ACT With Compassion

Several of the folks following us at ACT with Compassion have expressed an interest in learning about how ACT with Compassion can help clients who are dealing with the effects of interpersonal trauma. Some of you have noticed that survivors tend to experience high levels of shame. Others of you have shared that compassion-focused work seems to resonate with this population. Indeed, having a history of interpersonal trauma is linked to higher levels of shame, and shame is thought to play an important role in post-traumatic stress disorder (PTSD).  Therefore, it may be beneficial to consider compassion-focused approaches with this population to address the shame-proneness and/or self-criticism that may be maintaining PTSD or other presenting problems.

Shame Is Sometimes Trickier to Work with in Survivors of Interpersonal Trauma

Although it is the case that interpersonal trauma survivors are often highly shame-prone, it is also sometimes the case that working with shame can be especially tricky in this population. This is true for two primary reasons. First, there are often more obstacles to establishing a therapeutic relationship that is secure enough for work on shame and self-criticism to be fruitful. In fact, establishing the therapeutic relationship may itself be part of the shame work. For example, in order for your client to experience you as liking him, he has to be willing to take the perspective that he is likable by another human. This is often a difficult task for any highly shame-prone person, but even more difficult if the person’s learning history involved being violated by someone they depended on or trusted. Second, approaching issues related to shame, self-criticism, and self-compassion with this population may be likely to elicit a shutdown response which can interfere with learning that is needed in order for therapy to be successful. We discuss these issues below.

Getting Started in ACT with Compassion with Survivors of Interpersonal Trauma – Relationship Building and Case Conceptualization

Although the unique issues that arise for survivors are relevant throughout therapy, we focus on the initial stages of relationship building and case conceptualization in this post. The initial stages are the most critical in terms of establishing the relationship, and also are the best time to build the foundation for how you are going to approach these issues throughout your work together.

Establishing the Relationship

If you used our case conceptualization process with a client who experiences intense shame related to interpersonal trauma, you would do some functional analysis of the shame, explore their history related to criticism and history related to warmth, and ask the client to complete some self-report questionnaires. As you were doing that, you would simultaneously be establishing your initial rapport with the client. As stated in our case conceptualization materials, “Sometimes, it is through the relationship with the therapist that the individual is able to really experience this type of kind and compassionate relationship for the first time in their lives.” The relationship with you can be the foundation of a new, kinder self-to-self relationship for the client. However, for the abuse survivor, you may also be the scariest thing in the room with them.

How Dissociation and Shutting Down Interferes with Learning

In a beautiful blog post on Radical Acceptance, Tara Brach describes how working with traumatic abuse sometimes “short circuits” cognitive processing in a way that can interfere with learning:

Traumatic abuse causes lasting changes in our physiology, nervous system and brain chemistry. In the course of normal development, memories are consolidated as we evaluate each new situation in terms of the cohesive worldview we have previously formulated. When there has been trauma, this cognitive process is short-circuited by the surge of painful and intense stimulation. Instead of “processing the experience” by fitting it into our understanding of how the world works and thereby learning from it, we revert to a more primitive form of encoding—through physical sensations and visual images. 

Although the language that Tara Brach uses differs from the language of behavior analysis, her description captures something important about how clients can respond to trauma-related stimuli. For interpersonal trauma survivors, any stimuli related to intimacy, warmth, or interpersonal connection are likely to evoke trauma-related reactions. Thus, when you introduce the parts of the case conceptualization that relate to their history related to warmth and criticism, you may notice the client’s behavior change. She may break eye contact and stare blankly. Her voice may become more monotone and quieter, or she may stop talking entirely. You might get the sense that she can’t hear you anymore.

This trauma-related “shutdown” repertoire is akin to what happens in an animal that is “playing dead.” This reaction appears to be mediated by the emotion system (the “overwhelm” system) that is activated by cues interpreted as indicating the presence of overwhelming threat. The peripheral/bodily reactions associated the overwhelm system are mediated largely through the parasympathetic nervous system, specifically the subdiaphragmatic branch of the vagal nerve. The effect of this activation is an experience of immobilization as described above. Although this shutdown response is not harmful, how the therapist responds to it is essential in developing therapeutic trust and rapport. If the clinician proceeds with ACT as usual while the client is in shutdown, it may feel to the client like the clinician is doing things to her, while she is in a relatively immobilized state and unable to communicate her needs, perhaps similar to her experience during the trauma. Especially in early treatment, this can lead to dropout if not handled appropriately.

A second aspect of this shut down response is a lowered activation of brain areas related to language processing. Because the client loses some amount of verbal processing ability during these times, their ability to learn from your work together may be impaired when this shut down response occurs. Thus, it’s often important to help the client to return to a state in which they are not completely shut down before continuing with other work. Essentially, learning largely stops when the overwhelm emotion system is strongly activated.  There are many different strategies for helping your client return from a shutdown response. For example, the ‘dropping anchor’ exercise from ACT Made Simple guides your client to anchor themselves in the present moment by engaging sensory experience and expanding awareness. Some clients may benefit from other types of sensory experiences to help them to return from shutdown. For example, putting an ice pack on their face, eating an intensely sour candy, or briefly engaging in exercise (e.g., jumping jacks or running in place) may be helpful for some clients. As these exercises involve the client taking physical action you want to be sure to get their permission prior to engaging in them. Ideally, you would have talked through some of these options for handling a shutdown response before the shutdown response occurs and it becomes difficult for the client to have a sense of choice when they are shut down.

Guidelines for Initial Sessions

Below we provide some guidelines for the initial sessions of work with interpersonal trauma survivors that can help strengthen the therapeutic relationship and address the two issues above related to the shutdown response. The initial sessions of therapy are critical a phase in the formation of the therapeutic relationship and avoiding early dropout.

1. Acknowledge that this is a weird situation – I say to my clients something along the lines of, “You are here because you want to address possibly the most vulnerable thing that has ever happened to you. And here you are, talking to a complete stranger about it. What’s it like for you to be in this pretty weird situation?”
   
   
2. Feedback, feedback, feedback – Early on during the first session, let them know that you will be asking for their feedback often, in big ways and little ways. An example of a big way of asking for feedback might be to give them a form to take home about how the session went for them. An example of a little way of asking for feedback might be, “I wonder if [that thing I just said or did] was a bit off target…how did that sit with you?”
   
   
3. Share the things we can predict based on research – We can predict that some of the compassion-focused work might trigger trauma-related re-experiencing. We can predict that the client might shut down or dissociate [though I would ask about whether they are prone to dissociation] at times, and that will interfere with learning. That’s okay. It’s not dangerous, but it feels crappy. Start talking with your client early on about what they might need if and when that happens.
   
   
4. Mistakes are going to happen – Sometimes you will “overshoot” by presenting cues that strongly elicit the shutdown repertoire, so that the rest of the session is less likely to be effective.  Other times you may undershoot. For example, it may be that your own experiential avoidance or fear of harming the client will cause you to refrain from approaching certain topics, or engaging in certain behaviors, and so you will lose the opportunity to evoke behaviors that would be important to work with in treatment. Because mistakes are inevitable and a chance to learn (for both of you), it can be helpful to make a commitment, out loud with the client, to learning from the mistakes as much as possible. You might say, “You know how we discussed previously how it makes sense that you would shut down sometimes? In the beginning of our work together, we are probably going to be doing a bit of a dance to see how to work with that. The only way for us to learn what is effective is through trial and error. That means sometimes I am going to make a mistake that might feel like I went too far and it might cause you to shut down. I can’t commit to never making mistakes, but I can definitely commit to learning from them when they happen. How does this sound to you?” This commitment to learning from mistakes and accepting feedback may be one of the most transformative elements of the therapy given that their perpetrator(s)’ actions likely made this type of repair and healthy intimacy impossible.
   
   
5. Shutting down isn’t dangerous – Because the experience of shutting down may cause the client to feel helpless, terrified, or out of control, clients and therapists alike may have an urge and tendency to shy away from cues (e.g., certain topics) that make shutting down more likely to happen. Shying away from the shutdown response may have the effect of making the client believe that shutting down itself is dangerous. It is very important to communicate clearly and often to the client that shutting down can’t hurt them. In fact, it is an evolved response that likely helped them to remain as safe as possible through past trauma. This re-conceptualization of the shutdown is a key part of addressing shame for some people. I might say something like, “Although you believe there is something wrong with you because you shut down sometimes, it is actually something that has been there to help you when you needed it.”
   
   
6. Be clear about your assumptions – I assume that my client is durable and not fragile, that I am durable and not fragile, I assume we will make mistakes, and I assume and that we are both doing our best. Consider what assumptions will help you do your most effective work with survivors.
   
   
7. The client is in the driver seat when it comes to facing shame and trauma – Let the client know that it is always up to him whether and how much to share with you about his trauma/shame. I might say something like, “Sometimes deciding not to share is an act of higher self-compassion than deciding to share. It’s really important to me that you know, like really know, that you have a choice about how you use your words and your body. I hope that therapy will be an opportunity to develop an unshakable skill in choice and empowerment.” We might discuss this and then I might say, “So, while on the one hand, I want you to know that I will never make you talk about anything you aren’t willing to, on the other hand, it can be tempting to exercise choice and control by not sharing things that could actually be helpful to share. Part of my job will be to ask you if those is one of those times where it might be helpful to share, even when you don’t want to. And then you still get to choose. How does that sound to you?” This would also be a good time to explore with the client various options for handling a shutdown response and asking for their permission to guide them in those different exercises when a shutdown response occurs. As noted previously, it is difficult for a client to consent while they are shut down, so ask permission often and clearly.
   
   
8. Time – The case conceptualization process can be thought of as exposure to difficult internal experiences (including interpersonal warmth and all that has come to be associated with warmth), and a practice in willingness to be vulnerable in the presence of another person. This process can be very painful and transformative for survivors, and it takes time.
   
   
9. It’s supposed to be hard – If this work is hard, it means you (the therapist!) are doing it right.
   
   
10. Love yourself – The more you love yourself, the more effective you will be with your clients doing this work. Doing trauma related work is hard and it’s common for therapists to doubt themselves. This doubt is not a bad thing, but instead a sign that you are sensitive and responsive. Research even shows that therapist self-doubt is associated with better outcomes, as long as you are also loving with yourself.  If you are a survivor yourself, the more you can make space for your own feelings of shame, self-criticism, dissociation, or whatever else shows up, the more flexibility you will have in helping your client without getting fused or even ending up inside of your own shutdown repertoire if that is something you experience (e.g., dissociating). Be curious about what you need in order to stay present and flexible in the presence of trauma-related stimuli. And then be curious again tomorrow.

Written by Melissa Platt, Ph.D., and Jason Luoma, Ph.D.