healING the WOUNDS OF traUMa, ShaMe aND GrIeF

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case study healthcare Counselling and Psychotherapy Journal

April 2014

HEALING THE WOUNDS OF TRAUMA, SHAME AND GRIEF

case study

Through a case study, Elaine Beaumont demonstrates the effectiveness of using compassion-focused therapy as an adjunct to psychotherapy

C

ompassion-focused eye movement desensitisation and reprocessing (EMDR) can play a role in healing the wounds of repressed trauma memories, shame and grief. No one therapy is a panacea for all, and the developments of approaches such as compassionfocused therapy1 offer the therapeutic community exciting new interventions to investigate. Shapiro’s adaptive information processing model (AIP)2 suggests that the body and mind have a natural processing system. This model suggests that traumatic events can overwhelm the nervous system and possibly lead to repression, maladaptive emotions, intrusive thoughts, images and hyper-arousal. Parnell3 proposes that the information processing system becomes interrupted like a blocked wound when confronted with trauma. Freud4 suggested that painful repressed memories from childhood can resurface in adult life ‘like an unlaid ghost that will not rest until the memory has been solved and spell broken’. Van der Kolk and Saporta5 propose that ‘the body keeps score’ and somatically retains traumatic memories. Loftus and Ketcham6 suggest that traumatic memories, including sounds, smells, sensations and images, can be replayed like a video tape in the mind. The following quote delightfully captures this idea: ‘Like a magical homunculus in the unconscious mind that periodically ventures out into the light of day and grabs hold of a memory, scurries underground, and stores it in a dark corner of the insensible self, waiting a few decades before digging it up and tossing it back out again.’ Different therapeutic approaches can be helpful at different times of life; for example, a person-centred approach rather than a cognitive or behavioural approach may be better suited to help individuals who are grieving. A combined CBT approach, however, may be better suited to help individuals cope with anxiety-related symptoms. Working collaboratively with clients, using whatever therapeutic approach best meets their individual needs, is therefore an essential part of the therapeutic and recovery process. This consideration is emphasised by Maslow7, who stated that ‘if the only tool you have is a hammer, you will treat everything as a nail’.

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The case of Tom

Beaumont and Hollins-Martin8 found that a compassion-focused EMDR approach healed the wounds of grief for an individual who experienced physical and psychological trauma symptoms that were linked to past and present events. Assessment information for the case for Tom is outlined right.

Eye movement desensitisation and reprocessing (EMDR)

EMDR treatment protocol combines elements from a variety of psychotherapy theories (Shapiro9) including cognitive, behavioural, compassion-focused and client-centred approaches. Shapiro found that after rapid eye movements (eyes moving back and forth), disturbing thoughts and emotions improved. This type of therapy is recognised worldwide and has been used to treat a variety of disorders including post-traumatic stress disorder, flashbacks, depression, phobias and anxiety. The overall goal of EMDR is to reprocess distressing memories both from the past and present in order to alleviate painful psychological and physiological symptoms. Once the distressing memories have been processed, the therapist explores how the client would like to feel, believe and act in the future. EMDR is an eight-phase model which aims to stimulate both sides of the brain in order to help the individual process upsetting memories.

Compassion-focused therapy (CFT) CFT was integrated with EMDR to help the client develop experiences of inner warmth, compassion for themselves, safeness and soothing. CFT increases awareness and understanding of the automatic reactions experienced that have evolved and have been learned during childhood10.

The client was encouraged to employ self-soothing actions. The therapist focused on identifying client strengths, positive attributes, and coping strategies. Listening warmly, acknowledging and validating the client’s emotions and personal meanings were an essential part of the therapeutic process. Incorporating CFT strategies into therapy offers a creative way to work with individuals who report feelings of shame and guilt. CFT has been combined with CBT, and results suggest that self-compassion helps to develop the mind to be self-soothing, nurturing and kind, and suggests that compassionate mind training can be an important adjunct to therapy for victims of trauma11.

Questionnaires

Data were collected using four questionnaires which measured anxiety, depression, self-compassion and trauma-related symptoms: the Hospital Anxiety and Depression Scale (HADS); the Impact of Events Scale-Revised (IES-R); the Self-Compassion Scale – Short Form (SCS-SF); and the Dissociative Experiences Scale-II (DES II).

April 2014

THE CASE OF TOM as reported by Beaumont and Hollins-Martin8

Tom was a 58-year-old white married male who was referred for therapy to treat trauma-related symptoms following a Road Traffic Accident (RTA) in which he claimed to have injured his hand. Various physical examinations revealed no injury to his hand and he was therefore referred for psychotherapy. Tom was referred for help with anxiety, trauma and phobic symptoms. Since the accident, Tom had developed a fear of signing his name in front of people. CBT combined with a compassion-focused approach was the initial treatment option. However, after four sessions of therapy, Tom reported that he was struggling to engage with some of the CBT interventions outside of therapy. Tom and I decided that compassion-focused EMDR might be a more appropriate intervention.

Presenting problems Tom’s presenting symptoms included intrusive thoughts such as: ‘What will people think if they see me shaking?’ The most disturbing image reported by Tom was of him sitting, sweating and shaking, in front of people whilst attempting to sign his name. Tom’s physiological symptoms included poor concentration and sleep disturbance. Tom had nightmares and reported sleep problems due to repeated rumination. Tom was very self-critical and reported feeling tearful, frustrated, ashamed, and angry for developing the problem. Client history Tom had no noteworthy medical history, but had been prescribed beta-blockers by his GP to help him cope with anxiety-related symptoms. Tom described himself as a happy individual but had started to avoid stressful situations. Tom had a happy and fulfilled relationship with his wife that had lasted 25 years. There was no history of emotional, physical or sexual abuse. Tom had four siblings. Tom reported that his younger (sevenmonth pregnant) sister had been killed in a tragic car accident when he was 19 years old. Tom’s goals Tom reported that he wanted to learn to cope with and understand his trauma and anxiety-related symptoms. Tom wanted to sign his name in public without experiencing anxiety symptoms as this was a task he had avoided doing since his car accident. Tom wanted to engage again in social activities and stop avoiding fearful situations. The treatment plan incorporated interventions to help Tom develop self-compassion, an understanding of his symptoms and help him deal with feelings of shame and self-criticism.

case study

Compassion-focused EMDR

— Being asked, ‘When you bring up that picture, what would you like to believe about yourself now?’ Tom replied, ‘I have intelligence’. The Validity of Cognition (VOC) scale was used to measure how true on a scale of 1-7 (1 feels completely false and 7 completely true) Tom believed this statement. Tom replied, 1.

Tom reported that he could not remember much about his childhood, but did report that his sister was killed in a tragic road traffic accident (RTA) many years earlier. His recent car accident and signature phobia was the trigger that impacted on his cognitions, behaviour, emotions and physiology. Tom initially believed that his — Being asked how he felt when he recalled the picture/ hand had been injured in the accident because he began incident and he reported that he felt angry, ashamed to find signing his name in public extremely difficult. and afraid. When asked how disturbing the incident However, medical examination had ruled out physical felt on a scale of 0-10 (0 no disturbance and 10 the damage following the car accident. Hence, the tragic highest disturbance), Tom reported a score of 9. death of Tom’s pregnant sister was linked with the — Being asked, ‘Where do you feel it in your body?’ pseudo hand malfunction post accident and Tom’s Tom replied, ‘Head, stomach and right hand.’ phobia of signing his name in public8. Touchstone memories from childhood may be stored Throughout therapy, compassionate imagery, in a dysfunctional way in the memory system and compassionate letter writing, and mindful breathing therefore it is important to identify past events that exercises were utilised to help Tom tackle his internal have laid the foundation for current problems2. In a critic and feelings of shame. A ‘compassionate inner 8 advisor’ resource12 was installed before trauma therapy study reported by Beaumont and Hollins-Martin Tom was asked, ‘When was the earliest time you remember began. The ‘inner advisor’ was an image that offered feeling this way?’ Tom replied, ‘I can’t remember’. perspective, non-judgment, wisdom, strength and EMDR protocol is to use the ‘float back technique’3 nurtured feelings of safety and warmth. Tom reported which requires that the client float back to an earlier that this strategy helped him to become more time in their life when they experienced the same compassionate and caring towards his own suffering, thoughts, feelings and bodily sensations. Tom recalled as opposed to being judgmental and critical8. two early painful memories from his childhood. An essential part of the EMDR treatment is to ask The first was an incident when he was 13 years old clients a series of questions8 which, in Tom’s case, when his sister had opened a letter addressed to him. included: Tom reported that he remembered feeling angry but — Being asked to identify his worse memory, which he reported that opening the letter by accident was an reported was a memory of his hand shaking when he easy mistake as they both had the same two initials and held a pen in his hand. surname. After this incident, Tom decided to stop using his middle initial to halt confusion with incoming mail. — Being asked to identify his most disturbing image, He reported, ‘It sounds stupid now, but at the time when which he reported was of people watching him when we were kids, getting a letter addressed to you and he signed his name. opening it yourself was a big deal’. — Being asked, ‘What words go best with the picture The second incident Tom recalled was the day his sister that expresses your negative belief about yourself was killed in a tragic road accident. This was a painful now?’ Tom reported, ‘I am stupid’.

Table 1. Pre-therapy, mid-therapy, post-therapy and nine-month follow-up scores on the three questionnaires

Scale

Therapy session scores on the questionnaires Pre-therapy

4th session

8th session

9-month follow-up

HADS Anxiety Depression

18 11

14 8

5 5

6 4

IES-R Avoidance

28

17

5

4

Hyper-arousal

15

14

4

6

Intrusion

25

14

4

5

1.96

2.72

3.71

3.74

SCS

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memory that had been repressed by Tom for many years. Tom started using his middle initial in his signature after her death and reported, ‘I did this in memory of my sister’. Tom’s recent car accident had triggered unresolved emotions about his sister’s death and it became clear that Tom’s anxiety about signing his name was linked to the loss of his sister, because his hand would become stuck and shake when he wrote his middle initial. In a subsequent therapy session, Tom reported that he felt physical disturbance in his head and stomach. He recalled details about the day the police knocked on the door to tell his parents of the accident in which his pregnant sister was killed and how his mother became bereft with grief. Tom reported, ‘I was devastated but remember trying to hold it together for my parents.’ Three months after his sister’s death, Tom decided to use his middle name once again: ‘I remember thinking that I would start to use it again in memory of her.’ In the seventh session of therapy, Tom discussed his recent car accident in which he had become convinced that he had acquired a hand injury. Tom reported, ‘The crash has opened something in me that reminded me of my sister and her death… there is nothing physically wrong with my hand… my hand was getting stuck when I wrote my middle initial… maybe the car accident reminded me of the accident she had… when she died.’

April 2014

In the eighth and final session of therapy, Tom wrote a compassionate letter to himself which ended, ‘I have been through so much pain recently and am really proud that I am taking care of myself… I am sure my sister would be happy.’

Results

Scores pre-therapy, mid-therapy, post-therapy, and at nine-month follow-up, are reported in Table 1. Scores for anxiety, depression and trauma symptoms reduced throughout therapy, with self-compassion scores increasing.

Discussion of treatment

Tom reported that he welcomed the idea of working with ‘his bully within’ and reported, ‘I was my own worst enemy’. A compassion-focused EMDR approach was an appropriate therapeutic approach for Tom as EMDR is a recommended treatment for trauma13. EMDR is effective when guided by theory and a case formulation that identifies touchstone events, links between past and present, and blocks to future functioning. EMDR proved highly effective at resolving Tom’s physiological responses to his traumatic memories and provides data that evidence that compassion-focused EMDR can be a highly effective therapeutic intervention. Developing self-compassion and loving kindness helped Tom resolve the feelings of guilt and shame that were associated with his loss. Tom’s initial trauma, the loss of his sister, was repressed. He reported experiencing feelings of guilt and shame and thoughts of, ‘I am not good enough’. Compassion-focused EMDR resolved these.

… approaches such as compassion-focused therapy offer the therapeutic community exciting new interventions to investigate

case study

Tom was able to engage well with homework activities outside of therapy, with compassionate letter writing and compassionate imagery proving very successful interventions. Tom also incorporated mindfulness strategies (being in the moment without judging) and soothing rhythm breathing into his daily schedule.

Summary

After his recent minor car accident, Tom developed a fear of signing his name and reported overwhelming feelings of blame and shame, together with physical symptoms of distress. Compassion-focused EMDR proved a valuable therapeutic intervention for Tom, with benefits from using compassionate imagery and compassionate letter writing, and with mindful breathing exercises successful at tackling his internal critic. In the case of Tom, writing about his journey and imagining a warm, understanding, wise and kind self helped him develop compassion for his own struggles. This case study provides further insight into the role that traumatic memories can have on the psychological and physiological functioning of an individual. It is essential that psychotherapists continue to measure the effectiveness of interventions and tailor therapy to meet the needs of each individual referred for psychological intervention14. This case demonstrates that incorporating and developing compassion-focused interventions can help heal psychological wounds for individuals referred for psychotherapy. In the case of Tom, developing compassion and kindness for himself proved to be an important adjunct to therapy.

Implications for practice

As a therapeutic community, counsellors and psychotherapists are required to continue examining data from case studies and be open to new ideas and challenges. This case demonstrates that reports from case studies can develop counselling knowledge. Research suggests that incorporating alternative treatment interventions into EMDR practice can prove beneficial to individuals referred for psychotherapy15. Further research could examine if developing selfcompassion at an early age can help individuals deal with the everyday stressors of life in a healthier way. Counselling and psychotherapy will continue to develop and evolve as a profession and the development of approaches such as compassion-focused therapy offer exciting new challenges to explore, and possibly integrate into EMDR practice. Elaine Beaumont is a cognitive behavioural psychotherapist (BABCP accredited and UKCP registered) and an EMDR Europe Approved Practitioner. Elaine provides therapy for Greater Manchester Fire and Rescue Service and is a Lecturer in Counselling and Psychotherapy at the University of Salford.

acknowledgements:

For further information regarding this case study, please refer to: Beaumont E, Hollins-Martin CJ. Using compassionate mind training as a resource in EMDR: a case study. Journal of EMDR Practice and Research. 2013; 7(4):186-199. REFERENCES Gilbert P, Irons C. Focused therapies and compassionate mind training for shame and self-attacking. In Gilbert P (ed). Compassion: conceptualisations, research and use in psychotherapy. London: Routledge; 2005.

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Shapiro F. Eye movement desensitization and reprocessing: basic principles, protocols, and procedures; second edition. New York: Guilford; 2011.

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arnell L. A therapist guide to EMDR: tools and techniques for successful P treatment. New York: Norton; 2007. Freud S. Analysis of a phobia in a five-year old boy. In Strachey J (ed). The standard edition of the complete psychological works of Sigmund Freud. Volume 7. London: Hogarth Press; 1955.

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Van der Kolk BA, Saporta J. The biological response to psychic trauma: mechanisms and treatment of intrusion and numbing. Anxiety Research. 1999; 4:199-212.

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oftus EF, Ketcham K. The myth of repressed memory: false memories L and allegations of sexual abuse. New York: Martin’s Press; 1994.

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aslow A. The psychology of science. Chapel Hill: Maurice Bassett M Publishing; 1966. Beaumont E, Hollins-Martin CJ. Using compassionate mind training as a resource in EMDR: a case study. Journal of EMDR Practice and Research. 2013; 7(4):186-199.

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Shapiro F. Eye movement desensitization and reprocessing. New York: Guilford; 1995.

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ilbert P, Proctor S. Compassionate mind training for people with high G shame and self criticism: overview and pilot study of a group therapy approach. Clinical Psychology and Psychotherapy. 2006; 13:353-379.

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Beaumont E, Galpin A, Jenkins P. ‘Being kinder to myself’: a prospective comparative study, exploring post-trauma therapy outcome measures, for two groups of clients, receiving either cognitive behaviour therapy or cognitive behaviour therapy and compassionate mind training. Counselling Psychology Review. 2012; 27(1):31-43.

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ossman ML. Healing yourself: a step by step program for better health R through imagery. New York: Walker; 1987. Bisson J, Ehlers A. Psychological treatments for chronic post-traumatic stress disorder. Systematic review and meta-analysis. The British Journal of Psychiatry. 2007; 190:97-104.

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rant A, Townend M, Mulhern R, Short N. Cognitive behavioural therapy G in mental health care. London: Sage; 2010. Shapiro F. EMDR and case conceptualisation from an adaptive information processing perspective. In Shapiro F, Kaslow FW, Maxfield L (eds). Handbook of EMDR and family therapy processes. New York: Wiley; 2007.

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Reader response

The author welcomes feedback about this article. To contact Elaine, please email [email protected]

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