Social Theory & Health

https://doi.org/10.1057/s41285-019-00124-x

ORIGINAL ARTICLE

A model for cognitively‑based compassion training:

theoretical underpinnings and proposed mechanisms

Marcia Ash1 · Timothy Harrison2 · Melissa Pinto3 · Ralph DiClemente4 ·

Lobsang Tenzin Negi2

© The Author(s) 2019

Abstract
Across cultures and belief systems, compassion is widely considered to be beneficial
for the development of personal and social wellbeing. Research indicates that com-
passion-training programs have broad health benefits, but how and why compassion-
training programs are effective is still relatively unknown. This paper describes the
theoretical underpinnings of a specific compassion-training program, ­CBCT® (Cog-
nitively-Based Compassion Training), and proposes an integrative model that draws
on existing health behavior constructs to identify CBCT’s core components and
hypothesizes their directionality and interaction. The model includes two primary
categories of skill development: (1) intrapersonal skills leading to greater resiliency,
and (2) interpersonal skills leading to greater compassion. It is hypothesized that
these two pathways are mutually reinforcing and both contribute to greater wellbe-
ing. This model provides a foundation for theory-driven research on the underlying
mechanisms in CBCT training. An understanding of CBCT’s mechanisms is a criti-
cal step towards optimizing and personalizing the intervention to meet the needs of
specific populations.

Keywords Compassion · Wellbeing · Resilience · Contemplative practice ·

Mechanisms of behavior change

Introduction

The purpose of this paper is to provide a conceptual model that explains how
the components of Cognitively-Based Compassion Training (­CBCT®) lead to
greater resilience, compassion, and wellbeing. There is a compelling body of
evidence to support the role of compassion in improving health and wellbeing
(Hofmann et al. 2011; Kirby 2017; Seppala et al. 2017). Prior studies suggest

* Marcia Ash
[email protected]
Extended author information available on the last page of the article

Vol.:(0123456789)
 M. Ash et al.

that compassion appears to be a trainable skill; yet methods for cultivating com-
passion vary across compassion-based protocols. Some compassion-training pro-
grams use a process of cognitive reframing to cultivate a wish to see others free
from suffering (Jazaieri et al. 2012; Ozawa-de Silva and Dodson-Lavelle 2011).
Other related practices include loving-kindness meditations (LKM) which involve
a repeated process of wishing others to be happy (Shonin et al. 2014). Current
compassion-training programs, including CBCT (Pace et al. 2009), Compassion
Cultivation Training (Jazaieri et al. 2012), Mindful Self-Compassion (Neff and
Germer 2013), Compassion-Focused Therapy (Gilbert 2014), and Mindfulness-
Based Compassionate Living (Schuling et al. 2018), have been conceptualized
under broad frameworks (e.g., compassion meditation (CM)) with modest empha-
sis on describing the specific practices and pedagogical models.
A recent meta-analysis of existing compassion-based interventions empha-
sized the need for thorough articulations of the theoretical underpinnings of cur-
rent compassion interventions (Kirby 2017). There are relatively few theoretical
accounts that address the relationship among key concepts and practices that are
critical to the science of compassion training (for examples of existing theoreti-
cal accounts, see Mascaro et al. 2015). Just as different types of physical exercise
result in measurably distinct changes to the body, one would expect that different
practices of cultivating compassion may lead to identifiably distinct outcomes.
While CBCT has been studied across diverse populations and settings (Desbordes
et al. 2012; LoParo et al. 2018; Mascaro et al. 2013; Pace et al. 2009; Reddy et al.
2012), no synthesis is published which provides a comprehensive overview of the
CBCT protocol and its theoretical underpinnings. This paper seeks to fill this gap
by providing an overview of the theory and practices guiding CBCT.
While CBCT has been previously shown to be an effective intervention to
reduce depression and other negative health symptoms (Desbordes et al. 2012;
Mascaro et al. 2016), there is a lack of empirical research addressing the mecha-
nisms of change in a CBCT intervention. Here, we adopt the National Institute of
Health (NIH) Science of Behavior Change definition which refers to mechanisms
of behavior change as “malleable targets that play a role in initiating or main-
taining behavior change” (Nielsen et al. 2018). Mechanisms of behavior change
could take place at different levels of analysis including the psychological, social,
cultural or structural. In the case of the CBCT integrative model, ‘mechanisms of
change’ refer to the relationships among psychosocial skills developed through
participation in CBCT that are expected to lead to the outcomes of interest:
resilience, compassion, and wellbeing. The National Institute of Health (NIH)
Science of Behavior Change Program emphasizes the importance of utilizing
mechanism-focused methods to understand how and why interventions work to
effectively optimize and personalize behavioral interventions for specific popu-
lations (Nielsen et al. 2018). In keeping with that approach, this paper has two
aims: (1) to provide a comprehensive overview of the theoretical underpinnings
and practices of CBCT and (2) to propose a conceptual model that identifies the
psychosocial constructs that influence change mechanisms in CBCT training.
A model for cognitively-based compassion training: theoretical…

Defining compassion

Across existing compassion-training programs, compassion includes at least two

key components: recognition of suffering and a motivation to help (Goetz et al.
2010; Lazarus 1991; Strauss et al. 2016). In CBCT, compassion is understood
as a motivational state predicated on two necessary conditions: affection for oth-
ers and an awareness of their distress. CBCT defines compassion as the warm-
hearted wish to see others free from suffering (Negi 2005; Ozawa-de Silva and
Dodson-Lavelle 2011). Compassion involves an affective component reliant on
feelings of affection for an individual or group and a cognitive component that
includes the awareness of others’ difficulties. This understanding of compassion
as a multi-dimensional construct including both affective and cognitive qualities
is consistent with research in affective neuroscience (Ashar et al. 2016; Dahl et al.
2016) as well as conceptions of compassion detailed in the writings of the Dalai
Lama (2005), the leading spiritual figure in the Tibetan Buddhist tradition.
In the CBCT framework, affection is considered the most critical component
for compassion to arise. While a feeling of affection for another is a precondition
to compassionate behavior, compassion does not necessitate a behavioral change;
the motivation to alleviate others’ distress will frequently occur without knowl-
edge or means of how to alleviate such distress. As such, CBCT does not pro-
vide prescriptive instruction on how to act compassionately in particular circum-
stances. Instead, CBCT trains participants in psychosocial skills that are expected
to strengthen compassionate motivations which may prompt compassionate
behavior, but the resultant actions are dependent on additional factors such as
personal constraints (e.g. what is or is not in a person’s control) and context.
CBCT distinguishes between two forms of compassion: biologically based
compassion and extended compassion. This distinction is drawn according to
the recipient of one’s compassion. Biologically based compassion is rooted in a
natural human tendency to feel affection towards one’s kin. Attachment theory
supports the view that from infancy people seek to maintain loving, supportive
relationships (Bowlby 1982, 1988). Biologically based compassion serves as
the foundation for extended compassion; without training, though, biologically
based compassion is limited to those belonging to one’s immediate inner circle
(e.g. family and friends). Research with infants and young children suggests that
from a young age, helping behavior is often limited to those perceived as familiar
or similar to oneself (Hamlin et al. 2013; Wynn et al. 2017). CBCT provides a
model for cultivating compassion that extends beyond one’s immediate circle and
includes strangers and even adversaries. CBCT endeavors to train participants to
relate to others with increased affection by (1) seeing all others as similar to one-
self in their desire for wellbeing and (2) developing increased gratitude for others.
This training process occurs through the repeated practice of deliberate mental
exercise often referred to as ‘meditation’ or ‘contemplative practice.’ The specif-
ics of the meditation practices included in CBCT will be discussed later within
the CBCT Pedagogy section of this article.
 M. Ash et al.

Benefits of compassion training

Benefits of compassion training include increased positive affect (Fredrickson et al.

2008), decreased self-reported worry (Jazaieri et al. 2013), and increased self-
acceptance in response to anxiety (Jazaieri et al. 2017). Some research indicates the
potential for compassion training to buffer psychological stress and, at a neurophysi-
ological level, to alter the amygdala’s response to witnessing others’ suffering (Des-
bordes et al. 2012; Lutz et al. 2008a; Mascaro et al. 2016; Weng et al. 2013). Pre-
liminary research suggests that compassion training can enhance pro-social behavior
(Condon et al. 2013; Leiberg et al. 2011; Weng et al. 2013).
Research with CBCT has shown that participants exhibited a decreased response
to stress including lower resting cortisol levels, increased recovery from cortisol
surge due to social stress, and decreased inflammatory response (Pace et al. 2012;
Pace et al. 2009, 2013). CBCT practice has also been associated with decreased
depression (Desbordes et al. 2012; Mascaro et al. 2016) and increased empathic
accuracy (Mascaro et al. 2013). CBCT has been tested among diverse groups of
people—foster adolescents showed increases in levels of hopefulness (Reddy et al.
2012); breast cancer survivors reported decreased depression and increased psycho-
logical functioning (Dodds et al. 2015) as well as decreased stress related to fear
of cancer recurrence (Gonzalez-Hernandez et al. 2018); and among a population of
African American suicide attempters, CBCT participants showed increased levels of
self-compassion which mediated depression outcomes (LoParo et al. 2018; Zhang
et al. 2017). While current research highlights certain benefits associated with par-
ticipation in a CBCT intervention, markedly less research has focused on identify-
ing the possible mechanisms that give rise to these effects. The integrative model
proposed in this paper presents a conceptual framework with the aim of providing a
basis for further theory-driven research to investigate the processes for how and why
CBCT promotes health and wellbeing.

CBCT development

CBCT was developed at Emory University in 2005 by Dr. Lobsang Tenzin Negi.
CBCT was created as a secular compassion-based training program adapted from the
Indo-Tibetan Buddhist traditions of lojong (mind training) and lamrim (the stages of
the path for spiritual development) (for an overview see Jinpa et al. 2014; Kyabgon
2007). The definition of compassion adopted in CBCT is in alignment with Indo-
Tibetan Buddhist conceptions of compassion (Dalai Lama 2005), though CBCT is
presented entirely in non-religious terms. CBCT was intentionally designed to be
accessible to persons of any or no faith tradition. Initially, the CBCT protocol con-
sisted of eight distinct modules (Negi 2005). The CBCT protocol has undergone
several revisions since its inception. Currently, the CBCT protocol includes a foun-
dational practice followed by six modules (see Table 1).
Each CBCT module employs a meditation exercise (also referred to as ‘con-
templative practice’) as the primary training strategy. The bulk of scientific
research on meditation has addressed mindfulness-based interventions such as
A model for cognitively-based compassion training: theoretical…

Table 1  CBCT practice overview

CBCT modules Practice topic

Foundational practice: Resting in a moment of nurturance The value of kindness

I. Attentional stability and ­claritya The sensations of the breath
II. Insight into the nature of mental ­experiencea The present-moment experience
III. Self-compassion Personal ups and downs from a
broader perspective
IV. Cultivating impartiality Others’ shared desire for wellbeing
V. Appreciation and affection Interdependence
VI. Empathic concern and engaged compassion Others’ vulnerabilities
a
Modules I and II are present-moment practices, while the foundational practice and Modules III–VI are
primarily analytical practices

Mindfulness-Based Stress Reduction (MBSR) in which mindfulness is understood

as a state of non-judgmental present-moment awareness (Kabat-Zinn 2013). These
present-moment practices typically utilize introspective awareness to observe one’s
inner experience as it unfolds (i.e, watch one’s thoughts and feelings) without react-
ing or analyzing. The CBCT protocol does include training in such present-moment
practices; specifically, CBCT includes focused attention training (Module I)—typi-
cally practiced by focusing on the immediate sensations of breathing. CBCT also
includes open monitoring practices (Module II) in which participants expand the
focus of their attention to observe their unfolding sensations, thoughts, and feelings.
The intended outcomes of these first two modules are attentional control and meta-
awareness, respectively, which are potentially beneficial in and of themselves, but in
CBCT these skills are also taught as foundational tools to engage in the later analyti-
cal practices aimed at the cultivation of compassion.
CBCT—Cognitively Based Compassion Training—is aptly named because many
of the reflective practices include cognitive reappraisal strategies that are catego-
rized here as analytical meditation. Analytical meditation is a method for arriving
at personal insights through critical thinking; it is a process of mental investigation
including reflection and close examination of the CBCT practice topics in relation to
one’s own life experience. Table 1 outlines the practice topic for each CBCT mod-
ule and indicates which modules emphasize present-moment practices and which
emphasize analytical practices.

CBCT pedagogy

CBCT courses generally consist of 10 sessions taught over a 10-week period, meet-
ing 1.5 h per week. CBCT instructors complete a CBCT certification process that
includes a 1-week retreat and workshop, an 8-week seminar, and a 10-week super-
vised teaching assistantship. CBCT sessions include a pedagogical overview by the
certified instructor, guided meditations, and interactive exercises and discussion.
Participants are provided with guided meditation recordings for each module and are
 M. Ash et al.

expected to meditate 15–20 min/day. While this is the standard format for a general,
adult CBCT course, the CBCT course structure and content have been adapted for
other settings and populations.

Process of skill acquisition

The CBCT learning process utilizes two meditation strategies: (1) stabilizing medi-
tation (sustained concentration) and (2) analytical meditation. Together, these strate-
gies support the building of skills across three levels: content knowledge, personal
insight, and embodied understanding. See Fig. 1.

Content knowledge

The first level of skill acquisition relies on learning from an outside source such as
reading, hearing, or seeing. At this stage, content is understood on an intellectual
level.

Personal insight

The second level of skill acquisition develops via a process of reflection, person-
alization, and critical thinking. In this process, one critically reflects on the content
knowledge relative to one’s own life experiences. The goal is to understand the con-
tent at a personal level, and the process is successful when it generates a deeply felt
sense of understanding.

instruction

process of learning from an outside source such as

reading, hearing, or seeing

content • intellectual understanding

• memorization
knowledge

process of personalization, reflection and critical analysis

analytical meditation

personal • increased motivation/commitment

• adopt change strategies
insight • emotional/behavioral shifts

process of sustaining attention on achieved insights.

stabilizing meditation

• enduring motivation/commitment
embodied • sustained change strategies
understanding • embodied emotional/behavioral shifts

Fig. 1  CBCT process of skill acquisition

A model for cognitively-based compassion training: theoretical…

Embodied understanding

Personal insight is considered insufficient for a lasting shift in mindset or long-term

behavioral change. Once the personal insight is experienced, one purposefully sus-
tains attention on the achieved personal insight. Through repeated practice, this
insight becomes more embodied.

CBCT practices

The CBCT framework consists of a foundational practice and six modules that sys-
temically build upon and integrate skills from prior modules. Each module aims to
train specific skills, each of which are considered to be an active ingredient necessary
for the cultivation of extended compassion. The practice instructions for each module
are described below. A summary of the CBCT modules can be found in Table 1.

Foundational practice: Resting in a Moment of Nurturance

All CBCT practice sessions begin by resting in a moment of nurturance. Partici-

pants recall a time they felt cared for and safe. This might be a moment of receiving
kindness from another person but it could also include peaceful experiences with an
animal or in nature. Bringing the moment to mind in vivid detail, participants are
instructed to notice, cultivate, and sustain associated feelings of safety and comfort.

Module I: Attentional Stability and Clarity

In Module I, participants direct their attention to a specific object, which in CBCT is

typically the sensations of breathing. Participants are instructed to notice when their
attention has wandered, disengage from the distraction without judgment, and return
to the intended object of focus.

Module II: Insights into the Nature of Mental Experience

Module II practice utilizes attentional control skills cultivated in Module I and applies
them to a less-specific object of focus (i.e., no longer the sensations of the breath).
Participants are asked to observe sensations, thoughts, and feelings as they unfold
and change over time without getting caught up in particular emotions or thoughts.
The objective is to witness mental activity while resisting the urge to control, react, or
judge the content. When such reactivity is observed, the instruction is to release the
thought or feeling and return to observing present-moment experiences.

Module III: Self‑Compassion

Module III is the first practice within the CBCT sequence in which participants are
prompted to engage actively in cognitive reframing via analytical meditation. The
goal of Module III is to strengthen a compassionate attitude towards oneself by
 M. Ash et al.

re-examining one’s imperfections, vulnerabilities, and adversities within a broader

perspective than one is accustomed. First, participants are prompted to consider how
their thoughts, emotions, and behaviors reflect an underlying desire for wellbeing,
despite the presence of difficulties and distress in life. Through analytical exercises,
participants consider which thoughts, emotions, and behaviors hinder their desired
wellbeing and which support it, including whether they habitually respond to their
own limitations with overly harsh self-judgment. They are then asked to reconsider
personal difficulties in light of two realities: (1) all people experience adversities, lim-
itations, and vulnerabilities and (2) outcomes are not fully in one’s control because
they depend on many causes and conditions. These reflections are designed to engen-
der insight into underlying cognitive appraisals that often contribute to distress.

Module IV: Cultivating Impartiality

Module IV practice asks participants to examine their tendency to label others as

belonging to one of three categories: dear one, stranger, or adversary. Through reflec-
tive exercises, including visualization of one person from each category, participants
are prompted to consider the subjective and changing nature of these categories. Par-
ticipants are asked to consider that like themselves individuals in all three groups share
a desire for wellbeing. Recognition of the ways in which one is similar to others is
intended to foster increased identification and, in turn, an increased sense of affection.

Module V: Gratitude and Affection

The reflective exercises in Module V prompt participants to consider the many

ways they are dependent on others for their own wellbeing. For example, par-
ticipants are prompted to consider all the people who have contributed to an
object they routinely rely on, such as their mobile phone. How many people were
involved in developing, manufacturing, packaging, and shipping a single phone?
Participants are instructed to notice any feelings of gratitude that arise from con-
sidering how they benefit from the efforts of many others. Through visualizations
of individuals, beginning with a dear one toward whom there is already a felt
sense of gratitude, the increasing awareness of interdependence is called to mind
to allow others to be included in the field of gratitude. When expanded feelings of
gratitude emerge, the participant is instructed to sustain attention on the sense of
gratitude; thus, allowing the insight to become more enduring over time.

Module VI: Empathetic Concern and Engaged Compassion

After cultivating increased affection for others in Module VI and V, the Module VI
practice offers an opportunity to attune to the variety of ways others are suffering.
Participants are instructed to call to mind someone they see as vulnerable and allow
compassionate feelings to arise. Stabilizing techniques (developed in Module I and
A model for cognitively-based compassion training: theoretical…

II) are then employed to sustain and strengthen the arising feelings of compassion.
With practice, the compassionate feeling should deepen according to the CBCT pro-
cess of skill acquisition (Fig. 1) such that it becomes a more abiding disposition for
relating to others.

CBCT integrative model

The CBCT integrative model (Fig. 2) depicts the core skills developed in each
CBCT module. The lines linking each construct in the model represent the proposed
mechanistic pathway by indicating the direction and interaction of skills developed
in each CBCT module and their contribution to the primary outcomes: resilience,
compassion, and wellbeing. The CBCT integrative model is divided in two prin-
cipal pathways: intrapersonal (Modules I–III) and interpersonal (Modules IV–VI).
Intrapersonal skills, primarily focused on self-regulation skills and self-compassion,
are intended to lead to greater psychological resilience. The latter half of the model
addresses interpersonal skills with the goal of developing extended compassion for
others. This model proposes that both pathways are mutually supportive and con-
tribute to enhanced wellbeing. See Table 2 for definitions of each construct in the
model. In building the CBCT integrative model, several assumptions were made:
(1) CBCT modules are taught linearly, but the skills developed are mutually rein-
forcing and integrated both conceptually and through practice; (2) CBCT skills and
outcomes can be strengthened with ongoing practice according to the proposed pro-
cess of skill acquisition (Fig. 1); and (3) Competency in skills developed in Modules

MODULE I attentional
Attentional Stability
and Clarity control

meta-
awareness
MODULE II
security Insight into the resilience
priming
Nature of Mental
Experience
dereification

MODULE III
self-
Self-Compassion compassion
FOUNDATIONAL
PRACTICE
wellbeing
Resting in a Moment of
Nurturance

MODULE IV
Cultivating
Impartiality
identification

affection
prosocial MODULE V
Gratitude and gratitude
motivation Affection
compassion

MODULE VI
Empathetic Concern
and Engaged
Compassion
empathy

Fig. 2  CBCT integrative model

Table 2  CBCT skills and outcomes
Construct Definition

Intrapersonal Security priming The experience of remembered feelings of safety and care
Attentional control The ability to sustain focus on object of interest
Meta-awareness The ability to notice what one is thinking and feeling
Dereification The ability to distinguish thoughts from accurate representations of the world
Self-compassion Feelings of kindness and acceptance directed at oneself
Interpersonal Prosocial motivation The desire to engage in behavior that is beneficial to others
Identification The process of viewing others as similar to oneself
Gratitude Positive feelings directed toward others based on the recognition of received benefits
Affection Feelings of warmth, closeness, and connection directed toward others
Empathy The ability to understand what another person is feeling and/or thinking
Outcomes Resilience The ability to recover, adapt, or grow in response to stressful or adverse experiences
Compassion A sensitivity to the suffering of others coupled with the desire to alleviate it
Wellbeing A state of positive psychosocial health
M. Ash et al.
A model for cognitively-based compassion training: theoretical…

I and II is critical for engagement in analytical practices (Module III–VI) and each
contributes to the principal outcomes: resilience and compassion.
An overview of each skill included in the CBCT integrative model can be found
in the following section.

Foundational practice skills: security priming and pro‑social motivation

The nurturing moment practice has two important functions as the foundational
CBCT practice. Security priming—the ability to engender feelings of safety and
comfort—is intended to ready the participants for learning by generating a sense
of safety and openness. Within the domain of attachment theory (Bowlby 1982),
secure attachment is associated with increased cognitive openness and flexibil-
ity (Collins and Read 1994; Mikulincer 1997). The foundational practice should
allow participants to become more facile in voluntarily generating a sense of
inner calm. In the CBCT integrative model, the ability to volitionally induce feel-
ings of security is considered critical for the development of enhanced resilience.
Second, the foundational practice is intended to strengthen pro-social motiva-
tion by reminding participants of the value of compassion as a basis for develop-
ing and strengthening pro-social motivation. Prior literature supports that secu-
rity priming promotes care-oriented feelings and behaviors (Mikulincer et al.
2005, 2014). The pro-social motivation developed in the foundational practice
is intended to allow participants to more energetically engage in the cultivation
of compassion via the subsequent six modules. Thus, the foundational practice
serves as the basis for the development of both intrapersonal and interpersonal
skills as is depicted in the CBCT integrative model.

Module I skill: attentional control

The attentional control that is enhanced in Module I is considered a critical skill

that is applicable to all other CBCT modules. Attentional control refers to the
ability to sustain attention on an intended object of focus while noticing distrac-
tions and repeatedly returning to the intended object of focus. There is a robust
array of research demonstrating that practicing mindfulness meditation (of which
attention training is typically a central component) can improve attentional stabil-
ity including improvements in alerting-response functioning and executive atten-
tion (Jha et al. 2007; Tsai and Chou 2016; van den Hurk et al. 2010).

Module II skills: meta‑awareness and dereification

In Module II, participants gain insight into the impermanent nature of thoughts and
emotions by observing their unfolding mental activity through a process of meta-
awareness. Meta-awareness has been defined as an ability to observe the current
contents of one’s conscious experience (Schooler 2002; Smallwood and Schooler
 M. Ash et al.

2015). This definition is consistent with Indo-Tibetan Buddhist conceptions of meta-

awareness as most elaborately detailed in Abhidharma–Samuccaya (Asaṅga and
Webb 2001). Noticing when one’s mind has wandered involves processes of meta-
awareness. Several studies have shown that many people fail to recognize when their
attention has wandered and only engage meta-awareness intermittently (Schooler
2002; Schooler et al. 2011; Winkielman and Schooler 2011). A second and related
skill associated with Module II is dereification—sometimes referred to as decen-
tering (Williams 2010). Dereification is the ability to experience thoughts as just
thoughts and not necessarily accurate representations of the world; thus, Module II
practice is often described as a process of non-appraisal (Lutz et al. 2015). Both
meta-awareness and dereification are considered to be central dimensions of open-
monitoring practices (Lutz et al. 2015; Lutz et al. 2008b). Module I and Module II
together provide tools through present-moment practices that support the proposed
CBCT process of skill acquisition (see Fig. 1).

Module III skill: self‑compassion

Self-compassion is a burgeoning construct within the psychological literature (Neff

2015). Neff and colleagues who developed the Self-Compassion Scale define self-
compassion as relating to oneself with kindness, especially in times of difficulty or
personal suffering (Neff 2003). While this definition is similar to CBCT’s concep-
tion of self-compassion, CBCT frames self-compassion as both a skill to foster resil-
ience and as an important component to support the cultivation of compassion for
others in Modules IV–VI. For this reason, self-compassion is positioned as a moder-
ating skill in the CBCT integrative model while compassion for others is considered
a primary outcome of CBCT training. CBCT defines self-compassion as the abil-
ity to relate to personal difficulties in light of the reality that all people experience
adversities, limitations, and vulnerabilities. Self-compassion is not only seen as a
skill to promote personal happiness, but it is framed within a relational context. By
cultivating confidence to be able to experience difficult situations without becoming
overwhelmed, we expect the participant will become better able to respond to the
suffering of others with greater compassion. Previous research has shown a strong
negative association between self-compassion (measured by the Self-Compassion
Scale) and several markers of psychopathology including depression, anxiety and
stress (for overview, see MacBeth and Gumley 2012). A recent meta-analysis also
highlighted significant associations between self-compassion and psychological
wellbeing (Zessin et al. 2015). Research on the association between self-compassion
and compassion for others, however, has had mixed findings which warrant further
investigation (Lopez et al. 2018; Neff and Pommier 2013). Importantly, in the CBCT
integrative model, the development of self-compassion and the development of
compassion for others are understood to be mutually supportive.
A model for cognitively-based compassion training: theoretical…

Module IV skill: identification

Module IV is the first module in the CBCT sequence that explicitly addresses rela-
tions with others. The primary skill developed in Module IV is a more inclusive
sense of identification with others. Participants cultivate the insight that everyone,
even difficult people, are “just like me” in their desire for wellbeing. Module IV
practice is intended to soften feelings of extreme liking or disliking for certain indi-
viduals or groups. In CBCT’s integrative model, the recognition of common human-
ity—that everyone shares the wish to thrive and to avoid suffering—is the basis for
the cultivation of extended compassion.
Identification has been previously linked to increased likelihood of engaging in
helping behavior. For example, experimental research by Levine and colleagues
found that people are significantly more likely to stop and help someone wearing a
T-shirt supporting their favorite sports team than an unmarked or rival group T-shirt
(Levine et al. 2005). In the CBCT integrative model, identification is understood as
a building block for relating to others with affection.

Module V skill: gratitude

The purpose of Module V is to deepen a sense of gratitude for others. Gratitude has
been previously associated with a host of positive health benefits including better
sleep quality, decreased depression, and overall wellbeing (Wood et al. 2009, 2010).
Gratitude is also associated with increased social affiliation (Bartlett et al. 2012) and
prosocial behavior (Bartlett and DeSteno 2006; Tsang and Martin 2019). While the
benefits of gratitude are well documented, there still remains limited understand-
ing regarding the process for how gratitude can be cultivated; nevertheless, modest
evidence supports that journaling and reflection may provide a means for enhanc-
ing gratitude (Emmons and McCullough 2003; Frias et al. 2011; Sheldon and
Lyubomirsky 2006).
In Module V, participants engage in reflective strategies to extend feelings of
gratitude to others. By considering the ways in which they rely on interdependent
societal systems, Module V encourages participants to see that it does not make
sense to limit appreciation to only small groups of people who provide the most
obvious benefit. In the CBCT integrative model, it is assumed that if one feels a
sense of gratitude for another, then one will naturally begin to relate to that person
with increased affection—a critical ingredient for compassion.

Affection and its role in Modules IV and V

In the CBCT integrative model, identification and gratitude are intended to enhance
the cultivation of affection for others. In this case, affection is being used to translate
the Tibetan word “yid-‘ong” which conveys someone who is pleasing to the mind
(for a more detailed overview, see Cutler and Newland 2015). Under this definition,
affection should not be confused with feelings of romantic love. More appropriately,
affection can be understood as an endearing way of relating to others characterized
 M. Ash et al.

by a sense of tenderness. In the CBCT integrative model, affection is the most criti-
cal ingredient to allow for compassion to arise. If one does not relate to another
with some degree of affection, then one will not be motivated to respond to them
compassionately. While participants likely relate to some friends and family with
a degree of affection, CBCT practices aim to extend this quality of affection to a
broader circle of people through processes of critical thinking and cognitive refram-
ing. This emphasis on cognitive reflection as path to affection contrasts common
western notions of affection as state primarily driven by emotions. Both Modules
IV and V cultivate insights to allow for this extension of affection as a natural out-
growth of relating to others with increased identification and gratitude.

Module VI skill: empathy

Empathy is the experience of resonating with or understanding the way another per-
son is thinking or feeling. There is robust evidence that feelings of empathy can lead
to either a response of personal distress or empathic concern (Batson et al. 1994;
Decety et al. 2009; Eisenberg 2000; Eisenberg et al. 1989). An empathic distress
response results when one becomes emotionally distressed in response to the suf-
fering of another; in this case, attention becomes more oriented towards self than
towards the person suffering. In contrast, a response of empathic concern remains
other-oriented; in this case, one feels a sense of concern for the other and remains
focused on their situation. Empathic concern can thus elicit and sustain a motiva-
tion to help. More recent advances in affective neuroscience have shown distinct
differences in neural circuitry patterns when someone experiences an empathic dis-
tress response versus an empathic concern response (Singer and Lamm 2009). In
the CBCT integrative model, the affection developed in Modules IV and V is pro-
posed as a means to strengthen the focus on the other when confronted by suffering
and to buffer against the likelihood of an empathic distress response. We propose
that when one relates to another with increased affection, one will be more focused
on their suffering and how it may be alleviated and not be subsumed by one’s own
stress response. This view is consistent with research by Batson and colleagues who
showed valuing the welfare of others as antecedent to empathic concern. In Batson’s
model, empathic concern relies on perceiving the needs of another, valuing their
welfare, and taking their perspective (Batson et al. 2007).
It is important to note that the merits of empathy have been debated among psy-
chologists, most notably Paul Bloom, who argues that whom we feel empathy for is
often biased and short-sighted which can lead to immoral decision-making (Bloom
2017). We acknowledge the importance of this critique; it is for this reason that
the practice in Module IV: Cultivating Impartiality, wherein participants develop
increased identification with others, is of critical importance towards cultivating
extended compassion that is less subject to pre-disposed biases.
A model for cognitively-based compassion training: theoretical…

Resilience

In the CBCT integrative model, skills developed in the foundational practice and
Modules I–III are expected to enhance individual resilience. Resilience has been
studied across a variety of disciplines and contexts including psychology (Fletcher
and Sarkar 2013; Rutter 1987), sociology (Hall and Lamont 2013), and ecology
(Holling 1973). While definitions vary, in the context of the CBCT integrative
model, we primarily refer to resilience to consider psychological traits and processes
that enhance a person’s ability to recover, adapt, and ultimately grow in response
to adverse life experiences. In CBCT training, the security priming cultivated in
the foundational practice can be used as a tool to regulate the body when aroused
or distressed. Then, the attention cultivated in Module I is intended to foster par-
ticipants’ ability to choose where to place their attention, potentially disengaging
from distracting or harmful thoughts. Skills from Module II support participants
in observing their own mental activity through the use of meta-awareness. Further,
Module II practice is intended to lead to more accurate and granular perception of
one’s thoughts and feelings as well as an understanding that thoughts do not neces-
sarily align directly with external realities. Module III practice goes a step further by
asking participants to actively engage in cognitive re-appraisal strategies to respond
to their own challenges with kindness and self-acceptance based on the understand-
ing that adverse events are part of every human life and are due to many causes
and factors outside of the individual’s full control. Together, the skills cultivated
in the foundational practice and Modules I–III are intended to allow participants to
respond to challenges with enhanced resilience.
Importantly, the skills identified in the CBCT integrative model to promote resil-
ience are limited to components directly targeted in CBCT training. The model is
not intended to reflect an exhaustive list of factors that may promote resilience. For
instance, the prior literature suggests resilience is moderated by other psychologi-
cal factors which the proposed model does not directly address such as self-efficacy
(Schaubroeck and Merritt 1997) or positive affect (Tugade and Fredrickson 2004),
though these two factors in particular are likely encouraged by CBCT practices in
secondary ways. Furthermore, larger systems and structures related to economic
status, environment, cultural norms, and laws and policies are known to signifi-
cantly affect personal and social resilience (Bottrell 2009; Hall and Lamont 2013;
Walker et al. 2006). These findings are consistent with social ecological theories
which illustrate the ways in which behavior is subject to multiple levels of influence
including societal, communal, organizational, social, and personal (Bronfenbrenner
1977; McLeroy et al. 2016). In keeping with this view, we do not espouse that resil-
ience can be understood as simply an intrapersonal trait divorced from factors such
as social support, culture, or socioeconomic status. We acknowledge that social and
systemic factors are of critical importance to the promotion and support of resil-
ience, but they are outside the scope of intervening factors explicitly addressed in
Modules I–III of CBCT training.
 M. Ash et al.

Compassion

The skills developed in Modules IV–VI are expected to increase extended compas-
sion for others. Identification (developed in Module IV) and gratitude (developed
in Module V) are both expected to contribute to a sense of affection for a wider
group of people. This sense of affection is paired with a growing awareness of oth-
ers’ vulnerabilities through enhanced empathy (developed in Module VI). As such,
the final three modules train participants to both notice the suffering of others and
feel motivated to help as a result of increased and more inclusive affection. In this
way, skills developed in Modules IV–VI are potentially supportive of forms of social
resilience, which is defined as the ability of groups to sustain wellbeing in the face
of challenges (Hall and Lamont 2013). Module V explicitly trains participants to
consider the ways in which their wellbeing is dependent on other people and sys-
tems, often referred to as “interdependence.” We expect that a growing awareness of
their interdependent nature combined with a motivation to help may foster forms of
social resilience by empowering individuals to appreciate the ways their actions can
affect the communities in which they live. Thus, while CBCT is an intervention that
targets individuals, efforts to expand compassion to growing networks could have
social and societal implications.

Wellbeing

In the CBCT integrative model, wellbeing is conceived of as a state of positive psy-

chosocial health that is supported by intrapersonal skills fostering resilience and
interpersonal skills enhancing compassion for others. We propose that both path-
ways promote wellbeing and are mutually supportive. As stated previously, partici-
pation in CBCT has been associated with reductions in stress and depression (Des-
bordes et al. 2012; Mascaro et al. 2016). One possible explanation for this finding
is that if a person feels better equipped to respond to personal challenges, then he
or she should have more available energy to consider the needs of others. Similarly,
we expect relating to others with compassion would promote feelings of social con-
nection which support resilience. This conceptualization of wellbeing shares some
similarities with other wellbeing models. For instance, Ryff’s psychological wellbe-
ing framework includes constructs such as self-acceptance and positive social rela-
tionships (Ryff 1989, 2014). There are strong correlations between self-compassion
and psychological wellbeing (Zessin et al. 2015), though less is known about the
relationship between compassion for others and wellbeing. Lopez et al. did not
find a significant association between compassion for others and wellbeing (2018),
however, compassion training has been previously shown to boost positive affect
(Klimecki et al. 2013) and self-reported happiness (Mongrain et al. 2011). Further
research is necessary to better delineate the relationship between resilience, compas-
sion for others, and wellbeing.
A model for cognitively-based compassion training: theoretical…

Discussion

This article proposes a model for understanding CBCT’s key components and mech-
anisms. While recent research on CBCT has suggested a number of benefits from
its practice, little research has addressed how and why these practices are effective.
The CBCT integrative model proposes a framework for how key skills developed in
each module may lead to three principal outcomes of interest: resilience, compas-
sion, and wellbeing. The NIH Science of Behavior Change Program identified three
target classes that are central to behavior change: self-regulation, stress resilience
and stress reactivity, and interpersonal and social processes (Nielsen et al. 2018).
The proposed CBCT mechanisms of change include skills relevant to each identified
class. Module I through Module III primarily involve developing intrapersonal skills
intended to foster self-regulation and individual-level resilience. Module IV through
Module VI aims to develop other oriented, interpersonal skills that are necessary for
extended compassion. The CBCT integrative model proposes that wellbeing is con-
tingent on both personal resiliency and compassion for others. We expect these two
factors are mutually reinforcing—i.e. greater resilience may prevent burnout and
thereby facilitate the availability of more energy to care for others; likewise, experi-
encing greater compassion for others may allow for enhanced resiliency as individu-
als can respond to their own difficulties from a broader context.
While the CBCT integrative model provides a conceptual model indicating the
proposed relationship between key skills and outcomes developed in CBCT train-
ing, we expect a host of other factors not addressed in the model to likely moderate
effects of CBCT. For example, this model does not consider individual features and
contexts relevant to the participant including demographic variables, health and psy-
chological functioning, or prior exposure to contemplative practices. To date, there
is limited research directly investigating moderating variables pertinent to compas-
sion training. One study led by Goldin and Jazaieri found that demographic varia-
bles did not moderate effectiveness of compassion training, though they did find that
psychological functioning including perceived stress, mindfulness skills, and cog-
nitive reappraisal self-efficacy did moderate reductions in fear of self-compassion
after compassion training (2017). In a different study among a sample of medical
students participating in a CBCT intervention, Mascaro et al. found that those with
higher depression scores at baseline showed the largest increase in compassion for
others after CBCT was complete (2016), suggesting those in mental distress may
particularly benefit from CBCT training.
Similarly, the CBCT integrative model does not account for cultural and environ-
mental factors that may affect participants’ engagement with and benefit from CBCT.
Health behavior interventions at large have been criticized for their emphasis on tar-
geting individual level factors without consideration for the larger systems and social
structures that shape behavior (Holman and Borgstrom 2016; Stokols 1996; Thorlinds-
son 2011). There is increasing research utilizing social network theory to understand
the ways in which social ties and position within a social network influence a myriad
of behaviors (Borgatti et al. 2009). For instance, risk for obesity increases by 57% if a
friend becomes obese (Christakis and Fowler 2007), suggesting a contagion factor for
 M. Ash et al.

unhealthful attitudes and behaviors. It is possible that healthful behaviors may also be
transmitted through social networks. We do not yet have sufficient data to understand
the ways in which dynamic social and cultural processes influence engagement with
CBCT as well compassionate behavior, but we advise that future research should con-
sider the impact of social networks and cultural contexts. Given that CBCT’s principal
goal is to enhance compassion for others, it is essential that future research consider
social and systemic factors that may influence potential outcomes. It is our intention
that the CBCT integrative model will provide a theoretical basis to study how different
populations experience and potentially benefit from CBCT training.

Conclusion

The CBCT integrative model provides a framework for future theory-driven research
on CBCT. Previous research on CBCT has primarily examined changes in health out-
comes after participation in CBCT training. It is our goal that the CBCT integrative
model provides a conceptual framework to understand the psychosocial processes
that influence such change. The proposed mechanistic relationships in the CBCT
integrative model are drawn primarily from the Indo-Tibetan Buddhist lojong frame-
work from which CBCT was adapted. It will be important for future research to align
identified constructs with appropriate empirical measures to test the effectiveness of
the model. The constructs outlined in the model are not exhaustive; we expect other
factors to also impact the outcomes of compassion training. Next steps for future
research include addressing the following questions: (1) Can the proposed mecha-
nisms in a CBCT intervention be confirmed? (2) What is the relationship between
identified intrapersonal skills (e.g. resilience) and interpersonal skills (e.g. compas-
sion)? The CBCT integrative model assumes intrapersonal and interpersonal skills
are mutually reinforcing, but this assumption should be addressed empirically. (3)
What are the impacts of dosage and sequence for a CBCT intervention? A 10-week
CBCT intervention is divided roughly into thirds with equal emphasis given to pre-
sent-moment practices (Modules I and II), self-compassion practices (Module III),
and other-oriented compassion practices (Modules IV–VI). It will be important for
future research to examine the impact of sequence and dosage on potential beneficial
outcomes. (4) How should the current CBCT integrative model be revised according
to empirical findings? An improved understanding of the mechanisms present in a
CBCT intervention could lend important insight regarding how to optimize and per-
sonalize the intervention to meet the needs of diverse populations.

Acknowledgements We thank Bobbi Patterson for her input on an earlier draft of this paper.

Compliance with ethical standards

Conflict of interest Authors Marcia Ash, Timothy Harrison, and Lobsang Tenzin Negi are employed by
the Center for Contemplative-Science and Compassion-Based Ethics at Emory University. Authors Melis-
sa Pinto and Ralph DiClemente are on the Advisory Board of the Center for Contemplative Science and
Compassion-Based Ethics at Emory University. Lobsang Tenzin Negi is the developer of C ­ BCT®, but
neither he nor any of the other authors hold a financial stake in the intellectual property rights of ­CBCT®.
A model for cognitively-based compassion training: theoretical…

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 M. Ash et al.

Marcia Ash MPH is a doctoral student in the Department of Behavioral Sciences and Health Education
at the Rollins School of Public Health at Emory University. Ash is also a certified Cognitively-Based
Compassion Training ­(CBCT®) instructor. Ash holds a Bachelor of Arts in Philosophy, Neuroscience
and Psychology from Washington University in St. Louis and a Masters in Public Health (MPH) from the
Behavioral Sciences and Health Education Department at the Rollins School of Public Health at Emory
University.

Timothy Harrison M.Arch. is the Associate Director for C ­ BCT® (Cognitively-Based Compassion Train-
ing) at the Center for Contemplative Science and Compassion-Based Ethics at Emory University. He
oversees CBCT programs, including multiple research initiatives and the teacher certification process. He
regularly teaches CBCT nationally and internationally in academic institutions and healthcare settings,
and he advises on the tailoring of CBCT for research with unique populations. He holds a master’s degree
from Harvard University.

Melissa Pinto Ph.D., RN, FSAHM, FAAN is an Associate Professor in the Sue & Bill Gross School of
Nursing at the University of California, Irvine. She has expertise in the area of adolescent and young
adult behavioral health, self-management, development and assessment of eHealth and technology-based
behavioral health interventions, and psychosocial barriers to mental health treatment for adolescents. She
completed her PhD in Nursing Science at the University of Louisville and a KL2 Award at Case Western
Reserve University. Dr. Pinto is a Fellow of the Society for Adolescent Health and Medicine and the
American Academy of Nursing.

Ralph DiClemente Ph.D. is Chair of the Department of Social and Behavioral Sciences and Associate
Dean of Public Health Innovation at New York University. Dr. DiClemente has focused on developing
intervention packages that blend community and technology-based approaches that are designed to opti-
mize program effectiveness and enhance programmatic sustainability. He has published extensively in the
area of adolescent health, particularly HIV/STD prevention, among adolescents and young adults, and in
adolescent vaccine programs for influenza and HPV prevention. Dr. DiClemente holds a PhD in Health
Psychology from the University of California, San Francisco after completing a SCM at the Harvard
School of Public Health.

Lobsang Tenzin Negi Ph.D. is a Professor of Pedagogy in the Department of Religion at Emory Univer-
sity. He is also the Executive Director of the Center for Contemplative Science and Compassion-Based
Ethics as well as the developer of ­CBCT® (Cognitively-Based Compassion Training). He is a former
monk who completed his monastic education at Drepung Loseling Monastery in South India where he
received the Geshe Lharampa Degree—the highest academic degree granted in the Tibetan Buddhist tra-
dition. He completed his PhD at Emory University where he studied traditional Buddhist and contempo-
rary western approaches to emotions and their impact on wellness.

Affiliations

Marcia Ash1 · Timothy Harrison2 · Melissa Pinto3 · Ralph DiClemente4 ·

Lobsang Tenzin Negi2
Timothy Harrison
[email protected]
Melissa Pinto
[email protected]
Ralph DiClemente
[email protected]
Lobsang Tenzin Negi
[email protected]
A model for cognitively-based compassion training: theoretical…

1
Rollins School of Public Health, Emory University, 1531 Clifton Rd. NE, Room 549, Atlanta,
GA 30322, USA
2
Center for Contemplative Science and Compassion‑Based Ethics, Emory University, 1599
Clifton Rd. NE, Atlanta, GA 30322, USA
3
Sue & Bill Gross School of Nursing, University of California, Irvine, 284 Berk Hall, Room
100D, Irvine, CA 92967, USA
4
Department of Social and Behavioral Sciences, College of Global Public Health, New York
University, New York, NY, USA