Integrating Metta Into CBT: How Loving Kindness and Compassion Meditation Can Enhance CBT for Treating Anxiety and Depression

Negative Self-Views, Self-Criticism, and Shame in Depression and Social Anxiety

Conceptually, due to their focus on promoting a kind, accepting view of oneself and others, these interventions particularly resonate with disorders characterized by self-criticism and shame (Gilbert & Procter, 2006), anger, and hostility (Hofmann et al., 2011). The experience of shame and self-criticism is transdiagnostic, prevalent in disorders such as depression, social anxiety disorder, psychotic disorders, PTSD, eating disorders, and personality disorders (Gilbert, Pehl, & Allan, 1994; Thompson & Waltz, 2008).

For instance, in depression, the classical cognitive-behavioral model (Beck & Alford, 2009) emphasizes the role of negative core beliefs related to oneself (worthlessness/ helplessness, unlovability), which further lead to a strain of negative automatic thoughts supporting the depressed, negative affect. Depressed individuals thus often have a harsh, critical attitude towards themselves, which is difficult to change. In this sense, studies have found that self-coldness (i.e., the reverse of self-compassion, including self-judgment, isolation, and over-identification) is a strong predictor of depressive symptoms in the general population both cross-sectional and longitudinally, over a period of 1 year (López, Sanderman, & Schroevers, 2018). Also, depressed outpatients score lower on self-compassion as compared to never-depressed participants, even when controlling for depression levels, with symptom-focused rumination and behavioral avoidance mediating the relation between self-compassion and depression (Krieger, Altenstein, Baettig, Doerig, & Holtforth, 2013). Self-compassion also predicts subsequent depressive symptoms in clinical patients, while depression does not predict self-compassion (Krieger, Berger, & Holtforth, 2016), and the relation between self-compassion and depression appears to be mediated by emotion regulation skills (Diedrich, Burger, Kirchner, & Berking, 2017). Additionally, personality traits such as dependency (the tendency to rely excessively on other people and their approval) and self-criticism are related to depression severity scores in clinical (Luyten et al., 2007) and remitted depressives (Mongrain & Leather, 2006), and constitute independent predictors (Luyten et al., 2007).

Similarly, socially anxious individuals display low self-esteem, high self-criticism, and dependency, with self-criticism as the strongest predictor of social anxiety symptoms (Iancu, Bodner, & Ben-Zion, 2015). Also, people with social anxiety disorder show lower levels of self-compassion when compared to healthy controls, and within group, self-compassion is related to fear of negative and positive evaluation (Werner et al., 2012). Additionally, shame and shame-proneness (the tendency to experience shame frequently) are particularly important in social anxiety disorder, being associated with social anxiety symptoms even after controlling for levels of depression and guilt (Fergus, Valentiner, McGrath, & Jencius, 2010). Following psychological intervention, changes in social anxiety symptoms are further associated with decreases in shame proneness (Fergus et al., 2010).

Emotion Regulation and Negative Self-Schemas

Emotions can be regulated intrapersonally (Hofmann, Sawyer, Fang, & Asnaani, 2012) or interpersonally (Hofmann, 2014; Hofmann & Doan, 2018). Strategies that involve other people are interpersonal emotion regulation and include strategies such as soothing and social modeling (Hofmann, Carpenter, & Curtiss, 2016). These strategies appear to enhance emotions by targeting the social self (Hofmann & Doan, 2018). An example of an intrapersonal emotion regulation is cognitive reappraisal (e.g., Hofmann, 2016), a strategy aimed to cognitively modify one’s perspective as to elicit an alternative emotional response (as conducted in the process of cognitive restructuring). It is usually less effectively used by currently depressed participants (Visted, Vøllestad, Nielsen, & Schanche, 2018). Possibly, this is because cognitive reappraisal is demanding on the executive functions, which are sometimes impaired in depression, or because cognitive change is incongruent with the depressive mood and its subsequent negative and ruminative thinking style (Gotlib & Joormann, 2010). Alternative accounts posit that depressive thinking is hard to change because although patients may logically understand that their thinking is distorted, they cannot embrace kinder, healthier views of themselves if they lack the emotional experience of being cared for. Many depressed patients report having been abused, bullied, or heavily criticized during childhood, and experienced little parental warmth. Self-criticism thus becomes a sort of inner voice, towards which the patient often assumes a submissive position (Gilbert, Clarke, Hempel, Miles, & Irons, 2004). Therefore, in these cases, the motivational system related to soothing and safeness appears to be “malfunctioning”. Usually, the activation of the soothing system (i.e. prompted by affection and safety signals perceived from others or oneself) deactivates defensive emotions (e.g., anxiety) and behaviors, and also turns off behaviors related to goal seeking, achieving, and acquiring, instead eliciting a state of calmness and connectedness. However, with depressed individuals, this system seems to be suppressed, possibly because its development was impaired at critical times in the past (Gilbert, 2005). In other words, depressed people have difficulty soothing themselves because the experience of being cared for is affectively foreign. This is why metta interventions could be particularly useful, since they do not aim to merely restructure negative self-views, but to create an inner experience of warmth and peace by promoting a qualitatively different kind of attitude towards oneself. Furthermore, self-criticism is highly prevalent in social anxiety disorder compared to other anxiety disorders, and remains at elevated levels even in people with history of social anxiety only (Cox, Fleet, & Stein, 2004). Also, people with social anxiety often have high levels of perfectionism and unrealistic social standards (Hofmann, 2007), intrusive self-deprecating thoughts, and hostility and paranoia (Hofmann & Otto, 2018), which combine with poor cognitive and emotion regulation strategies in the face of perceived threats and challenges, further complicating treatment (Flett & Hewitt, 2014). Cognitive models of social anxiety disorder also emphasize maladaptive self-beliefs (Clark & Wells, 1995; Farmer, Kashdan, & Weeks, 2014) as central to symptom development, like high standard self-beliefs, conditional self-beliefs (e.g., “If people see I’m anxious, they’ll think badly of me”), and unconditional beliefs (e.g., “I’m weak”). Similarly to depressed patients, individuals with social anxiety disorder also have diminished levels of positive affect due to lack of normative positive biases, unusual processing of positive events in the form of dampening positive affect, and lack of positive self-evaluations, which also contribute to living in a cold, harsh inner world (Farmer et al., 2014).

Efficacy of Metta Interventions in Depression and Social Anxiety. Can We Change the Inner Experience (Qualia) in Relation to Oneself?

Compassion-based (metta) interventions have been found to be effective in treating depression, anxiety, and shame, although the conceptualizations and treatment approaches are diverse (Finlay-Jones, 2017; Kirby, 2017). For instance, compassion-focused therapy (Gilbert & Procter, 2006) is itself a form of psychotherapy, including the functional analysis of self-criticism and safety behaviors, explicitly training clients in decentering from their inner self-critical voice, and using experiential techniques such as compassion imagery, compassionate letter writing, or the two-chair technique. Compassion-focused therapy has been found to be effective in increasing happiness and mindfulness and decreasing worry and emotional suppression in the general population (Jazaieri et al., 2014), as well as in schizophrenic, anxious, depressed, and disordered eating populations (see Graser & Stangier, 2018 and Kirby, 2017). Another type of compassion intervention, mindfulness-based compassionate living was administered online and was found to be effective in reducing depressive and anxiety symptoms in participants with high levels of self-criticism, thus pointing to its potential as a transdiagnostic intervention (Krieger et al., 2019).

As an emotion regulation strategy, self-compassion is similarly effective as reappraisal and acceptance in reducing depressed mood following a mood induction task in depressed participants, but the effect seems to be moderated by baseline levels of depression, in the sense that self-compassion appears to be more effective than reappraisal for more severely depressed participants (Diedrich, Grant, Hofmann, Hiller, & Berking, 2014). Also, even a short, 7-minute LKM exercise (i.e., imagining two loved ones sending their love to the participants) can increase explicit and implicit positivity towards strangers and implicit positivity towards the self, as well as positive affect (calm, happy, loving) when compared to a control condition (Hutcherson, Seppala, & Gross, 2008).

Regarding social anxiety, a recent study (Cȃndea & Szentágotai-Tătar, 2018) examined self-compassion as an emotion regulation strategy (i.e., for people with social anxiety) comparing self-compassion to cognitive reappraisal and waitlist. They found no differences at posttest between the groups, although the self-compassion group had significantly lower levels of shame-proneness and fear of negative evaluation at posttest compared to the pretest levels. Also, shame-proneness decreased from pre to posttest only in the self-compassion and cognitive reappraisal groups. Similar results had been previously obtained, showing that self-compassion and cognitive reappraisal as emotion regulation strategies are similarly effective in reducing self-conscious negative emotions (a combination of shame, embarrassment, shyness, guilt, and regret), and more effective than responsibility reattribution and control condition (Arimitsu & Hofmann, 2017). All these results suggest that metta interventions can qualitatively change the inner experience of oneself, thus fostering feelings of warmth, acceptance, and peace.

Positive Affect and Its Role in Depression and Social Anxiety: How Metta Interventions Can Help

The data previously presented suggest that being overly self-critical and exhibiting an inflexible vision of oneself are at the core of depression and social anxiety disorder. Therefore, metta-focused interventions may be particularly beneficial for treating these problems. According to the emotion dysregulation model of mood and anxiety disorders (Hofmann et al., 2012), apart from the enduring negative affect, both depression and social anxiety are characterized by deficiencies in positive affect (Brown, 2007), which are less specifically targeted by CBT protocols, potentially with the exception of behavioral activation. Increasing positive affect is especially important in depression and social anxiety since, apart from increasing well-being as proposed by the broaden and build theory (Fredrickson, 2001), it enhances behavioral repertoires, promoting approach behaviors to relevant situations (e.g., social situations, pleasant activities, new contexts and challenges), instead of the typical withdrawal and avoidance behaviors. Essentially, positive emotions extend the behavioral spectrum in reverse to negative emotions, which are associated with more circumscribed responses (e.g., withdrawal associated with sadness). When it comes to loving kindness and compassion specifically, the action tendencies that follow are those of interactional and interpersonal engagement, even if the emotional responses may differ between the two (happiness versus compassion), thus pointing to their unique contribution in alleviating depression and social anxiety (Hofmann et al., 2011). Metta meditation has the potential to increase positive affect, especially since it does not rely on transient, hedonic values, but fosters a deeper sense of kindness and connectedness (Hofmann et al., 2011, 2012). In this sense, meta-analytic results show that loving kindness increases the level positive emotions, potentially more so the peaceful and prosocial emotions, to a larger extent compared to compassion interventions (Zeng et al., 2015). This is not surprising, given the fact that compassion and self-compassion interventions stem from the experience and acceptance of suffering. Also, in a proof-of-concept study, loving kindness meditation, administered as a 12-session group intervention, was found to be effective for symptoms of dysthymia and depression, as well as for increasing positive affect (Hofmann et al., 2015).

Including Metta Interventions Into CBT

Apart from using them as independent interventions, metta interventions can be used adjunctively to CBT protocols in order to increase positive affect levels and to create an appropriate emotional climate for clients to easily accept the cognitive restructuring of negative self-schemas. Metta meditation can be time restricted as to accommodate typical CBT sessions, with the advantage of facilitating cognitive restructuring and potentially also increasing the level of positive affect. Metta interventions can be delivered as exercises in individual and group psychotherapy, practiced in the beginning or at the end of the CBT session, and then also as homework. We can also design interventions which include one or two sessions of metta interventions, then maintain the interventions as homework while the protocol proceeds as usual. Some authors also designed protocols where compassion-based sessions are introduced at the end of treatment, following the first standard CBT sessions (e.g., Asano et al., 2017). However, given that both loving kindness and self-compassion meditation are, like mindfulness, abilities acquired in time, it is essential to practice them continually. Nowadays, we can find various types of loving kindness and self-compassion exercises online, which is a useful resource for both patients and practitioners. Although we believe these interventions can be easily practiced by CBT trained therapists (with no additional credentials), exercising these abilities oneself, as well as advanced reading and practical training are important prerequisites. So far, few studies have tested the combination of CBT and metta interventions in clinical trials.

To date, experimental data has shown that adding a preparatory self-compassion exercise prior to a cognitive reappraisal task increases the efficacy of the latter in depressed individuals, thus providing encouraging results (Diedrich, Hofmann, Cuijpers, & Berking, 2016). That is, participants who practiced a self-compassion exercise (seeing oneself as from outside with a compassionate mindset) showed afterwards a greater reduction in negative emotions during cognitive reappraisal, following a negative mood induction task. These results point to the usefulness of metta interventions in facilitating cognitive restructuring, thus providing another argument for incorporating them into CBT.

Similarly, one of our ongoing studies aims to investigate how group CBT plus positive affect training (including mindfulness and loving kindness meditation) fares for people with low positive mood, irrespective of disorder. In this study, the protocol (12 sessions) introduces the concept and practice of mindfulness as an adjunct to forthcoming loving kindness meditation in the first two sessions, while the concept of loving kindness is introduced and practiced starting with session 3 (approximately 40 minutes). The following group sessions (4-12) begin with a brief 10-minute mindfulness exercise, then classic CBT techniques and exercises (e.g., thought record, cognitive restructuring, behavioral activation) are introduced, and followed by metta meditation (10 minutes) and debriefing (10 minutes), each time promoting a more challenging target of loving kindness (e.g., beloved friend, then someone neutral, etc.). Participants are also instructed to practice the meditation exercises at home.

Other studies have investigated the use of compassion-based interventions (i.e., not only meditation, but also exercises such as letter writing) in combination with CBT. For instance, a single group feasibility study tested the combination of CBT with compassion intervention sessions in depressed participants with good results (Asano et al., 2017). The protocol (10 sessions) used standard CBT and, in the last three sessions approached shame and self-criticism, memories of compassion, and compassion letters. Combining CBT with compassionate mind training in 12 sessions (combining imagery exercises with other techniques, like letter writing and grounding) was also shown to be effective for people referred to therapy as victims of traumatic incidents, with the CBT plus compassionate mind training scoring higher on self-compassion post-therapy (Beaumont et al., 2012).

Finally, we have to keep in mind the fact that some barriers may restrict the usefulness of metta interventions. For instance, individuals high on self-criticism often show a fear of compassion and self-compassion, because these states are experienced as unfamiliar and sometimes, as a sign of weakness (Gilbert, McEwan, Matos, & Rivis, 2011). Also, precisely because metta interventions foster a sense of calm and soothing rather than a more energetic kind of positive affect, they may appeal less to some people who value the latter kind of emotions more (Galante et al., 2014). In these cases, introducing other compassion-based techniques besides meditation could be helpful (e.g., two-chair technique with the critical and the criticized self).