The image of compassion
On how compassionate imagery exercises may help with mental wellbeing and the barriers to doing so, which may be helped by role play or the use of natural stimuli.
Welcome to the latest Compassionate Nature article, which looks at recent research around how using compassion based imagery exercises may provide benefits to mental wellbeing and how using role play or nature based stimuli may be a helpful complementary approach.
“Imagination is more important than knowledge. For knowledge is limited, whereas imagination embraces the entire world, stimulating progress, giving birth to evolution. It is, strictly speaking, a real factor in scientific research.”
Writing in 1931 about the 1919 solar eclipse had supported his Theory of General Relativity, Albert Einstein uses the word imagination to represent our ability to consider how theoretical events might happen within reality. He had said similar in an interview in 1929 and often the quote is shortened to include the first sentence only which renders it a different meaning than the context Einstein meant it in.
Imagination is a powerful tool. It allowed Einstein to picture something that many of us struggle to understand which science then demonstrated was a valid interpretation of reality. In a way our imagination supports a version of personal time travel, allowing us to picture different futures and supports us in reviewing our past. It provides the ability to pretend to be someone else or see ourselves differently. Part of imagination is the ability of mental imagery, to be able to visualise places, events and people, which is something most people can do, with varying degrees of ease and accuracy. Interestingly for a small minority of people it appears to be impossible, a phenomenon termed aphantasia in 2015 by Adam Zeman and colleagues.
Personally I am a visual thinker and planner. This may be in part due to dyslexia, I find it much easier to plan things pictorially, using visual techniques. When writing a personal blog a few years ago I used imagery and metaphors a lot. The only time I really struggle with visualisation is when my wife asks me about a paint colour for a room and then it all goes blank.
Anyhow, you may now be wondering what mental imagery has to do with compassion?
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Some key exercises within approaches such as Compassionate Mind Training (CMT) utilise mental imagery, including imagining a safe, soothing space and visualising a compassionate other. These can be termed Compassion Focused Imagery (CFI) exercises. The idea behind using imagery is to help individuals identify compassionate attributes that a caring, nurturing other may present towards them and to work towards embodying those attributes themselves, especially with regard to self-compassion. Paul Gilbert (2017) highlights that imagery can help with both giving and receiving compassion, and that mental imagery can be more powerful than talking or writing as it can invoke related physiological effects. For example if you imagine a favourite edible treat it’s likely your mouth may start to water simply by just thinking about it.
The use of mental imagery by an individual and their ability to visualise can be hard to assess given it is principally reliant on self-report and undertaking CFI exercises can be challenging for some people. A couple of recent papers have helped to explore individuals experiences of using CFI to imagine a compassionate other, how this was helpful to them and the barriers they felt in doing the exercise. Before looking at those experiences, a systematic review from 2022 provides more insight into the evidence base.
Reviewing the image
Safir Maner, Paul Morris and Bethany Flewitt’s 2022 systematic review of the evidence base for CFI considered its effectiveness using different studies of clinical and non-clinical groups. The review covered studies published between 2020 and 2022 that looked at CFI as the primary intervention in aiding someone develop or enhance a compassionate view of themselves. The review included 20 studies, mainly from the UK, of which 10 covered non-clinical groups while the remainder related to different clinical groups. The majority, bar 3, were delivered as in-person interventions and 11 used a control condition as a comparison to CFI. Various self-report measures were used within 13 of the papers, covering psychological constructs such as self-compassion, self-criticism and self-reassurance. Physiological measures, such as heart rate variability (HRV), were also used in 6 of the studies.
Of the studies without a control condition, 5 found significant increases in self-compassion following CFI, with moderate to high effect sizes, with 2 also finding significant reductions in self-criticism and low mood. In the studies that did include a control condition, 7 reported significant improvements from CFI in comparison to the control, with decreases in paranoia and increases in self-reassurance, reductions in sense of shame and reductions in sense of disgust within the treatment of OCD. The studies relating to traumatic brain injury (TBI) found no significant effects from CFI. However the review highlights that out of the 15 studies where improvements were reported, 8 had no control condition. 4 studies also had a high risk of bias, principally as a result from issues around blinding.
Research geek aside - blinding within a study means that the participant does not know which study condition they are part of (single blinding) or neither the participant nor the researchers know which condition the participant is in (double blinding). Blinding, occasionally called masking, is important to avoid biases such as participant expectation effects or selective allocation and treatment of participants by researchers.
The review was also limited by not being able to undertake a meta-analysis of the available statistical results and highlighted limitations in the reporting methodology within some of the selected studies. The review suggests that CFI showed benefits to key psychological constructs which can be beneficial to mental wellbeing, especially with regard to self-compassion, self-criticism and shame. It also highlights that highly self-critical individuals or specific clinical populations may struggle with CFI.
Individual perspective and swapping places
As the systematic review highlights there can be barriers to individuals ability to engage with CFI. Two recently published and related qualitative papers perhaps help to understand this more based on research undertaken with an Improving Access to Psychological Therapies (IAPT) service based in Manchester in the UK.
Rachel Crone, Richard Brown and Tobyn Bell’s 2023 paper provides insight from individuals being treated for social anxiety. The sample included 8 participants who had yet to receive any other elements of Compassion Focused Therapy (CFT) and who undertook a single session of CFI to explore a compassionate other, sometimes called the “perfect nurturer”. The participants were aged 22 to 53 years old (average 33 years old) and all white British, with 3 males, 4 females and 1 who identified as non-binary. Based on participant interviews the qualitative analysis identified three themes. Firstly obstacles and resistance were described, with participants expressing various reactions towards the imagery exercise, including feeling silly, that it was irrelevant or feeling self-critical of how they were doing it and were not meeting expectations. These reactions did result in some participants adapting their approach, such as trying to worry less about how they were doing the exercise. The second theme related to how participants formed the image of a compassionate other, with some using humour or memories to help. Building the image of a nurturer often involved imaging different sensory attributes, for example the tone in which the compassionate other spoke. Some participants visualised the compassionate other based on someone they knew, which provided familiarity and reassurance, while others used an idealised image. The third theme was that CFI helped the participants with self-discovery, with 7 participants sharing that the exercise helped them identify and connect to their emotional needs more, along with being aware of how self-critical they were. The study did not report on the influence of CFI to their symptoms of social anxiety.
The use of role play may be helpful to support imagery and James Hackley and colleagues 2024 paper considered the role of CFI supplemented with chair work to support individuals with depression. Chair work is a psychotherapeutic technique where using different chairs to represent different parts of oneself can help, by encouraging the participant to move around and imagine discussions between the different versions or parts of themselves In this case the chair work supported the development of the compassionate other and by sitting on one chair the participant role-played that imagined presence. The sample consisted of 8 women, 6 of whom were white British, aged between 30 to 62 years old (average age 46). Based on interviews the qualitative analysis again identified three themes. The first theme was that participants sense of care towards them from the compassionate other felt more real by using the different chairs, which invoked a sense of receiving care and warmth from a comforting presence. Secondly the chair work enhanced the imagery exercise, making it feel richer and by moving from chair to chair helped to provide a different perspective. Some participants noted that it helped address self-critical thoughts, as the different chairs provided a sense of separation and in turn this enabled more embodiment of the compassionate other. The third theme related to challenges the participants felt, which included that chair work was hard and it initially felt weird and silly. Some of the participants felt it was hard to express compassion towards themselves. All the participants reported the CFI and chair work session was a positive experience which provided personal insight and a heightened awareness of compassion.
Both studies are small scale and provide subjective insights specific to the contexts they were held within. However I think they both provide insight into the way that CFI can be helpful and empowering, as well as the common barriers and challenges that people experience when trying it. Those challenges have implications for therapists to consider when using mental imagery exercises.
The addition of nature
Jasmiina Ryynanen and colleagues at Edinburgh 2023 paper brings in some nature to aid the use of mental imagery (the perfect combination for a Compassionate Nature article!), in this case supporting adolescents with their mental wellbeing. The rationale for the proof of concept study was to consider a way to help individuals who struggle with mental imagery due to high self-criticism or poor emotional regulation by presenting natural stimuli which also invoke mental imagery processes. The study was additionally informed by the soothing element of the emotional regulation model of CFT, with the use of nature based images and sounds guided by the results of the separate Project Soothe Young Citizen Science Project. The online study involved 88 participants, mainly males, aged between 13 to 17 years old (average age 15.6). The participants provided baseline measures of their mood, serenity, state anxiety and state depression before being randomly allocated to be presented with either natural images such as landscapes, listen to nature sounds or a combination of both stimuli. The same images and sounds were used in the conditions and the sounds were matched to the images. Each condition had 25 stimuli, with each stimuli presented for 30 seconds and the participants asked to rate the stimuli on a soothing scale of 1 to 7. After completing viewing the 25 presentations in the condition they were allocated to, the participants again responded to the mood and emotion measures to enable comparison to the baseline measurements.
The study results showed that overall 76% of the participants found the stimuli soothing and there was no significant difference between the conditions, all three provided similar benefits. Those benefits were significant reductions in negative affect, state anxiety and state depression along with significant improvements in serenity. No significant improvements were found in positive affect. Significance relates to statistical significance in the differences between baseline and post-stimuli measurements, with all the effect sizes found to be small. Overall the natural stimuli (image, sound or combination) appear to provide similar benefits, with perhaps some greater benefit noted to participants who reported higher scores on the anxiety and depression measures. It is a small scale, proof of concept study and there could have been confounding online factors which influenced the results. The authors note that the 30 second presentation was quite long, so further studies could explore different presentation times. There was no control condition either which a future study could employ. Taking those limitations and the results into account, the study suggests that using natural stimuli may be an approach which could be explored further as a way of overcoming some of the barriers and challenges individuals may face with mental imagery exercises such as CFI.
We don’t have to be Einstein to use our imagination. Mental imagery is a powerful part of our imagination, which can support us positively, such as helping to make plans, as well as catching us out through aiding rumination over past mistakes. Being able to harness imagery as a tool to help visualise a compassionate other, to support developing acceptance of receiving compassion and to help identify compassionate attributes towards oneself, can be powerful especially within the treatment of some mental health conditions. However using imagery can also be challenging, with the inner critic often placing barriers in the way. Using role play supported by techniques such as chair work may provide a sense of separation and perspective that helps overcome those barriers. Using natural stimuli to help foster a soothing, restorative sense as part of imagery exercises may also be a helpful approach.
Considering the support and comfort that a compassionate other may afford you can be a helpful way to foster greater self-compassion and address self-critical thinking. Visualisation and using mental imagery is one way to approach this.
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References
Crone, R. L., Brown, R. J., & Bell, T. (2023). ‘Like I'd been listened to without actually saying words’: Picturing the nurturer in compassion‐focused therapy. Counselling and Psychotherapy Research. https://doi.org/10.1002/capr.12730
Gilbert, P. (2017). Compassion as a social mentality. In P. Gilbet (Ed), Compassion : Concepts, research and applications (pp. 31-68). Routledge.
Hackley, J., Dixon, A., Royle, C., Moss, C., Brown, R., & Bell, T. (2024). “Seeing myself through someone else’s eyes”: Embodying the perfect nurturer in Compassion Focused Therapy. OBM Integrative and Complementary Medicine, 9(1). https://doi.org/10.21926/obm.icm.2401021
Maner, S., Morris, P. G., & Flewitt, B. I. (2023). A systematic review of the effectiveness of compassion focused imagery in improving psychological outcomes in clinical and non‐clinical adult populations. Clinical Psychology & Psychotherapy, 30(2), 250-269.https://doi.org/10.1002/cpp.2801
Ryynanen, J., MacLennan, K., Witten, E., Tipp, C., Wisdom, S., & Chan, S. W. (2023). Investigating the mood effects of nature sounds and soothing images in adolescents: A proof-of-concept randomised control pilot study. Wellcome Open Research, 8(433), 433. https://doi.org/10.12688/wellcomeopenres.19584.1