“Cultivating the Conditions for Safeness”: An Exploration of Patient’s Experiences of a Compassion Focused Group Psychotherapy Program for People with a Diagnosis of Personality Disorder

Katherine Lucre ^1,*, Neil Clapton ², Paul Gilbert ³, Chris Jones ⁴, Alex Copello ⁴

1. Birmingham and Solihull Mental Health Foundation Trust, 52 Queensbridge Road, Moseley, Birmingham, B13 8QY, UK

2. Avon and Wiltshire Mental Health Partnership Trust, Bath NHS House Combe Pk, Bath BA1 3QE, UK

3. University of Derby, Kedleston Rd, Derby DE22 1GB, UK

4. University of Birmingham, Birmingham, UK

* Correspondence: Katherine Lucre

Academic Editor: Marianna Mazza

Collection: Compassion Focused Therapy (CFT) – Advances and Innovations

Received: October 11, 2025 | Accepted: April 10, 2026 | Published: May 12, 2026

OBM Integrative and Complementary Medicine 2026, Volume 11, Issue 2, doi:10.21926/obm.icm.2602016

Recommended citation: Lucre K, Clapton N, Gilbert P, Jones C, Copello A. “Cultivating the Conditions for Safeness”: An Exploration of Patient’s Experiences of a Compassion Focused Group Psychotherapy Program for People with a Diagnosis of Personality Disorder. OBM Integrative and Complementary Medicine 2026; 11(2): 016; doi:10.21926/obm.icm.2602016.

© 2026 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

Feeling safe is an emotional experience which many of us take for granted. We use derivatives of this word interchangeably to describe a variety of neurobiological and emotional states [1,2,3,4,5], but there are important differences between states of safety and safeness and the internal and external stimuli which can trigger such states [1]. It is important to distinguish between safety and safeness in the context of exploratory group psychotherapy. Understanding how one facet can block therapeutic opportunity and how the other may be required for compassion to unfold and flow in the group process is crucial for healing and transformation to occur. This paper will explore these distinctions and report the findings of a qualitative study examining the impact of a Compassion Focused Group Psychotherapy Programme, which has identified the significance of cultivating the conditions for safeness.

1.1 Safety and Safeness–The Important Distinctions

Safety and safety seeking are part of the Threat detection and avoidance system, which involves activation of the sympathetic nervous system and amygdala [6]. In essence these systems enable us to monitor potential threats and react accordingly and protectively. These evolved defensive strategies, also referred to as the defense cascade [7], can be divided into three sequential innate options. The first is the mobilised reaction to enable us to fight or take flight, the second is semi mobilized, which is freeze or hide and the final stage is an immobilized shutdown, when all other avenues of defense and resistance have failed [1,6,8]. It is possible for threats to be internally generated as well as from an external stimulus and that we may move through the defense cascade, before shutting down and disconnecting [1,7,9]. These systems are patterned within us according to our life experiences, thus potentially reordering the sequence, e.g. persistent and unsuccessful activation of the mobilized. Threat response can result in a tendency towards immobilised Threat reactions over time [7].

Conversely, safeness systems are activated in the absence of threats in response to and stimulated by care giving from supportive others [1,10,11,12,13]. This safeness system is developed in the context of secure, predictable and consistent early attachment figures who can attune to the needs of the child, thus developing overtime an internal capacity for safeness and soothing [1,13]. It is possible to make a further distinction between the reactivity of the Threat system and the responsiveness of the safeness system.

1.2 Safeness, Safety Seeking and Those at the Edge of Therapeutic Opportunity

Individuals who have suffered ruptures in these fundamentally important attachment relationships often experience high levels of Threat activation and difficulty in feeling a sense of inner safeness [14,15]. Consequently, there are often significant problems feeling connected, to their own emotional states, to others and an understandable resistance to such experiences [16,17].

These attachment ruptures often originate in early life experiences marked by intrusive, abusive, or absent caregiving relationships [14,15,18]. Such experiences can be associated with a compromised capacity to feel socially safe and connected [19], to seek appropriate care and support from others, and to engage in self-soothing behaviours [20,21].

Some of these competencies may be required to engage in psychotherapeutic interventions, thus creating a significant barrier to engaging with and making use of such interventions [12,18,22,23,24]. These patients are also prone to experiencing excessive shame, harsh self-criticism poor distress tolerance, impulsivity and social mistrust [18,25,26,27,28] and are often repeat presenters to mental health services [29].

These patients often come to mental health or other statutory services with complex emotional and relationship difficulties, along with multiple overlapping needs (for example, housing, substance use support, trauma treatment, social care [30,31,32]) that can attract a diagnosis of personality disorder [24]. Such behavioural manifestations can be more helpfully understood as “complex adaptations to early adversity” which have important functions to regulate stress ([33], p. 61). Given the often dangerous and impracticable nature of the early environment, these ‘adaptations’ were functional at the time. However, in the absence of new learning, these strategies remain fixed and appear ‘dysfunctional’ in a seemingly less hostile environment, thus giving rise to stigma and judgment [33,34].

There is now considerable evidence that these rearing environments also have a negative impact on emotional maturation, self-regulation, mentalizing and empathy, including epigenetics [35,36,37,38]. These adaptive and understandable responses can be confusing and difficult to manage for those attempting to offer care and psychotherapeutic treatment [12,22,24,39]. The paradox this creates is often a repeating cycle of rejection and ejection, which for many mirrored their early life experiences [40].

1.3 Implications for Psychotherapy

The cultivation of inner safeness requires the repeated experience of others as caring, available and responsive [1,14]. Conversely, repeated absence, intrusion and misattunement results in signals of social safeness triggering the Threat response system and consequent defensive or even aggressive reactions [1]. These patients can also have a generalized struggle with compassion for the reasons outlined above [41]. This is of course the opposite of what is needed for those whose attachment systems have been ruptured [37,42].

The internalised trauma is both relational and linked to the attachment, “Trauma is not just an event that took place sometime in the past; it is also the imprint left by that experience on mind, brain, and body.” ([43], p. 21).

Gilbert [1] proposes how this state of social safeness can promote and support a more open, exploratory and playful state of being. This can in turn facilitate the development of a sense of social trust and validation. Van de Kolk points out, “Being able to feel safe with other people is probably the single most important aspect of mental health; safe connections are fundamental to meaningful and satisfying lives.” ([43], p. 79-80). But for those who have suffered ruptures in their attachment systems, there is of course an absence of this capacity for play and often accompanying poor vagal tone [9,44,45].

There is some evidence that longer term group psychotherapy has better outcomes for people with a diagnosis of personality disorder [46,47]. This is also supported by the NICE guidelines for the treatment of Borderline Personality Disorder which recommend that treatments of less than 3 months should not be considered for this group of patients [48,49]. Within the NHS in the UK, however, it remains a significant challenge to procure the necessary resources for longer term group psychotherapy programmes and adequate care pathways [50,51,52]. The result for this group of patients can often be a repeated offer of short-term interventions, where the long term impact is not evaluated [53].

1.4 Long, Slow and Compassionate–The Case for Compassion Focused Group Psychotherapy

Compassion Focused Group Psychotherapy (CFGP) has been devised to address these understandable survival strategies and the consequent impact on therapeutic engagement, through a slow paced, rolling psychotherapeutic program. In essence the programme runs continuously and group members join at prescribed points, creating a senior/junior group dynamic which facilitates group-based support and replicates the reality of rupture and repair. The programme has been designed to activate the affiliative and safeness systems in a measured way, which slowly over time develop the group’s collective capacity for compassion across all three flows [24,54].

The Compassion Focused Group Psychotherapy intervention was developed by an experienced psychotherapist with over 10 years of training and supervised practice in CFT. Supervision for the program was given by Prof. Paul Gilbert (CFT), Dr. Chris Irons (CFT) and Susie Taylor (Psychodrama Psychotherapist). The program was delivered by the therapist who developed the programme and a senior Group Analyst with 3 years’ training and supervised practice in CFT.

CFGP is a long-term process driven exploratory psychotherapeutic programme designed to offer therapeutic opportunity to those whose ruptured or absent early attachments often make this difficult [12,18,24,55].

This model has five phases (Table 1), designed to support the gradual introduction of the evolutionary psychology model and core elements of Compassion Focused Therapy (CFT), with a specific focus on replicating the key attachment functions of safe haven, secure base and proximity seeking [12,18,24,56]. The initial attention to Compassionate Mind Training (CMT) in phases 1-3 supports the development and practice of motivational switching, enabling patients to ‘try on’ compassion orientated roles [54,57,58,59]. Phase 4 supports the development of new reparative attachment relationships with each other and themselves whilst reworking early traumatic experiences through the lens of compassion. This reworking of shame based trauma memories [60,61] which can also be described as Compassion Focused Trauma work, utilises Action Methods approaches to support group members to turn back to such memories using the group to bring compassion and new meaning [24] for a more detailed explanation.

Table 1 The Phases of Compassion Focused Group Psychotherapy.

The programme reported in this paper has been developed and underpinned by interconnected aspects of psychotherapeutic theory and practice. This model is rooted in the evolutionary theory and practice of compassion focused therapy with adaptations to make this model more accessible to those with attachment and relational trauma. This programme includes elements of living and learning democracy from Therapeutic Communities [62,63], delivered through a medium of action methods, play and psychodrama [64,65,66] and embedded in key principles of group analysis, where the group are invited to work together to bring their inner world to the group [67]. Full details of the process and content of CFGP can be found in Lucre [24].

1.5 Research Aims

The aims of this study were two-fold, firstly to explore participants’ perspectives regarding the important elements of the group psychotherapy and secondly to understand the possible mechanisms of change. Ultimately, the aim was to put these insights to use in further developing and refining the group psychotherapy programme.

2. Methods

2.1 Recruitment and Eligibility

This qualitative study formed part of a seven-year study evaluating the efficacy of a 12-month Compassion Focused Group Psychotherapy program (CFGP), utilising a mixed methods design. The quantitative arm of this study has been published in a separate article [12].

All participants had been referred to a National Health Service (NHS) Specialist tertiary Psychotherapy/Personality Disorder Service for treatment relating to unresolved early childhood traumatic experiences. The process for participants to enter the Compassion Focused Group Psychotherapy Program had two components. There was a 3-session assessment and formulation process which explored capacity to engage in group psychotherapy and aimed to develop a shared understanding of the early life events and the impact on current difficulties (see Table 1 above). During this assessment process, patients would be invited to share something about their early life experiences and attachment relationships. The three assessment sessions are designed to ensure that a clear picture of the patient’s early experience was explored and their suitability for exploratory group psychotherapy established [24]. As a tertiary service, offering long term exploratory psychotherapy (up to two years) only patients with complex emotional needs and severe childhood traumatic experiences would be referred.

Following completion of the assessment a screening tool was utilised (Forms of Self-Criticising/Attacking & Self-Reassuring Scale (FSCSRS see Table 2)) to provide a consistent quantifiable measure of self-reassuring capacity and tendency towards self-criticism and self-hatred. Participants needed to score 4 on at least 3 items of the Inadequate Self and Hated Self subscales and 0 on at least 3 items of the Reassured Self subscale. This was not based on researched clinical cut offs for this measure but believed by the authors to give an indication of severity of self-criticism and self-hatred.

Table 2 Table of participant’s descriptive characteristics.

At the commencement of the study, all participants who met the criteria were invited to consent to take part in the group, which included a post therapy follow-up interview about their experiences. Only those participants who completed the whole 12-month program were eligible to be invited for a follow-up interview about their experiences. The qualitative data used for the analysis were collected from those participants who completed the 12-month CFGP.

2.1.1 Participant Information, Attendance and Drop Out

The 12-week PEG group began in September 2014 and completed in May 2018. Overall attendance was 83% attendance, 10% did not attend and 7% sent apologies. The group followed a slow open-rolling format with module-based entry [12].

The 40-week CFTG started in December 2014 and the study completed in March 2019. Attendance increased for this phase to 85%, 9% did not attend, 6% sent apologies. Attendance was tracked session-by-session and verified via electronic databases [12].

2.1.2 Participant Sample

From the original sample of 41 participants who commenced the CFGP program, 31 participants completed the 12-month programme. During the 12-week PEG intervention, one participant dropped out. In the 40-week CFTG intervention, nine participants dropped out within the first eight weeks, with many citing the transition from PEG as a contributing factor, though this was not formally tested. Overall, the study had a 21% dropout rate [12].

2.1.3 Sampling Process

The whole sample of 31 participants were divided into five small groups who had completed the program during approximately the same time period and had therefore received treatment together. Participants were randomly sampled from each of the five treatment groups. Participants were only eligible for random sampling if they attended at least 70% of sessions over the course of the entire year. Two participants were selected at random from each small group with the aim of offering a broad spread of opinion about the program over the five-year time period. The final sample that took part in this study was 9 as one transcript failed to record. Descriptive characteristics of the nine who completed the interviews are presented in Table 2.

The age of the participants ranged from 23 years to 66 years; mean age 45 years. 95% of the Cohort had a primary diagnosis of personality disorder (See Figure 1 for category breakdown).

Figure 1 Diagnostic Categories by % of the whole cohort (n = 31).

The scores for the Forms of Self Reassuring and Self Attacking Scale were as follows: inadequate self (M = 31.66; SD = 4.59), reassured self (M = 6.88; SD = 5.01) and hated self (M = 14.78; SD = 4.29). These scores were significantly higher than the mean clinical scores reported by [68], indicating a high level of severity in critical self to self-relating. The Fear of Compassion scale scores, for others (M = 31.34; SD = 10.77), From others (M = 45.90; SD = 10.73) and to the self (M = 44.15; SD = 14.73), similarly indicated much higher levels of fear and avoidance in comparison with student populations [69]. 54% of the sample were single at the outset of the study and 73% of the participants were unable to work due to sickness. Despite the ethnic diversity of the sampling area, 75% of the sample were White English.

2.2 Qualitative Data and the Interview Process

Data were collected from face-to-face individual interviews using a semi structured schedule see Table 3 below. Interviews were conducted by a research assistant not familiar with the CFT model or the research protocols. This was to reduce potential bias and ensure impartiality and curiosity in the mind of the interviewer [70]. The interviews were conducted between 1 and 3 months after completion of the 12-month CFGP program. The interviews were all between 50 and 70 minutes in length and recorded on a digital device to enable verbatim transcription by the first author. The participants’ names and other identifiable information were anonymised at the point of transcription.

Table 3 Interview Schedule and Questions.

2.3 Analysis

The transcripts were analysed according to the Thematic Analysis method, used for the “identifying and interpreting patterns in qualitative data” ([70], p. 12). This method is recursive in that movement is required between the stages, rather than a linear process of exploring the data [71].

The analysis followed the [71] six stage process which is concerned with the development of observable themes which can be used to interpret the data and extrapolate meaning (See Table 4 below).

Table 4 Summary of Six Phases of Thematic Analysis [72].

2.4 Ethics

This full study gained ethical approval from NHS Health Research Authority (IRAS No. 15/WM/0387) and from the University of Birmingham Ethics as this study formed part of a PhD in Psychology. The transcripts and emerging themes were independently reviewed by an academic professor and academic tutor from the University of Birmingham. The study also underwent regular review via the IRAS system and subsequently passed the PhD examination.

3. Thematic Analysis Results

The study presents five overarching themes, with coordinating sub-themes, each presented with illustrative verbatim quotes from participants, see Figure 2 below.

Figure 2 Tree Diagram of Themes and Subthemes.

3.1 Theme One: The Experience of Safeness

This main superordinate theme emerged from the data which was shared by all participants and describes the experience of the overall therapeutic journey. Participants described different ways that the experience of being part of the group and being with the other groups members and the group facilitators enabled them to engage fully in the therapeutic intervention. Five subthemes emerged to describe the different ways that participants experienced the phenomena of connection and the links which were made to the mechanisms of change.

3.1.1 Subtheme One–From Reticence to Connection

Many participants described a particular process or journey which started with reticence to be with and share with others and ended with a deep sense of connection.

“At first, I hated being in the group… But then I started to rely on the group and wanted to be part to it sharing things… Emotional… Hurtful thing and the group became very important definitely” (Ben)

“We gained a bond I’d bonded different with all the people in the group… when one group member went into hospital we all felt it” (Louie)

Similarly, this participant expressed surprise that she was able to make connections with other participants and tolerate the group process as it unfolded.

“I was thinking I don’t know how I was going to be in a group but I was able to tolerate others… also I ended up bonding with people as well over a year and seeing them in a way… tolerate more I suppose” (Sherelle)

3.1.2 Subtheme Two–Common Humanity between Participants Creating Safeness

Predominantly participants described that the process of being treated within a group setting with others who had similar difficulties created a sense of safeness,

“Something just shifts and you make a connection” (Joanne)

“Everyone in this group is here for the same reasons… we are all equal and was how we treated each other” (Louie)

“Enforced exposure to other human being that made me realise that we are all in the soup we are all swimming in the soup erm and because I realised that it wasn’t just me in the soup on my own” (Paulette)

“Some people would say things that… struck a chord with you…” (Serena)

“It’s seeing your experience mirrored back… reflected in everyone else’s experience… Understanding we are all suffering” (Paulette)

3.1.3 Subtheme Three–Honesty and Authenticity as a Mechanism of Change

For some participants there seemed to be a focus on where members were invited to be authentic and honest with each other and themselves.

“The emphasis was really on… on… the safe space and this was a place where you could come and you could… I used to refer to it as the no bullshit zone… you know you come here and you can drop your mask” (Sarjen)

“I think I just found that just opening up and being honest I think that was really powerful” (Sarjen)

Another strand to this subtheme was the idea that group participants supported each other with acceptance and offered “safe challenges” (Damien) to stuck patterns of responding, as a means to facilitating connection to feelings of vulnerability and ultimately to change.

“You had to be honest with yourself and that opens you up and when you open up it shows who you truly are and it’s very difficult… the openness within the group… there were times when I’d draw back or other people would draw back but people in the group would challenge and that was part of the therapy trying to get you drawn out” (Damien)

“You can present yourself warts and all people will go yeah ok… something great about being able to realise this stuff… and for that to be acknowledged not sort of automatically forgiven… challenging as well but that you could work it through safely…” (Sarjen)

“The first time in my life where I’ve had a family… it’s ok you’re accepted and you kind of have your hand held” (Paulette)

3.1.4 Subtheme Four–Learning from the Group and the Instillation of Hope

Linked closely to the previous subtheme was the experience that participants reported of learning from each other through being connected, trusting and mutual support.

“Everyone brought something to the table I learned something from each individual member of that group and hopefully I gave them something too yeah” (Ben)

“One person we had to bring out because they got really stuck and had gone into a space and couldn’t get themselves out and that was good” (Louie)

“It was emphasised that this was a safe space and it can’t work without it is an essential part” (Sarjen)

The implicit learning from observing group members make changes and try new things acted as a catalyst for participants and instilled hope.

“When you see other people embrace what’s happened and come further and further it helps yourself as well… if they’re brave enough to do it then you know I’ve got to be brave enough and it happened over and over in the group” (Louie)

“Seeing people change in small ways that gives you a lot of hope… maybe this could happen for me… and making bonds with people” (Ben)

3.1.5 Subtheme Five–Trusting Relationship with Facilitators

The impact of the facilitators on therapeutic process was referred to explicitly by every participant. The experience of the participants can be clustered into a number of interacting ideas. Initially there were a number of comments indicating the participant’s perception of a compassionate motivation and intention of the facilitators towards the group.

“I got a strong impression that they weren’t just coasting they were serious about this… they were serious about helping this group” (Sarjen)

“…they were very compassionate people and very sneaky (laugh) they were able to see through the bullshit and draw out the real side of things… being lighthearted in stressful moments but also having the understanding and care that they have… don’t change” (Damien)

Another participant spoke about the experience of the facilitators as attuned and the impact that this had on undermining the internal critic.

“Things were said made me realise that they were paying attention… that means a lot if you have a negative self image… when somebody pays attention 2 or 3 months later and they remember something you said… that is worth a lot” (Phillip)

Participants spoke of similar experiences of developing a bond with the facilitators and that this was the foundation to change.

“I had to tell him that he had been the most significant male figure in my life ever… because I grew a bond” (Ben)

It was trust… it was trust… I build a relationship with this lady who was sat next to me… and I trusted that… she was gonna sit there with me until I felt OK to make a decision (Paulette)

The differences between the way and style of engaging in the therapy was also found by some to be important.

“[he – facilitator] was a bit more challenging… provocative whereas [she – facilitator] had a more gentle approach not too gentle the contrast was empathic… I liked the combination they were just different and it worked” (Sherelle)

Table 5 illustrates words frequently used by participants to describe the experience within the group which linked to ‘safeness’.

Table 5 Frequency of word usage.

3.2 Theme Two–The Flows of Compassion

Many participants identified and made reference to the implicit and explicit focus on developing the three flows of compassion (to others, from others and to the self) and the associated development of an internal compassionate motivational system. Participants also made reference to the impact of the group process in experiencing and developing a capacity for giving compassion to others, receiving compassion from others and giving compassion to the self, coupled with an acknowledgement of the significant emotional challenge associated with the therapeutic work. Two closely linked subthemes emerged from the data connecting the teaching and the group experience in blocks to and developing flow of compassion.

3.2.1 Subtheme One–Working with the Fears, Blocks and Resistance to Compassion

A number of participants spoke of the initial reticence and suspicion that they had about the concept of compassion and how the experience in the group enabled them to learn a new way of thinking about compassion.

“I realised that compassion isn’t necessarily all about fluffy kind of… Of yeah you know we love ourselves, it’s not like that it was quite tough, a tough kind of passion” (Sherelle)

“I didn’t think I would ever feel compassion for anybody because I was so bitter and angry with the world… but then something shifts and you make a connection…” (Jamie)

“I am focused on compassion and the need for it and how essential it is… It’s just that it is difficult…” (Ben)

Participants also spoke of developing an intuitive understanding of their own compassionate competencies and the ongoing challenges associated with this.

“Getting more assertive… I didn’t see that as looking after myself and being compassionate to myself but by actually doing that it made such a difference” (Sherelle)

“I’m getting better at taking compassion from others… but if people are too compassionate to me I’m obviously going to burst into tears…” (Louie)

3.2.2 Subtheme Two–Compassion for Others as a Vehicle for Self-Compassion

There were a number of explicit references to the ways in which experiencing compassion in one area supported the development in another. Participants spoke of the experience of feeling compassion for others as a precursor for beginning to acknowledge the need to practice it for the self.

“It was a natural response of compassion sympathy empathy and wanting to sort of reach out… Then the penny dropped that it was time to do it for myself” (Phillip)

“I started feeling it [compassion] with them I’d get upset for other people and the realise… well hang on they’ve just said something that is really identical to you” (Ben)

“CFT gives you the tools to be able to understand yourself… understand what’s happened… what’s gone on and gives you the tools to actually deal with it and move forward you know… the compassion you can feel for others you can actually start to feel for yourself” (Damien)

Other participants described the experience of giving and receiving compassion within the group process as a significant element of the therapeutic process, but also linking with subtheme One regarding the challenges.

“Compassion was an alien concept… scared the crap out of me… but feeling compassion for everybody understanding that it was compassion for everybody and that they were feeling compassion towards me without any strong without any other motives… it was very very strange… you were with a group you were asking for help and they’re asking for help and you were helping each other… asking for help in the beginning was hard” (Damien)

“One of the things a lot of people think is erm… namby pamby touchy feely therapy… it’s nothing like that… when you come to something like this you’ve got to understand that it is hard work and it knackers you out because of the emotional work” (Damien)

3.3 Theme Three–The Impact of the Structured Elements of CFGP on the Participant’s Engagement with the Program

A number of key themes emerged from the data and the participants observations about the aspects of the structured programme and the impact that this had on their therapeutic journey and experience of change.

3.3.1 Subtheme One–Routine and Ritual

This referred to the Soothing Breathing Rhythm practice (SBR) at the commencement of each session, followed by a ‘check in’ session. These parts of the group were referred to by every participant, with a general theme emerging about the significance of this as a regular predictable element of the programme and the consequent experience of safeness in the room as a result. The check in was also identified by many as key to learning ‘turn taking’ and structured ways to begin to engage with each other.

“Then the breathe… it was almost like a trigger for the group that’s when the work started” (Damien)

“The breathing practice to get everyone in the flow of the group session … and gather yourself in really … then we’d do a check in… then you’d pass it on to someone else and it’s a way of bonding as well and you also got to learn people’s names” (Ben)

“I say relaxation it’s actually no it’s bringing yourself into the moment so it’s the breathe… Helps you sit back and gather yourself in really… Then the group share that was really important” (Damien)

“The stuff that happened that was good … happened in the round the room check in” (Phillip)

The experience of trust and containment in the room was also linked by participants to the explicit development of a ‘Safe Space Agreement’, a group based collaborative behavioural contract which everyone agrees to abide by.

“It’s the people that you respect and trust and all the rest of it and because the ground rules stay the ground rules and they are the ground rules we came up with and all that trust and shared history is still there” (Damien)

“so you could actually remove yourself from the group but still be part of the group and go and calm yourself and then come back” (Damien)

“there was a safe chair… you could put yourself and sit there until you felt comfortable enough to come back…” (Phillip)

3.3.2 Subtheme Two–Soothing Breathing Rhythm in Group to Embed Home Practice

This interconnected theme explicitly linked the ‘breathe’ practice in the group with the development of regular home practice and the value of this.

“I do many breathes throughout the day if I start feeling… So, I’m mindful of where I am… And just go… Take a moment… And sometimes you can catch it and sometimes you can’t” (Sarjen)

I now practice that [SBR] at home was sparked off by doing it in the group… slowly day by day… (Serena)

“it’s like the breathe we did once a week and everybody practiced it at home… and that just became natural… it formed a habit… it’s like the critical part of me… it’s building blocks as long as I don’t let things slip I can only improve on it” (Louie)

Table 6 demonstrates the significance of the SBR practice for all group members as it was named by every participant and the word occurred frequently in the text.

Table 6 Participant words to describe the Soothing Breathing Rhythm Practice and their frequency.

3.3.3 Subtheme Three–Psychoeducation as a Mechanism for Addressing Shame

The teaching of the evolutionary psychology model was linked to a greater understanding by participants of their emotional experience. The ‘normalising’ seems to have been key to reduction in the experience of shame related to their difficulties.

“It’s like being afraid and ashamed of your own humanity… But the compassionate mind set… in a way you are being realistic about human frailty and the kind of problems we all have… It really did address shame you know” (Louie)

“Before I’d think I’m an idiot there’s somit wrong with me but it (the old brain new brain teaching) got rid of that and the feeling of helplessness” (Ben)

“it wasn’t just go there and pour your heart out… it was educational which you need because without understanding how can even begin really on that path without understanding” (Ben)

3.3.4 Subtheme Four–The Compassionate Kitbag

The significance of the use of objects in the therapeutic work was referred to by every participant and the meaning associated with being given gifts from the group. This is the concept of the ‘compassionate kitbag’ developed to support group members with A&RT who need a concrete representation of compassion to support the work [55] Links were made with the helpfulness of using stones, beanbags and buttons in the context of a sensory focus in the SBR. But perhaps most significantly participants described the use of the stones as a way of connecting with and reminding of the group and the therapeutic work, as a transitional object [55].

“It’s a virtual kitbag you might keep the breathe exercise in there and for me it was the little stones… A picture… A smell… That calms and reminds you of the group” (Ben)

“The stones that can help you focus… you have that visual form that is great to go back to… refresh it for yourself… something physical there that. brings you back to the group in a way” (Ben)

“I’ve still got my stone it’s got a little nick in it… and every now and then if I feel stressed I’ll pick it up and do a breathe with it” (Louie)

“One of the tools is the stone it’s the first stone I had… but for me it’s a reminder of what I wanted out of the group which was to be a more whole person to understand my emotions to understand erm the Threat system… to understand that I’m not alone” (Damien)

3.3.5 Subtheme Five–Playing and Playfulness as a Medium of Change

The theme of playfulness was present in many of the participants feedback about what enabled them to engage with the therapeutic work. This seemed to be particularly connected with how playfulness was woven into the structure of the programme.

“There was a great sense of humour… we all started being silly and the pressure is relieved… there was space to do that without it being like you know no this is serious therapy… you can’t laugh” (Phillip)

“The togetherness it’s the whole group… not feeling self-conscious about a playing a silly game… it was good” (Jamie)

“so we’d play each other up by jumping in their chairs… general tomfoolery… then we’d get the breathe going” (Damien)

“before I was pacing along the road looking out for dangers… listening out for dangers causing issues… now I’m looking around for fun… looking to play up… looking to have a laugh so I actually get to live life now whereas before I couldn’t do it” (Sherelle)

3.4 Theme Four–A Moment of Change

This theme brings together a number of themes around the ‘Action Methods’ or work in action element of the Compassion Focused Trauma Group (CFTG). All participants made reference to either observing and or taking part in chair work, compassionate transformation and group-based activities. A number of interwoven subthemes also emerged regarding the particular mechanisms of change. Participants described the experience of working in action, addressing early trauma, becoming upset and overwhelmed but that this was accepted and not judged.

3.4.1 Subtheme One–Therapeutic Work in Action Changed the Meaning of Early Trauma

Many participants spoke of a sudden and immediate moment of change, building on the foundation of early work in creating a sense of safeness.

“And it was a sudden understanding shit that’s me I’ve drawn me and wanting comfort… comfort and strength it’s just like shit because that is something I never received” (Damien)

“Wow that’s quite difficult to answer what was best… it being a group and running for a long time and getting off my chest some things… the best bit was that I was waiting for 30 years to get that off my chest” (Ben)

“I spoke about it as an epiphany and it is one of those moments when you realise you’ve changed from that to… this and you don’t know where the middle has gone but you know it was a sudden understanding” (Damien)

“things come up which I wasn’t expecting it wasn’t like I could think about it cognitively… like I am gonna talk about this when I am sitting there… it’s just things really emotional came from a different part of me… quite challenging and important aswell…” (Joanne)

“It is the first time I was upset without being angry and part of that was because I felt safe” (Damien)

3.4.2 Subtheme Two–Group Members as Enablers of the Change Process

All participants described the significance of the other group members in supporting, challenging and facilitating working through early shame-based trauma memories.

“they’d be like well [participant name] you’ve never done that before and I’d be like you’re right actually… you’re right because I wouldn’t see that but others do and the group can help you see what you can’t or don’t want to” (Ben)

“The verbal beating was just echoes of things said erm in an overly expectant impatient father and that was a denial of legitimacy you or your feelings are wrong or you have no right to feel them… then the group allowed you to unpick it because you’re not trying to constantly shove it down… it just allows… it is just who I am” (Phillip)

“I was showing emotion I was getting upset… I was embarrassed I was frightened because of the understanding that I was crying but afterwards it made me realise actually this is a good place because you can bring that out and you won’t be criticized” (Damien)

There was also an acknowledgment that observing the trauma work taking place also impacted on the therapeutic journey.

“the impact on other people in the room, it changed things for them it wasn’t just the person at the front in the chairs it was everybody” (Serena)

“so I began to realise that what happened to me was just a normal response to trauma” (Joanne)

In addition to the impact of group members, many participants also identified the impact of the facilitators in this change process.

“That was a turning point… I felt like that trigger… my need to escape when things got tough didn’t feel active anymore… I could walk a middle path now… Because I had built a relationship with this lady [facilitator] and I trusted her” (Paulette)

He [facilitator] said to me… you felt that your love wasn’t good enough… It flipped a switch in me… The years… the inadequacy just fell away and made me realise… The love I have is ok (Phillip)

3.4.3 Subtheme Three–Resolution of Conflict in the Group

This theme emerged for some participants around developing new ways of dealing with conflict through the group experience where a resolution was possible. Participants also spoke of this as a contrast to the early experiences of unresolved conflicts and how this reinforces the importance of the group work programme.

“There was a big who ha… doors were slammed…then she came back and said I felt like and you made me feel like this and you know people apologise and actually she became quite a part of the group… I guess again it’s a testimony to the effectiveness if you know for those people who kept at it… it bears fruit” (Joanne)

One participant described meeting with a group member outside of the group, which was generally discouraged as this kind of situation generally disrupts the group’s sense of safeness.

“I met him outside the group… it did change things for me in the group… I felt bad… but then I asserted my boundaries and said no to him… so then I brought it up in the group like in a confessional… I’ve gone against the rules… I’m glad I got it off my chest… it changed things for me… being more assertive and practicing in group” (Serena)

“he [participant] said something to me which I found offensive… previously I would have sat there and boiled or I’ve would’ve lost my temper… but I made eye contact with him and said your behaviour made me feel uncomfortable… he apologised… it was a turning point…” (Paulette)

3.4.4 Subtheme Four–Emotional Distancing and Softening the Inner Critic

All participants made either specific reference to an ‘internal critic’ or described the experience of a disparaging self to self dialogue, which through the course of the therapeutic work was softened through different mechanisms. In particular, many participants described the significance to creating emotional distance from the voice as a means to bringing a level of understanding.

“we were all struggling with the inner critic… so they said give it a physical form… I went for plasticine and made this little gremlin thing… it was really useful you could put your inner critic on the table over there and just separate from it for a second… and it wasn’t about squashing it or anything …over time I could then explain it… my monster is being a pain in the butt today… and over time not such a screaming voice in my head…” (Serena)

“this internal monologue very critical merciless… you’re useless… you will fail… that has largely stopped… quite dramatic really” (Phillip)

“you know that kind of negative dialogue… I’d sit there and compare and think they definitely don’t like me… I can actually now challenge those negative thoughts… before they were just automatic and take you off into a tail spin now I can challenge more often” (Louie)

“They didn’t drum it into you but the whole mind set is don’t be so hard on yourself and it’s about reinforcing the idea… every week so… over time you kind of gradually… the voice get a bit quieter” (Serena)

3.5 Theme Five–The Challenge of Managing Transitions and Endings

The final theme generated from the data was built around the experience that participants described transitioning between different stages of the group programme and of the ending. All participants made reference to the challenging nature of these elements of the programme with a focus on understanding the function and impact on their therapy journey.

3.5.1 Subtheme One–‘Moving Up to Big School’

The transition from the preparation and engagement group (PEG) to the Compassion Focused Trauma Group (CFTG) element of the program, was cited by all group members as a significant source of anxiety with many initially questioning the structure.

“a safety almost in that group identity which and some people were just starting to open up and somebody new come and they close up again so then they have to sort of go through that process again” (Phillip)

“it was difficult to be honest because the 12 week group I’d settled in… then all of sudden it was flipped on it’s head coz I was going to the afternoon group… but then when you get in there that all changes because it was the same as the morning group…” (Ben)

For others the value of a rolling programme and the consequent changes were more clear in relation to the impact that this had on the participants move from being a ‘junior’ group member to a senior’ and all the conferred advantages that this brought.

“so having that rolling program is a great benefit if we had all started on the same day… a room full of frightened silent people wouldn’t have been of great benefit but where some had been there for months and were ready to move on… seeing people at different stages of development that kind of gave me hope”. (Paulette)

“The older ones showed us the ropes… Then you look after the newbies you just take on that role and I don’t know it naturally shifts.” (Serena)

3.5.2 Subtheme Two–The Impact of Ending: From Grief to Connection

All participants made explicit reference to the strong feelings of loss and sadness associated with the ending of the programme. This linked to a therapeutic experience which was of value and connections made with other group members.

“I do remember as I was coming to the end 3 or 4 people that I considered my group all graduated and left me behind… I felt the broken connection… that was a little stumble… and it made me realise that we had built up quite a bond” (Paulette)

Many participants simultaneously connected to the underlying therapeutic journey and recognised the ending as an important mechanism of the change process.

I suppose it’s not grieving it’s actually quite positive but you still feel upset that I wasted most of my life being the person that I was when I am actually beginning to like who I am… that makes a massive difference (Damien)

It’s changed my life really even though it’s small it’s still changed my life… I’m a different person now for the good… so I think it’s essential it’s essential it’s the best and hardest thing I’ve ever done in that sense… (Sarjen)

It has changed my idea of therapy so yeah it was physically hard mental, hard… and… but it works… even though you may not think it when you go through it (laughter) (Damien)

“If you plant a tree and then every day you go and pull it up and if the roots are any bigger. you have to believe and just let it do it’s thing” (Phillip)

Finally, explicit reference was made to the self-directed ‘Moving On’ or maintenance group’ which was developed by participants following completion of the program. A theme emerged for some about the way that looking forward to and engaging with this group, enabled the work from the group to be continued and the grief associated with the ending to be worked through.

“a lot of people including myself felt fear coming to towards the end… but you don’t have that loss because you know there something else… all that trust and shared history is still there” (Damien)

“although at the end I could feel the immeasurable difference I had a feeling that you hadn’t completed a journey and you felt like you were doing really well and all of sudden it stopped… and there was nothing else… which is why we decided to start the social group” (Jamie)

“we talk about check in and stuff you know strengthening what we are going through but like I said self-compassion is a work in progress so we help each other” (Louie)

4. Discussion

As far as the authors know, this is the first study exploring in detail participants’ experiences of a 12-month Compassion Focused Group Psychotherapy Programme and as such it makes an important contribution to the current research literature. The qualitative data indicated that group members cultivated the capacity for compassion through the repeated experience of social safeness within the group room with each other, and it seemed to be on this basis that participants built new reparative attachment relationships. This notion was supported by the quantitative analysis which demonstrated significant change across all measures of symptom and process and were maintained at one year follow up for all those who completed the programme [12]. Service utilisation also dropped significantly, with over half the cohort having been discharged by other mental health services, with a significant proportion having moved into education and employment of various forms at one year follow up [12].

Gilbert’s [1] distinction between the absence of perceived threat and the presence of an experienced sense of interpersonal safeness is important to understanding relational dynamics in the early stages of group development.

They may not feel that the other group members will harm them, but it takes many months and an explicit focus on cultivating safeness to facilitate the group members becoming like a family or tribe which means that hold each other in mind and expect to be attended to and cared for. This seems to be part of the transformative process of Compassion Focused Group Psychotherapy which is then internalised to create an inner secure base.

The thematic analysis revealed five key overall themes with associated sub-themes that were present in most participant interviews. The overall themes included participants reporting a feeling of ‘safeness’ in the group; ‘compassion flows’; specific aspects of ‘psychoeducational components’; ‘change moments’ and ‘transitions and endings’. Each theme is discussed below in relation to the existing research literature.

The main superordinate theme from the study related the experience of safeness as a key mechanism in the change process. The cultivation of a space of safeness and connection within the group and between the participants, including the experience of containment from the therapists was evident. Safeness has been identified as a key mechanism in ameliorating the experience of psychosocial suffering and is linked to the experience of closeness with others [73,74].

There is also a clear link between the experience of social safeness and capacity to give and receive compassion, which is dependent on the quality of early attachment relationships [19,56,75,76,77]. This finding is supported by the body of literature about the importance of establishing safeness for psychological work with this patient group [12,14,27,55,56,78]. This overarching theme was a strand which emerged in each of the other subordinate themes and seems to have been the foundational internal construct which facilitated the necessary therapeutic engagement and mechanism of change. The programme was also designed to foster and support group cohesion and synchrony which are positively correlated with each other and found to be determinants of high rates of attendance [15,78,79]. The consistent 85% attendance rates throughout the study, coupled with the qualitative reports of this as a factor in the feeling of connection to the group, offers further evidence of the practical mechanisms of cultivating compassion in the therapeutic space [12].

There have been a number of qualitative studies exploring the impact of mostly short term (6- 12 session) CFT groups. A few reported studies have offered longer 20-24 weeks but these are in the minority of reported studies. A recent review of the qualitative literature identified only 12 studies which met the criteria for a robust qualitative analysis [80]. The main findings of these studies are broadly consistent with the significance of group process and safeness as a mechanism for change. It is of note however that these studies do not report a specific process orientation or identify safeness as a key concept [12,24,80,81].

Lucre and Corten ([82], p. 395) reported “the comfort of shared group experiences”, [83] (p. 293) described “the group as a key mechanism of change” and Lawrence and Lee ([84], p. 501) reported the “emotional experience of therapy”. [85] found the connection with others and the group as secure space was significant to change. Similarly, most studies identified the developing connection, a sense of belonging and the benefits of the group process [86,87,88,89].

There are other significant overlaps with the findings of this study and the current body of research evidence, however it is of note that this is the first study reporting safeness as the dominant theme. The significance of this may be linked to the length of the treatment which was also a unique component, in that the psychotherapeutic programme was one year with a further one year follow up. Yalom & Leszcz [78] found that group members reported that the impact of group members was as significant if not more so than the impact of the facilitators on creating the conditions for change. The other significant difference with the current body of qualitative research evidence is the patient population. This is the first and only study to report the impact of a Compassion Focused Group Psychotherapy programme for patients who could attract a diagnosis of personality disorder [12,18,24].

Gilbert ([1] and [56], p. 10) explores in detail the importance of cultivating safeness within the therapeutic context and links the activation of this system with the capacity for play and “social relating”. Gilbert [1,56] goes on to further identify the differences between safeness and safety through the lens of attachment theory, via the primary attachment figure through the provision of secure base, safe haven provide a place of safeness for the child to begin to explore their environment and individual potential. Geller and Porges [2] also identify the use of polyvagal theory to make sense of the process of therapeutic presence and the consequent client experience of safeness,

“it appears that feeling safe is a necessary prerequisite to establishing strong social bonds” ([2], p. 188).

The CFGP programme has been designed to create the conditions for group members to experience a secure base and safe haven, which are central to the process of therapeutic change [12,24]. Group members can seek ‘emotional proximity’ to others by sharing experiences of the group as safe haven and a secure base and with it the experience of social safeness.

The data supports the view that from this foundational construct, similar to the early primary attachment relationship, participants were able engage with the cultivation of the three flows of compassion [23]. This emerged as the second main theme, again with the group process as a significant medium for this work [78]. In keeping with much of the published literature reporting CFT interventions, the initial experience of Fears, Blocks Resistances to compassion were reported by all participants [82,83,84,90,91,92].

In addition to this, a novel subtheme emerged which has not been reported elsewhere in the literature, namely ‘compassion for others as a vehicle for developing compassion for self’. It is of note that this study is the first reporting a long-term intervention and it is possible that this process of repeatedly being exposed to the feelings of sympathy and empathy for others and the consequent development and tolerance of similar feelings for the self, requires time to emerge.

The structured components of the group process were identified as a further main theme, which included a number of subthemes identifying the function, specific elements and key emotional experiences associated with the psychoeducation and Compassionate Mind Training. Some elements of this intervention are consistent with other published studies, specifically the significance of the ‘not your fault’ message in addressing shame being evident in most published CFT studies [82,83,84,90,91]. The unique components of this intervention, in particular the compassionate kitbag and the use of playfulness as a medium for delivery of the structured components, were identified by most participants as key to the experience of change in the group [18,55,93,94].

A further unique component of the CFGP programme was bringing Compassion Focused Trauma work, which was identified by all group members as the main theme, ‘a moment of change’, whereby this work in the group triggered a shift in perspective, compassionate capacity and meaning associated with early traumas. These ideas are supported by the wider trauma focused psychotherapeutic literature [22,93,95,96] The subthemes capture the ways in which participants were able to use the group as a medium of change [78], change the meaning of their early traumatic experiences [97,98] and soften the internal critical dialogue through emotional distancing [82].

Participants also identified a sub-theme of ‘Grief to connection’ in the context of the ending of the program. This manifested in participants bringing a compassionate response to the grief associated with the ending and a capacity to utilise the therapeutic change process to accept the ending of therapy and focus on the positive impact of the experience. This is supported by the literature on the importance of managing endings and transitions within psychotherapy and supporting patients to grieve for the loss of the therapy and plan for moving on [78,80,99,100].

Feedback from patients indicated that the group-based nature of the intervention was an important component of the change process, which links to the substantial body of evidence for group cohesion as a key therapeutic factor [12,24,78,80,101,102].

4.1 Areas of Future Research

Given the promising outcomes observed in the present study, further research should aim to conduct a more rigorous evaluation of this intervention, ideally through a randomized controlled trial (RCT). However, consideration must be given to ethical constraints, as well as the duration of both the intervention and treatment-as-usual (TAU) conditions, which may present challenges for study design and implementation. CFGP has also been replicated in other NHS Psychological Therapy Services and data from these programmes are currently in press.

The findings highlight the experience of safeness as a potentially significant mechanism underpinning therapeutic change and engagement in psychological processes. Future studies are therefore encouraged to include explicit measurement of this construct. The Early Memories of Warmth and Social Safeness Scale [103] may be a suitable instrument to assess individuals’ perceptions of social safety. Its inclusion would facilitate a more comprehensive evaluation of the role of safeness within therapeutic contexts and provide an opportunity to quantitatively examine themes identified in the qualitative data.

In addition, while the current study focused on individuals with a history of ruptured early attachment relationships, significant childhood abuse and associated relational difficulties, future research would benefit from incorporating standardized measures to assess developmental and relational factors. Recommended instruments include the Adverse Childhood Experiences Scale [104], the Central Relationship Questionnaire [105] and the Experiences of Close Relationships Scale [106]. The integration of these measures would enable a more detailed characterisation of participants’ early experiences and attachment patterns, supporting a dimensional and integrative framework rather than reliance on categorical personality disorder diagnoses.

4.2 Concluding Comments

The key message from this analysis would seem to be the significance of the group-based nature of this intervention, in that participants used the group process and affiliative connections with fellow participants to develop the capacity and competencies in compassion to put these ‘to work’, in the context of reworking attachment traumas from early life. Therefore, developing a sense of ‘safeness’ in the room and with each other, coupled with the implicit and explicit cultivation of ‘Flows of Compassion’, with the ‘Structured components of the model’, enabled participants to use the group as a safe haven and secure base to undertake the exploratory therapy identified by the ‘Moments of Change’ and finally to manage ‘Transitions and Endings’. These processes combined enabled the group to develop new attachment bonds with themselves and each other and to create new and more meaningful life experiences. To end with the words of a graduate from the CFGP programme who now works in our Mental Health Trust bringing compassion to staff through her wisdom and lived experience,

“I find a creative magic in groupwork which fascinates me and, I suspect, will continue to be at the heart of my exploration as my role develops. Our ability to come together around the campfire to gently hold, examine and pass around the precious artefacts of our experience in a place that, even if just for now, feels like home, is a privilege and a gift to everyone brave enough to step into the circle.” ([24], p. 214).

Author Contributions

Dr. Katherine Lucre: Conceptualization, writing – original draft, formal analysis, review and editing. Dr. Neil Clapton: review and editing. Professor Alex Copello: Academic Supervisor, Conceptualization, review and editing. Dr. Chris Jones: Academic Supervisor, Conceptualization. Professor Paul Gilbert: Model Founder, Clinical Supervisor, review and editing. All authors have read and approved the published version of the manuscript.

Funding

This research was funded and resourced as part of the Author’s PhD which was funded 50% by NHS and 50% by author, no other funding or resources were received.

Competing Interests

The authors have declared that no competing interests exist.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.