Skip to main content

Verified by Psychology Today


Charlie Heriot-Maitland on Compassion and Psychosis

On the future of mental health

Eric Maisel
Source: Eric Maisel

The following interview is part of a “future of mental health” interview series that will be running for 100+ days. This series presents different points of view about what helps a person in distress. I’ve aimed to be ecumenical and included many points of view different from my own. I hope you enjoy it. As with every service and resource in the mental health field, please do your due diligence. If you’d like to learn more about these philosophies, services, and organizations mentioned, follow the links provided.


Interview with Charlie Heriot-Maitland on Compassion and Psychosis

EM: What is compassion-focused therapy?

CH: Compassion Focused Therapy (CFT) is not actually a distinct ‘school’ or ‘brand’ of therapy, but more a framework for focusing multi-modal interventions, which is based on evolutionary and neuroscientific understandings of the mind.

In particular, CFT draws on the evolutionary understanding that minds are organized in line with basic social motives, and on research that shows how organizing our minds around motives for compassion (to self and others) can bring a variety of mental, physical and health benefits.

Essentially, CFT aims to create the conditions within our body and mind that will give us the best chance of working with/integrating our threat-based emotions and experiences.

So in CFT, we would firstly aim to establish a bodily experience of safeness through, e.g., practice of grounding, posture, and soothing breathing, which activates the (threat-calming) parasympathetic system, and to then gradually develop the compassionate mentalities and qualities that are required to do the intervention work.

The CFT claim, based on a science of the mind, is that whatever threat-related intervention is required in therapy (e.g. addressing a fear, trauma, avoided emotion, behavior), this will be more successful if we have first created these ‘optimum’ physiological and motivational contexts.

EM: You are interested in applying CFT for individuals with psychosis. Can you tell us about your intentions for this approach and how it works?

CH: People with psychosis often live in a constant world of internal and external threat; whether it’s a voice they hear making explicit threats, a feeling they're being watched, a conspiracy, or the threat implicit in having their life influenced by outside forces.

What this means, at the physiological level, is that the entire brain-body system that has evolved to process and respond to threats is being constantly stimulated. And the more this system gets activated, the more sensitized it becomes.

As if this weren’t problematic enough, psychosis-related conditions like ‘schizophrenia’ carry severe social stigma, and many of those diagnosed will internalize this stigma to experience shame. This brings an additional layer of threat linked to one's social position.

CFT is particularly well suited to address these key (threat-based) processes in psychosis, because, as we have seen, the approach is specifically designed to regulate threat by building feelings of safeness, and through cultivating compassion for self and others.

So while there is a strong theoretical rationale for applying CFT in psychosis, and a good understanding of what processes we are targeting, we are still in the very early stages of evaluation, so as yet, there is no evidence for (or against) its effectiveness. It is my intention to conduct this needed research.

EM: You write about the compatibility of biomedical and psychological approaches to treating what is called “psychosis.” What are your thoughts on their compatibility or incompatibility?

CH: I would love to see compatibility, and have aspirations for what will, one day, be joined-up bio-psycho-social approaches. But what I see today is incompatibility. Psychiatric drugs are still being routinely used to suppress/eliminate the very same experiences that psychological therapies are trying to explore, talk about, understand, and relate to. What kind of mixed messages does this send?

Biomedical and psychosocial approaches are caught in a bind, and I think one reason is that our whole scientific approach in mental health has been predominantly treatment-led. We've constructed a ‘science of treatment’, which assumes that something is wrong and needs fixing (and favors researching outcomes), rather than a ‘science of the mind/brain’ (which favors researching process first … then outcomes).

My aspiration for compatibility will come when we combine our efforts and resources on trying to understand 'normal' brains and how they operate in different environments (e.g. calm, safe environments, or distressing, adverse). Then our treatments can be compatibly designed to create new bio-psycho-social environments in which the ‘normal’ brain can function and flourish.

I think the concept of neuroplasticity is very important here because, not only does it help us construct more joined-up bio-psycho-social understandings of how past experiences have shaped the brain, but can also guide the design of psychosocial interventions that directly influence the future firing and wiring of neuronal networks. It will also be fascinating to see what implications emerge as we get a better understanding of the psychosocial influences on genetic expression (through methylation).

So we may no longer have to rely solely on drugs or electric shocks to balance our brain biology. Maybe we can better learn how to do this through talking, meditating, and relating to others and ourselves in a different way.

EM: What are your thoughts on the current, dominant paradigm of “diagnosing and treating mental disorders” and the use of so-called “psychiatric medication” to “treat mental disorders” in children, teens and adults?

CH: The current medical paradigm demonizes the threat system. The threat system is a fundamental part of our evolved brain. Sure, it can cause great suffering, and can drive humans to do some awful acts. It has done so throughout history. That is tough, that's really, really tough. But, it's not our fault. Our brain is very tricky, it's a product of evolution – it's not perfectly designed for our happiness and wellbeing. It's a survival machine, and our threat system doesn't care about much else other than doing its job – protecting us.

Sometimes we need to hear what our threat system has to say. What are we afraid of? What can we do to help? In a way, demonizing the threat system just invalidates all the distressing experience and memory held within. I think if we really understood the nature of tricky brains, we would see that the last thing we need is a paradigm that demonizes the threat system, and even worse, which adds its own new layer of threat – i.e. the threat of social devaluation/rejection from having a ‘mental disorder.’

What we really need is a paradigm that enables us to experience our threat system in a safe way. We need integration, not demonization.

EM: If you had a loved one in emotional or mental distress, what would you suggest that he or she do or try?

CH: I would try not to suggest at first, but just be there and listen. If she is very distressed, then her mind is likely to be organized in such a way that it will be difficult for her to process and utilize my suggestions. So instead, I’d get alongside her, listen, allow, hold, wait, until she feels safe enough to start generating her own wisdom, ideas, and plans.

The same would apply for her social environment (friends, family, networks, etc.) – I’d help her to create an environment in which she feels safe. We know from attachment theory that a safe base, within affiliative connections, is the ideal kind of platform for us to start developing the confidence and courage to explore our experiences.

If she does want to extend her network into health services, then again, I would favor a service that can facilitate her experiences of safeness. In my opinion, the treatment approaches that are most explicitly geared for this are open dialogue (external social safeness) and CFT (internal social safeness). However, any warm, caring mental health worker will have the potential to help her feel calm, safe, validated, and understood.


Charlie is a clinical psychologist, researcher and trainer at King’s College London. He is currently researching the social context of anomalous experiences and the application of Compassion-Focused Therapy for people experiencing distress in relation to psychosis. He provides psychological therapies in NHS psychosis services, and in private practice. He also runs various compassion training workshops for practitioners and the general public.

A 5-min film illustrating the CFT approach to voice-hearing

Compassion-focused therapy, training and resources in London

The Compassionate Mind Foundation:

A two-day workshop on CFT for Psychosis (26-27 April, London) is being facilitated by Charlie Heriot-Maitland and Eleanor Longden (who appeared earlier in this series on Feb 18):


Eric Maisel, Ph.D., is the author of 40+ books, among them The Future of Mental Health, Rethinking Depression, Mastering Creative Anxiety, Life Purpose Boot Camp and The Van Gogh Blues. Write Dr. Maisel at, visit him at, and learn more about the future of mental health movement at

To learn more about and/or to purchase The Future of Mental Health visit here

To see the complete roster of 100 interview guests, please visit here:

More from Eric R. Maisel Ph.D.
More from Psychology Today
More from Eric R. Maisel Ph.D.
More from Psychology Today