A Narrative Review of Compassion Focused Therapy on Positive Mental Health Outcomes

Background: Compassion-focused therapy (CFT) has been attracting attention in mental health practice and research. CFT is effective in reducing a variety of negative mental health symptoms. Positive mental health (PMH) focuses on an individual’s functioning, quality of life, and well-being, aiming to achieve fulfilment. A need for PMH has been increasingly recognised such as national policies incorporating recovery-oriented approaches. However, how effective CFT is for PMH outcomes remains to be investigated. This narrative review aimed to identify the literature that reports evidence on CFT used against PMH outcomes. Methods: Our research questions (RQs) were as follows: RQ1. What PMH outcomes are targeted in CFT intervention research? RQ2. Is CFT effective for PMH?” Medline, Embase, and PsycINFO were searched on the Ovid platform. All studies that mentioned “compassion focused therapy” and “compassion-focused therapy” were searched. Results: Sixteen RCTs were included published since 2012. Nine studies were from Europe, four from Asia, two from Northern America, and one from Australia and New Zealand. CFT was used for diverse PMH outcomes, and the effects were overall positive. Self-compassion and compassion were the most frequently evaluated outcomes. Conclusions: The mechanism of action for CFT on PMH needs to be evaluated. CFT can be used as part of personal recovery in mental health. More evidence from non-WEIRD countries including LMICs is needed.


Introduction 1.Compassion-Focused Therapy
Compassion-focused therapy (CFT) was developed by Paul Gilbert, aiming to reduce shame and self-criticism [1].Shame and self-criticism are detrimental components in many mental health problems including depression.CFT integrates cognitive behavioural therapy with components from other sciences such as evolutionary psychology, social psychology, developmental psychology, Buddhist psychology, and neuroscience [2].In working with clients, CFT involves psychoeducation focusing on compassion: compassion to others and to themselves (self-compassion).Compassion helps people regulate their emotions, leading to feelings of safeness, comfort and soothing.The key element of CFT is for the psychotherapist to have a compassionate mind to help clients experience compassion [3].
Despite its history being only about 20 years [4], numerous studies have reported the effects of CFT on mental health problems.A 2023 meta-analysis on clinical populations, based on 15 studies, found that CFT is especially effective for the improvement of outcomes such as self-compassion, self-criticism, depression, and eating disorders [5].Likewise, an early systematic review published in 2015 (n = 14 studies) reported that CFT was effective for mental health problems, in particular for self-criticism [6].Reviews about CFT for people with intellectual disabilities reported that CFT reduces shame and self-criticism and supports safeness, but the methodological reporting of the included studies was poor [7,8].Evidence suggests that CFT is effective in reducing mental health problems.
CFT is understood to address shame and self-criticism by activating our soothing system that is related to compassion, contentment and safeness [3].CFT's emotional regulatory systems present that our emotions are categorised into three systems: threat system, drive system, and soothing system.The threat system is related to emotions such as fear anxiety or anger.The fight-or-flight response is one common response when the threat system is highly activated, protecting us from various dangers.The drive system is related to emotions such as excitement or pleasure, as this system is about pursuit, resource acquisition, and achievement.In CFT, mental distress is thought to arise from the overuse of these two systems [3].When your threat system is foregrounded, you may feel anxious, fearful, or angry, then stressed.When your drive system is foregrounded, you may be temporarily excited about something you are pursuing, but if you do not obtain it, you feel ashamed and self-critical.On the other hand, the soothing system relates to contentment where we have no threats to protect ourselves from, and no goals that must be achieved.The soothing system can foster social safety, curb excessive resource-seeking and threatoriented behaviour, and promote feelings of safeness and contentment, which are strongly linked with mental health [9].Many CFT exercises aim to get in touch with the soothing system by developing a compassionate mind, hence a sense of safeness, contentment and calmness, which in turn can address shame and self-criticism.

Positive Mental Health
Positive mental health (PMH) aims to achieve fulfilment by promoting an individual's functioning, quality of life, and well-being [10].PMH is different from traditional mental health, which mainly focuses on the prevention and reduction of negative mental health symptoms including depression and anxiety [11].PMH helps people cope with daily life stress, have a meaningful occupational life, and connect with their community [12].Promoting PMH can prevent people from mental health problems, and facilitate recovery from mental health problems [13].
PMH can be categorised into two types.Hedonism attends to positive emotions and eliminates negative ones.Eudaimonism aims to achieve one's potential and to live well [14].Combining those two types, PMH is thought relevant to emotional, psychological, and social well-being.The six characteristics of PMH are as follows: (a) problem-solving and self-actualisation; (b) personal satisfaction; (c) autonomy; (d) interpersonal relationship skills; (e) self-control; and (f) prosocial attitude [15].These are essential to living well.Research about PMH is needed.
Despite the high need for both CFT and PMH, evidence for CFT on PMH has not been investigated in depth.Theoretically, it makes sense to think that accessing our soothing system, facilitated by CFT, will improve PMH outcomes.Indeed, CFT on self-esteem was investigated in a meta-analysis (n = 10 studies) [16].The effect size of CFT on self-esteem was medium.However, many other PMH outcomes remain to be explored.

Study Aims
This narrative review aimed to identify studies that report the effect of CFT on PMH.We chose this type of review to provide an overview of CFT on PMH, as it was a rather under-explored area [17,18].Our findings would be especially helpful (a) to CFT practition-ers and educators who aspire to apply CFT to PMH outcomes, and (b) to mental health policy-makers who need effective approaches for supporting PMH outcomes.

Materials and Methods
The design of this review is a narrative review.Our research questions (RQs) were as follows: RQ1: What PMH outcomes are targeted in CFT intervention research?and RQ2: Is CFT effective for PMH?" The inclusion criteria for articles were clarified using the PEO (Population, Exposure, and Outcomes) framework: (P) anybody, (E) CFT, and (O) PMH outcomes such as quality of life, well-being, fulfilment, and resilience.We retrieved these outcomes by reviewing systematic reviews on PMH [19,20].We did not specify the population because, as noted above, we were aware that this area of research was thin.Additional filters were randomized controlled trials (RCTs) and being published in English in a peer-reviewed journal.Table 1 summarises the eligibility criteria.Medline, Embase, and PsycINFO were searched from the Ovid platform as these databases were relevant to mental health and psychotherapy research.All studies that mentioned "compassion focused therapy" and "compassion-focused therapy" were searched using the multi-purpose function (i.e., "compassion focused therapy.mp.").Six hundred and ninety-three studies were retrieved by JB, which was reviewed by YK: 152 on Medline, 206 on Embase, and 335 on PsycInfo.Duplicates (n = 17) were then removed.The remaining 676 articles were title/abstract-screened by JB, after concordance established from reviewing 10% of the 676 article (68 articles) with YK.Forty-eight articles were deemed possibly includable, so were full-text reviewed by JB again after 10% (n = 5) concordance established with YK.Finally, 16 were included, which were confirmed by AME, MC, and AK.PRISMA flowchart is presented below (Figure 1).

Results
Sixteen papers were included (Table 2).
Overall, improvements were reported for most of the PMH outcomes.No significant improvements were found in self-reassurance, emotion regulation psychological well-being (PWB) for the general population in France [26], psychological flexibility and breastfeeding satisfaction for mothers of infants [31], motivation for intervention, empathy, self-compassion, and relaxation for people with severe head injury [45].
To answer our RQs, CFT studies targeted various PMH outcomes.Self-compassion and compassion were more common than the other outcomes (RQ1).CFT's effect on those outcomes were, in general, positive.Only 3 studies of 16 reported non-significant improvement in PMH outcomes.Effects on self-compassion and compassion were all positive, except for one study that evaluated self-compassion among people with severe head injury [45] (RQ2).

Discussion
This review evaluated CFT on PMH outcomes.Sixteen studies have been published since 2012.CFT was used for diverse PMH outcomes, and the effects were overall positive.Self-compassion and compassion were the most frequently evaluated outcomes.
Our findings can add new evidence to the CFT research landscape which predominantly focuses on its positive effect on a range of negative mental health outcomes [52].Our findings demonstrate that CFT is not only helpful in reducing negative MH outcomes, but also is helpful in improving diverse PMH outcomes such as resilience, self-reassurance, mindfulness, life satisfaction, well-being, meaning of life, quality of life, gratitude, and motivation.One possible explanation for this is that CFT allows individuals to access their soothing system.The soothing system is one of the three emotional regulatory systems of CFT and is related to the activation of the body's parasympathetic nervous system to induce a state of calmness, soothing, and safety [3].Recent studies report facilitating calmness and soothing are not only effective for reducing negative symptoms but also effective for improving PMH outcomes [53][54][55].This suggests that CFT can be used for nonclinical populations who want to augment their PMH resources [56,57].However, it is also important to note the cases where CFT did not improve PMH outcomes significantly in populations such as the French general population [26].Implementations of CFT in nonclinical fields may need to be further encouraged.
CFT also de-escalates the other two emotional regulatory systems: threat and drive systems [58].The threat system is a mechanism designed to detect and respond to threats in the environment.The threat system relates to our sympathetic nervous system, which prepares us for fight, flight, or freeze responses when faced with perceived danger or threat.The drive system is associated with our desires, ambitions, and motivations.The emotions that the drive system can bring include excitement, enthusiasm, and determination.These emotions are conditional to whether rewards pursued are obtained or not, and when not obtained, we will experience shame and self-criticism.CFT calms these systems down, which in turn can help us focus on PMH [3].Calming down the threat and drive systems leads to a reduction in negative symptoms such as shame and self-criticism, which result in augmented PMH outcomes [27].These two approaches-directly supporting PMH outcomes and calming down negative emotions-may illustrate how CFT supports PMH outcomes.These mechanisms of action need to be empirically evaluated.
CFT's effectiveness on PMH outcomes suggests its adaptation to personal recovery in mental health.Personal recovery in mental health is described as the subjective process of taking control of one's life (including one's symptoms), having optimism for the future and taking personal responsibility for one's own recovery [59].Many national policies such as ones in the United Kingdom, Australia, and Canada, highlight the importance of providing mental health interventions that are oriented towards personal recovery [60][61][62].Growing support for recovery-oriented interventions has been recognised by the World Health Organization, locating personal recovery as the guiding vision of mental health systems internationally [63].Compassion-based approaches can be used to facilitate personal recovery.For example, a randomised controlled trial identified that a self-compassionate writing intervention can improve self-rated self-compassion, proactive coping, mental health, and physical health [64].Moreover, a systematic review identified that compassion-focused imagery intervention studies often report improvements in self-compassion and positive affect and reductions in self-criticism, shame, and paranoia for both clinical and non-clinical adult populations [65].Outcomes such as improved coping, self-compassion, and reduced selfcriticism are similar to the outcomes of recovery-oriented interventions [66].Introducing compassion-based interventions, such as self-compassionate writing and compassionate imagery, to the public through recovery-oriented interventions may subsequently benefit personal recovery on a wider scale.For example, Recovery Colleges (RCs) are a globally used, recovery-oriented approach offering mental health education to the public [67,68].RCs can introduce compassion-based techniques and/or psychoeducation informed by CFT to help improve the mental health of people, including those who do not access conventional services.
More international studies are needed in CFT.Out of the 16 included studies, only 4 were from a non-Western country, having taken place in Japan and the developing country of Iran.This reflects the current landscape of mental health research where populations within Western, Educated, Industrialised, Rich, and Democratic (WEIRD) countries are overrepresented in social and behavioural science research, despite accounting for 12% of the global population [69,70].The overrepresentation of WEIRD data in social and behavioural research contributes to a culture of "fundamental attribution error" where there is a disregard for behaviours being intertwined within one's cultural context, in favour of attributing behaviour to individual personal traits [71].This error relates to our tendency to interpret other people's behaviour based on their personality or internal qualities while ignoring the influence of situational factors [72].Self-compassion is governed by various cultural practices and group norms [73].For example, in some Asian cultures, high levels of self-criticism and low levels of compassion have been attributed to notions of selfimprovement being a function of shame [74].In some low-and middle-income countries (LMICs), in order to sustain their daily living, contentment may not be valued in the same way as it is in high-income countries.CFT evidence from non-WEIRD countries needs to be collected.
Especially CFT evidence from LMICs is valuable.Eighty percent of the global population who have mental disorders live in LMICs and researchers expect depression (which often encompasses shame and self-criticism) to be the third leading cause of mental distress in LMICs by 2030 [75].While interventions to reduce negative symptoms in LMICs have been proposed [76], how to augment PMH in people in LMICs is under-researched.Simple, low-cost, and self-help CFT exercises such as letter writing, can be recommended to support PMH of people in LMICs.Digital tools can be used to facilitate this process and have been shown to be useful in LMICs [77].
Limitations of this review need to be noted.First, this was not a systematic review therefore only three databases were searched, and a quality assessment for the included studies was not carried out.Our aim was to provide an overview of CFT on PMH, so a narrative review was chosen as the design instead of targeting more specific outcomes (e.g., a meta-analysis published during this review that evaluated the CFT effects on compassion [78]).Second, grey literature and studies in non-English languages were not included.The authors were not aware of RCTs in the effect of CFT on PMH outcomes in any other languages.Third, three studies reported [26,31,45] non-significant results.As those studies were heterogeneous, we were not able to further discuss them; how-ever, future research can explore outcomes, populations and contexts where CFT does not work.Similarly, weaknesses of CFT such as unidentified mechanisms of actions or components [79] were not considered in this review.Finally, all authors were researchers and/or practitioners in mental health.We might have missed an uncommon influential factor in mental health research.

Conclusions
This review evaluated the effect of CFT on PMH outcomes.Diverse PMH outcomes were targeted in CFT studies, where self-compassion and compassion were the most common outcomes.Overall positive effects were reported.CFT's mechanism of accessing our soothing mind may help explain its effect on PMH.CFT application to recovery approaches and implementation in various settings need to be developed in future research.Our findings will help researchers and practitioners to understand the current status of CFT on PMH, and to plan future research and applications.