Compassion-Focused EMDR

Self-Critical Cognitions

A cognitive theory developed by Ehlers and Clark (2000) proposed that trauma experiences can be appraised in a self-critical manner, and this critical appraisal can become a primary organizing principle for the impact of the trauma. In posttraumatic stress disorder (PTSD), previously held assumptions about the world may have been shattered. In attachment trauma, the assumptions made about the world and self are inherently problematic from the start and later, trauma simply confirms them (Allen, 2013). Such cognitions are emotionally disabling by their impact on self-worth and sense of efficacy (Tracy, Robbins, & Tangney, 2007). Meta-analysis of research using the self-compassion scale showed that critical judgements about the self were strongly associated with psychological disorder (Neff, 2003b). Compassion-focused therapy initially evolved out of cognitive behavioral therapy as issues of social comparison, shame-based cognitions, and tone of alternative appraisals began to be understood (Gilbert, 2014). It is notable that people can feel threatened by their own self-critic, which may manifest as depressive thoughts or psychotic voices (Gilbert et al., 2001). Self-criticism can be functional when it is safer than blaming the parent on whom you are reliant even if that person is abusive (Bowlby, 1980; Gilbert & Irons, 2005). Therefore, abuse-related dominance-submissive patterns may be played out internally in relation to the self. A nonjudgmental but assertive stance toward unwanted thoughts or memories is likely to be more helpful than internal criticism or hatred toward those aspects of self-experience. The person can begin to find ways of engaging with those challenging parts of themselves with a calmer, kinder attitude. Destructiveness can then be contained and managed so that their origins or functions can be understood. Such attitudes reflect true wisdom (Meeks & Jeste, 2009).

Shame

Shame is the appraisal of the self as worthless and bad. It elicits hypoarousal and a motivation to hide from others, attack others or the self, and avoid internal experience and self-knowledge (Gilbert, 1998; Nathanson, 1987). Avoidance of unwanted aspects of internal experience can lead to a phobia or lack of containment of some self-states, and trauma memories may become compartmentalized away from the core self and contribute to the maintenance of PTSD or dissociative disturbance (Steele, van der Hart, & Nijenhuis, 2005).

Gilbert (1998) describes “internal shame” as that which is directed from the self to the self. “External shame” is that expected from other people. Shame can be particularly an issue for people who have experienced early attachment trauma or abuse (Herman, 1997), and shame can have a role in PTSD as well as fear (Harman & Lee, 2010; Lee, Scragg, & Turner, 2001). As social animals, extreme social emotions caused by neglect, abuse, isolation, bullying, and others can be as psychologically damaging as a threat to life (Fonagy, 1996; Gilbert, 1998; Herman, 2011), and shame memories can act as trauma memories (Matos et al., 2013). However, shame memories exceed being feelings and beliefs; they are held as procedural (i.e., automatic) memories of patterns of relating (Allen, 2013), which may often involve submission to negative appraisals (Gilbert et al., 2001). Such shame-based fear of compassion and difficulties in attachment style have been implicated in a range of emotional issues (e.g., Gilbert, McEwan, Matos, & Rivis, 2011).

Impaired Self-Soothing and Emotional Regulation

Liotti and Gilbert (2011), Fonagy (1996), and many other developmentally based researchers describe how people cannot learn to emotionally regulate in the same way as they learn facts. Social encounters can soothe us when in distress, and it is through repeated experiences of such support that people can come to learn to sooth and emotionally regulate themselves in an automatic and implicit way (Fonagy, Gergely, & Jurist, 2003; Germer, 2009; Gilbert, 2009; Schore, 2012; Siegel, 2010). Babies begin their lives experiencing extreme and unintegrated bodily sensations (Allen, 2013). Allen (2013) states “integration of disparate experiences is a developmental achievement, and such integration rests on a mentalizing infant–caregiver relationship in which the caregiver holds the infant’s mind in mind” (p. 82). There is much evidence from the child development literature that demonstrates the important ongoing role that attachment figures have in helping us tackle challenges and anxieties in life. For example, Sorce, Emde, Campos, and Klinnert (1985) showed that infants who saw an encouraging figure at the other end of a visual cliff felt enabled to walk across transparent Perspex and overcome any uncertainty about the apparent drop beneath them. Infants whose mothers looked afraid did not move across the Perspex because they were signalled of danger. Compassionate internalized representations of self and other can therefore give us courage to approach problems and fears. Interpersonal trauma, however, compromises the development of emotion regulation capacities (Schore, 2012; Siegel, 2010) and the capacity to integrate various aspects of experience (Liotti & Gilbert, 2011). Gilbert (2009) describes how there can follow an escalation of difficulties because when the soothing system is compromised by threat, less caring impulses will emerge. Such behaviors shut out possible sources of reparative emotional support.

Theory Underlying Compassion-Focused Therapy

The neurobiological model of CFT sees key anxieties as emerging from the interaction between the life history of the person and the “tricky” nature of our evolved brains (Gilbert, 2000, 2009, 2014). Traumatic memories are tagged by the brain’s threat-based alarm system, called the amygdala, as emotionally significant (Steel, Fowler, & Holmes, 2005). In addition, complex subsystems in the brain unconsciously record expectations regarding social experiences (Fonagy, 1996; Siegel, 2010). Such emotional learning brings about protective actions (Gilbert, 2000; Ogden, Minton, & Pain, 2006). Trauma and its impact on the amygdala compels us to act in particular self-protective ways, for example, fight, flee, freeze, collapse, cry for help, and appease. Such reactions will be represented in people’s best efforts to cope and may unfortunately have unintended consequences which reinforce the key fears and impulses (Gilbert, 2009). The CFT model uses the soothing and drive systems (Depue & Morrone-Strupinsky, 2005) to moderate threat responses and facilitate emotional recovery. Compassion is an active engagement with suffering motivated toward well-being (Gilbert & Choden, 2013).

Research Studies on Compassion-Focused Therapy

The CFT model has been used successfully with a range of different presentations including psychosis (e.g., Gumley, Braehler, & Macbeth, 2014) and eating disorders (e.g., Goss & Allan, 2010). Its application to PTSD and emotionally unstable personality difficulties shows the effectiveness of harnessing the power of compassionate motivations and skills in managing trauma-related conditions (Beaumont, Galpin, & Jenkins, 2012; Lee, 2012; Lucre & Corten, 2012).

How EMDR Addresses Shame and Self-Criticism

There are many ways in which EMDR can already address issues of shame and dysregulation. The use of interweaves to address self-critical cognitions is part of standard processing (Shapiro, 2001). Parnell (1999) discusses how shame can be resolved by more emphasis on stabilization, a focus on symptom relief rather than memory retrieval, and addressing attachment issues with the therapist and others. Blore, Holmshaw, Swift, Standart, and Fish (2013) uses a blind therapist protocol to minimize provoking inhibiting levels of external shame while targeting memories. This trains the client to monitor his or her own change so that the therapist does not need to know the details of the target image. Wesselmann et al. (2012) describes successfully using EMDR methods to address shame emerging from attachment experiences. This article is an attempt to outline another framework to address such issues.

During Phase 1

Engaging the client in EMDR is essential from the beginning, and the very presence of the clinician will alter what is observed in the client during the processing (Dworkin, 2005). However, EMDR may appear as if it is applied by one person to another (Dworkin & Errebo, 2010). The addition of intersubjective attunement can facilitate processing during EMDR, particularly if the nature of therapeutic relationship evolves over the different phases (Dworkin & Errebo, 2010). To take an example of a potential relational barrier, one of the expectations of EMDR is that clients are honest. Shame is a natural barrier to openness (Gilbert, 2009). In addition, clients with learned responses of submission may not be conscious of the ways that they seek approval from the therapist to avoid perceived disapproval or rejection. To deal with this, Dworkin (2005) states that EMDR therapists benefit from awareness of their own blocks and unresolved networks that may resonate with that of their clients. Such awareness prevents barriers emerging, which are cocreated by the alliance. CFT training involves much practice of the principles and techniques on the self so that one can have firsthand experience of the struggle our “tricky” minds have in dealing with competing motivations and the suffering of life (Gilbert, 2009).

Shapiro (2001) acknowledges the importance of unconditional regard and safety in therapeutic engagement, and Parnell (1999, p. 66) elaborates this by describing how the EMDR patient with attachment trauma could come to incorporate the kind presence of the therapist as a “positive self-object.” Therefore, the therapeutic relationship may play a key role in transforming someone from a threat state to one of safeness. Because our brains are sensitive to social cues, how we experience the mind of the therapist can be a healing process in itself (Gilbert, 2007). We think and feel differently when in the presence of someone who we feel holds us in mind kindly to when we imagine they might condemn us.

CFT supposes that working with threat is not just a matter of reduction in negative arousal. Compassionate affiliations create a context not only for soothing but also for growth and well-being. CFT does not just process threat states and associated defenses, but it also stimulates oxytocin-based networks of safeness (Gilbert, 2009, 2013). In this way, it pulls resources from different adaptive networks toward the processing of threat. The evolutionary stance of compassion-focused therapists means they engage with clients from a position of shared humanity and innate principles, which is deeper than empathy. A warm and nonjudgmental stance is critical in CFT, although this in itself can trigger conditioned fears for those with relational trauma (Gilbert, 2007).

During Phase 2

EMDR uses images in resource building, in particular, the “safe place.” Resources are not always limited to a sense of physical safety (e.g., see Shapiro, 2001, p. 435). Dworkin (2005) describes his personal use of a movie character as a resource representing emotional resilience. Parnell (1999) uses nurturing figures, inner advisors, wise figures from history or culture, and positive memories. Recent attachment-based research would support such ideas. Imagery involving good internal attachment figures has the potential to regulate arousal. Mikulincer and Shaver (2007) found ways of encouraging patients to bring to mind secured attachment experiences. This had the effect of enhancing caregiving, improving self-worth, reducing distress relating to trauma, and even reducing attachment issues temporarily. Selcuk, Zayas, Änaydin, Hazan, and Kross (2012) used an experimental design to examine if recalling an attachment figure could help affect regulation after recalling an upsetting event. Bringing to mind a positive person in his or her life had an impact on both reported distress and implicit measures of distress. It also lessened the amount of negative thinking that the person engaged in. CFT links people to emotion regulatory capacities through such imagery. Scripts for compassionate image work are documented in the CFT literature (e.g., Lee, 2012). The image can be an ideal self (perhaps based on a memory of when one has been kind to another), another archetypal being (such as a character from literature or a perfect nurturer), or a perceptual representation (maybe a color). Compassionate mind training has been demonstrated to be a useful resource to patients struggling with adversity (e.g., Gilbert & Proctor, 2006; Mayhew & Gilbert, 2008). Such research supports the use of compassionate images and an encouraging relationship toward oneself as resources during EMDR. Beaumont and Martin (2013) describe using such compassionate mind training successfully as a resource strategy in an EMDR case study. Resourcing the self is a precursor to processing in Phase 2 of EMDR protocols, for closing incomplete sessions and for resourcing future-focused targets (Shapiro, 2001). In this way, the resourcing of a compassionate self aids the engagement with a functional ego state characterized by wisdom, safeness, warmth, and authority. This wise and caring mental network elicits a supportive relationship toward oneself and one’s problems. Having a compassionate self state is an additional resource that uses a specifically positive emotion system as a therapeutic way of bringing emotional regulation within the therapeutic window (Siegel, 1999). In keeping with EMDR resourcing, it allows the person the capacity to experience traumatized states with resources at hand but ones which are specifically tied to internalized soothing relationships (e.g., Lee, 2012). This can be further enhanced by using an object which is conditioned to the image or attachment/soothing memory to elicit embodied safeness. Such compassionate objects are more akin to transitional objects than grounding objects (Winnicott, 1953).

During Phase 3

The negative cognition reflects the maladaptive self-assessment which accompanies an image (Shapiro, 2001). However, CFT would frame this differently to avoid negative judgments about the person’s responses to threat. Compassion-focused EMDR may call this thought the key fears of the inner critic. It avoids language that may be perceived by the clients as suggesting their thought is “wrong” because it is very likely to be linked to attempts to make sense and protect oneself. It also defines the thought as one possible thought of the whole self. The therapist could ask, “What words go best with that experience that expresses your inner critic and deepest hidden fears?” The positive cognition has an important role in establishing a goal and stimulating neural processing. However, the CFT model of the mind incorporates the tonal quality of internal wisdom. The positive cognition in compassion-focused EMDR (CF-EMDR) may be slightly different from a “positive” one in that it would be framed within the “soothing” system (rather than “drive”) to ensure it has warmth and connection inherent in it. In CF-EMDR, the positive cognition is reframed as compassionate wisdom using the mindset of the compassionate image to reflect on the thought, “When you bring up that picture (or feeling state), what would your compassionate self say about the idea, remembering to use a supportive tone of voice toward yourself?”

During Phases 4 and 5

During Phase 6

Compassionate bodywork involves learning to recognize what postures and activities ground and center the person. Breath and bodywork, image work, and the internalization of constructive relationships all contribute to the strengthening of soothing internal representations (Germer, 2009; Gilbert & Irons, 2005). Many therapies already use such mindfulness and sensorimotor attention. The difference is the primacy of the compassionate intention to be warm and accepting toward the experience of the body. Compassionate body scans are described by Gilbert and Choden (2013, pp. 203–205) as including both awareness of the sensations and tolerance of them. It is the second element that harnesses compassionate motivations, which are important to be present with warmth. Relating to the body with compassion opens the soothing system, which brings with it a capacity to contain and integrate experience (e.g., Gilbert & Choden, 2013; Schore, 2012).

During Phase 7

Shapiro (2001, p. 167) suggests closing sessions after ensuring that clients are in a positive state of mind and safe enough to return home. CFT uses strategies to regulate emotion that do more than reduce threat in the body. They are positive strategies for a bodily experience of well-being. These can be achieved through the kind of image work outlined for Phase 2 but also by the practice of soothing rhythm breathing (Gilbert, 2009; Gilbert & Choden, 2013). Soothing rhythm breathing is a way of finding a calming rhythm which is usually slower than routine breath, and hence, it harnesses the body’s natural mechanism to downregulate arousal. This, too, can be part of Phase 2 when patients are helped to stabilize themselves (Gilbert, 2009; Lee, 2012) but is usefully employed at the end of an incomplete session in lieu of a safe place in the standard protocol.

CFT can add practice at home. This might include nonjudgmental journals about their daily practice of compassion. This practice may be image work, breathing, thought journals, or gratitude journals. What this is intended to do is first to shift the focus of attention from threat to something supportive, in particular, their caregiving motivation toward themselves. Second, it reinforces that effort and practice are required to build a sense of safeness and healthier inner relationships.

During Phase 8

Such homework or therapeutic attunement can illustrate the nature of the fears, blocks, and resistances to compassion and recovery. These issues need to be worked through using standard EMDR phases. However, CFT acknowledges that such blocks are inevitable when working with attachment traumas because of the fears that became conditioned to care, dependency, and closeness. The language of CFT would seek to accept such “blocks” into a broader understanding of the nature of our brains. Its focus on strengths and resilience building suggests CFT could be particularly helpful for work on dealing with future anxieties and assimilation into a satisfying life. There are scales and questionnaires that can help show changes in the clients’ fears and self-compassion (Gilbert et al., 2011; Neff, 2003b). Otherwise, discussion of changes in behavioral reactions to events is critical to knowing when issues are resolved sufficiently to move on.