distress tolerance – Ability to tolerate the discomfort that arises from working directly and actively with suffering. 
    

  “With compassion, we notice suffering, we are moved by it, and we want to help. In order to do this, we must work to tolerate distress, and to nonjudgmentally and empathically understand the causes and conditions that contribute to the suffering and difficulty” (Kolts, 2016, p. 29).

  The competencies relating to the second component of compassion – a motivation and willingness to act to prevent and alleviate suffering – includes (with explanations summarised from Kolts, 2016):

  • Compassionate thinking and reasoning - Relating to thoughts mindfully and cultivating compassionate ways of thinking, reasoning and understanding to generate skilful and helpful ways of working with suffering. 
    
  • Attention and sensory focusing – Cultivation of mindfulness and focusing attention in a way that calms the threat system (e.g. via breath and body awareness).
    
  • Imagery – Used as a technique to help generate ideas and affective states relating to what compassion looks and feels like. 
    
  • Compassionate feeling and emotion – Understanding and cultivating compassionate feelings of warmth, kindness, courage, affiliation and safeness.
    
  • Compassionate Behaviour – Compassionately motivated efforts to work skilfully with sources of suffering utilising range of tailored behavioural activation strategies.
    

  All competencies are developed within the context of three key compassionate qualities - WARMTH, STRENGTH, AND COMMITMENT.

  Fears, blocks and resistances

  It is imperative for any practitioner aiming to cultivate compassion with men who have been sexually abused in childhood to have an understanding of the fears, blocks, and resistances (FBRs) which may be present. Supporting clients to overcome these FBRs is central to the process and not something that can be simply mentioned in passing. The cultivation of compassion will not be possible if clients remain afraid of it. 

  There are many reasons why clients may be reluctant to cultivate compassion. For example:

  • Misconceptions about self-compassion – Some people mistake self-compassion for concepts such as self-pity or self-indulgence (see Appendix A for responses from Kristin Neff about how self-compassion is different). One of the biggest challenges in working with men is the misconception that self-compassion represents weakness and belongs in the domain of women. Therefore, it is very important to highlight the strength and courage required to turn towards suffering and act with wisdom to alleviate it.  
    
  • Poor relational templates – It is hard to offer yourself something you have never experienced. Practitioners have a critical role in modelling compassion to clients and themselves, and offering it as a safe, helpful, alternative way to cope and live. This is particularly important when responding to therapeutic issues that may perpetuate further experiences of shame, such as addictions, sex-related issues, and problematic relationships. 
    
  • Association with threat – If the person/people relied upon to provide care and compassion were the same people who abused and/or responded to care-seeking efforts with rejection and hostility, it becomes something not to be trusted. Even small, initial efforts to cultivate compassion may trigger a reminder of the absence of it throughout life. A compassionate response offered by a therapist can be triggering in this way, and there may be an initial rejecting and mistrust of this caring response. In Mindful Self-Compassion this concept is referred to as backdraft, based on the phenomenon whereby fire that is deprived of oxygen will become explosive when it is first exposed to fresh air. 
    
  • Perception of non-worthiness – A motivation towards compassion is influenced by an assessment of worthiness. Compassion is less likely if it is perceived that the person is responsible for their own suffering. Therefore, if clients believe they are to blame for the sexual abuse perpetrated against them, they will consider themselves non-deserving of compassion. Feelings of inadequacy and self-hatred have been shown to be associated with increase fear of compassion (Gilbert et al. 2011). Addressing perceptions of blame is therefore an important therapeutic consideration for removing this barrier to compassion.  
    
  • Low coping self-efficacy – It is important for practitioners to recognise that offering self-compassion means that suffering first needs to be acknowledged. As coping strategies often rely on doing the exact opposite to this (i.e. avoidance), it can feel very risky for clients to let go of this familiar, albeit maladaptive coping strategy.  It is therefore important that the skill of self-compassion is cultivated gradually and with regular practice, until clients develop the confidence and belief in themselves and their ability to tolerate the inevitable discomfort and pain that arises from acknowledgement of suffering.
    

  How to begin

  The most helpful and effective way to help clients cultivate self-compassion is to learn how to cultivate it yourself. Compassion needs to be experienced and embodied, and it is important that clients experience compassion offered and modelled to them as genuine.

  Websites/meditations

  In CFT there are a number of key meditation and imagery exercises which help to prepare the mind and body for the cultivation of compassion and provide a sense of what compassion looks and feels like.  Some of these can be found on the Compassionate Mind Foundation website in the ‘Resources’ section, and include:

  • Soothing rhythm breathing
  • Compassionate self imagery
  • Compassionate other imagery
  • Safe place (place of peace/contentment) imagery

  Mindful Self Compassion also utilises a number of key meditation and imagery exercises, many of which can be found on the founder’s websites - www.self-compassion.org (Kristin Neff) and  www.chrisgermer.com (Christopher Germer), including:

  • Affectionate breathing
  • Compassionate body scan
  • Loving-kindness meditation
  • Self-compassion break
  • Compassionate letter writing

  Compassionate Mind Australia keeps up to date with relevant training events and other useful practitioner resources, and you are able to join their mailing list to remain up to date.

  Videos

  There are also a number of useful video resources, including a freely available 4-part workshop by the founder of CFT, Paul Gilbert (links below). A video search for Kristin Neff will also generate a number of informative videos on Mindful Self-Compassion.

  Part 1:

  Part 2:

  Part 3:

  Part 4:

  Recommended books

  • The Compassionate Mind by Paul Gilbert
    
  • CFT Made Simple: A clinician’s guide to practicing Compassion-Focused Therapy by Russell Kolts
    
  • Recovering from Trauma using Compassion Focused Therapy by Deborah Lee
    
  • Experiencing Compassion-Focused Therapy from the Inside Out: A Self-Practice/Self-Reflection Workbook for Therapists by Russell Kolts, Tobyn Bell, James Bennett-Levy, and Chris Irons.
    
  • Self-Compassion by Kristin Neff
    
  • The Mindful Path to Self-Compassion by Christopher Germer
    

  “Probably the most important piece (for practitioners) is to practice committedly engaging in the various compassion practices that we intend to utilise with our clients… Doing this, we’ll see how challenging it is to create space for the practices in our lives. We’ll be faced with resistance that we’ll have to learn to work with. And we’ll see the benefits of cultivating compassion firsthand, giving us a deep understanding of just why the process is worth it” (Kolts, 2016, p. 43).
• References
  

  References

  American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC.

  Au, T. M., Sauer-Zavala, S., King, M. W., Petrocchi, N., Barlow, D. H., & Litz, B. T. (2017). Compassion-based therapy for trauma-related shame and posttraumatic stress: Initial evaluation using a multiple baseline design. Behavior Therapy, 48(2), 207-221. doi:10.1016/j.beth.2016.11.012

  Finkelhor, D., & Browne, A. (1985). The traumatic impact of child sexual abuse: A conceptualization. American Journal of Orthopsychiatry, 55(4), 530-541. doi:10.1111/j.1939-0025.1985.tb02703.x

  Gilbert, P. (1997). The evolution of social attractiveness and its role in shame, humiliation, guilt and therapy. The British Journal of Medical Psychology, 70(Pt 2), 113. 

  Gilbert, P. (2009). Introducing compassion-focused therapy. Advances in Psychiatric Treatment, 15(3), 199-208. doi:10.1192/apt.bp.107.005264

  Gilbert, P. (2014). The origins and nature of compassion focused therapy. British Journal of Clinical Psychology, 53(1), 6-41. doi:10.1111/bjc.12043 

  Gilbert, P., McEwan, K., Matos, M., & Rivis, A. (2011). Fears of compassion: Development of three self-report measures. Psychology and Psychotherapy, 84(3), 239-255. doi:10.1348/147608310X526511

  Gilbert, P., & Procter, S. (2006). Compassionate mind training for people with high shame and self-criticism: Overview and pilot study of a group therapy approach. Clinical Psychology & Psychotherapy, 13(6), 353-379. doi:10.1002/cpp.507

  Kaplow, J. B., Dodge, K. A., Amaya-Jackson, L., & Saxe, G. N. (2005). Pathways to PTSD, part II: sexually abused children. American Journal of Psychiatry, 162(7), 1305. doi:10.1176/appi.ajp.162.7.1305

  Kirby, J. N., Tellegen, C. L., & Steindl, S. R. (2017). A Meta-Analysis of Compassion-Based Interventions: Current State of Knowledge and Future Directions. Behavior Therapy, 48(6), 778-792. doi:https://doi.org/10.1016/j.beth.2017.06.003

  Kolts, R. (2016). CFT Made Simple. Oakland, CA: New Harbinger Publications Inc.

  Kolts, R. & Chodron, T. (2015). An open-hearted life. Boulder, Colorado: Shambhala Publications Inc

  Lee, D. (2012). The compassionate mind approach to recovering from trauma using compassion-focused therapy. London: Robinson.

  Maheux, A., & Price, M. (2015). Investigation of the relation between PTSD symptoms and self-compassion: Comparison across DSM IV and DSM 5 PTSD symptom clusters. Self and Identity, 14(6), 627-637. doi:10.1080/15298868.2015.1037791

  Neff, K. D. (2003). The Development and Validation of a Scale to Measure Self-Compassion. Self and Identity, 2(3), 223-250. doi:10.1080/15298860309027

  Palm, K., & Follette, V. (2011). The roles of cognitive flexibility and experiential avoidance in explaining psychological distress in survivors of interpersonal victimization. Journal of Psychopathology and Behavioral Assessment, 33(1), 79-86. doi:10.1007/s10862-010-9201-x

  Pinto-Gouveia, J., & Matos, M. (2011). Can shame memories become a key to identity? The centrality of shame memories predicts psychopathology. Applied Cognitive Psychology, 25(2), 281-290. doi:10.1002/acp.1689

  Polusny, M. A., & Follette, V. M. (1995). Long-term correlates of child sexual abuse: Theory and review of the empirical literature. Applied and Preventive Psychology, 4(3), 143-166. doi:10.1016/S0962-1849(05)80055-1 

  Romano, E., Lyons, J, & St. John, E. (2015). Male childhood sexual abuse, self-compassion, and trauma symptoms. International Journal of Child and Adolescent Resilience, 3(1), 34-51

  Shin, K. M., Chang, H. Y., Cho, S.-M., Kim, N. H., Kim, K. A., & Chung, Y. K. (2015). Avoidance symptoms and delayed verbal memory are associated with post-traumatic stress symptoms in female victims of sexual violence. Journal of Affective Disorders, 184, 145-148. doi:10.1016/j.jad.2015.05.051

  Thompson, R., Arnkoff, D., & Glass, C. (2011). Conceptualizing mindfulness and acceptance as components of psychological resilience to trauma. Trauma, Violence & Abuse, 12(4), 220. doi:10.1177/1524838011416375

  Thompson, B. L., & Waltz, J. (2008). Self-compassion and PTSD symptom severity. Journal of Traumatic Stress, 21(6), 556-558. doi:10.1002/jts.20374 

  Ullman, S. E., Peter-Hagene, L. C., & Relyea, M. (2014). Coping, emotion regulation, and self-blame as mediators of sexual abuse and psychological symptoms in adult sexual assault. Journal of Child Sexual Abuse, 23(1), 74-93. doi:10.1080/10538712.2014.864747

  Ullman, S. E., Townsend, S. M., Filipas, H. H., & Starzynski, L. L. (2007). Structural models of the relations of assault severity, social support, avoidance coping, self-blame, and PTSD among sexual assault survivors. Psychology of Women Quarterly, 31(1), 23-37. doi: 10.1111/j.1471-6402.2007.00328.x

  Whiffen, V. E., & Macintosh, H. B. (2005). Mediators of the link between childhood sexual abuse and emotional distress: a critical review. Trauma Violence Abuse, 6(1), 24-39. doi:10.1177/1524838004272543

  
  
• Appendices
  

  Appendices

  • Appendix A - What self-compassion is not Page