The service context involves a secondary care community mental health team in a deprived area of South Wales. In this service context an audit completed by the Psychologists revealed a high level of reported abuse, including emotional and psychological, in the client population. Thus, services are configured within a trauma informed approach, and much of the work revolves around trauma. Within the Psychological services, there is also an explicit acknowledgement and inclusion of the findings of the ACE report and the Psychological services in particular are activated around this information. Resultantly, the psychological services have focussed on introducing the term complex trauma into the services and have argued against the use of the psychiatric diagnostic categories to simplify the experience of trauma. Therefore, there is a focus on following the three step model of trauma (Herman) to ensure that clients are given protection against the effects of their trauma and future development of mental health difficulties as well. In fact a contribution made to the draft Matrics Cymru by the Psychologists in this service demonstrated their belief in the evidence base for trauma and their view that this has been neglected in the Matrics, which instead focussed on diagnostic categories. This response to the draft Matrics, together with the audit completed within the service revealing a high degree of trauma amongst the client population and the ACE report formed an important part of my induction to the service. This is mentioned to provide an introduction of the backdrop and context of the Psychological services in which this client was referred.
The client had been referred to Psychology by the Care Coordinator, who has care coordinated this person for nearly seven years. The referral stated that the client had OCD and high standards for how people should behave which is causing problems for the partner. In fact, this view that the client held high standards for how others should behave also formed a significant part of the narrative of the notes in the file. The referral stated that the client’s partner makes frequent phone calls to the service demanding a service to help with his wife’s OCD and for high standards for how he and others should behave. The referral revealed that the client is in the seventies for age. The reason for referral was that the care coordinator felt psychological treatment of the OCD was required. Conversations with the care coordinator revealed a frustration about the number of phone calls to the service by the client’s partner.
In the assessment phase client and her partner attended together. Much of the assessment thus became dominated by the partner’s view about the problem. It seemed that the client’s partner thought the client had OCD because she often became frustrated about the partner’s hoarding problem, though he did not mention that it was a hoarding problem. Thus, it was difficult to initially obtain an accurate view of the client’s difficulties. However, it was noticeable to myself and my supervisor that whenever the client spoke she appeared to endorse a self-blaming response. However, a conflict became apparent when the client contradicted her partner’s description and so I realised it was important to see the client alone. In the additional assessment session, client described to me the difficulties of living with someone who hoards and also the difficulty of living with someone who does not acknowledge her view on most things. However, despite this, the client once again endorsed a self-blaming response to say that to be able to better cope should be her priority. This session, however, made it clear that the criteria for OCD were not met. In this session the client’s presentation also changed quite radically because there were no longer long pauses before speaking and she also did not stutter as she did in the first assessment session.
The formulation developed revealed that early experiences in which her mother and father had been critical of her, and showed a lack of affection, had led to self-criticism and shame. The shame particularly developed as a result of the critical statements referencing specific problems in her character and also experiences of public humiliation. The formulation also illustrates the development of subsequent schemas and core beliefs that pertain to being inadequate, worthless, a failure and so on. The rules for living describe strategies to over-compensate or cope with the consequences of such internal attacks on the self. In particular, one of the client’s over-compensatory strategies is to focus on self improvement and efforts to achieve high standards with the assumption that others would not then be disappointed in her and would not shame her. Her husband’s hoarding behaviour in fact was interpreted as a failure on her part to resolve the problem and led to the belief that she would be shamed by others for this, leading to not inviting any of her friends to the home, which had also led to the experience of loneliness. In particular the client held beliefs that the woman is responsible for the house and so she would be judged harshly for this problem and would be ashamed once again. In more recent years the coping response had become a learned helplessness as a result of which the client had stopped broaching any topics with her partner, leading to sleeping during the day so that the self-critical thoughts could not be stimulated as she would not thus judge herself to have failed to improve the situation at home. This response had led to a diagnosis of depression. The particular formulation developed for this client also showed the development of a strong inner critic which told her she had failed and was inadequate.
An important point to note therefore is that in our formulation depression was thought to be a consequence, as opposed to a singular presentation in its own right. This provided the justification for using CFT with CBT, as opposed to CBT for depression as a single presentation. In fact, research has shown that self criticism is a strong predictive factor for the development of depression (Zuroff et al., 2004). Further, the tendency to become accepting of one’s self attacks is thought to be an important target of therapy in CFT (Gilbert, 2005) and is particularly relevant for this client. Further, problems with self-soothing as a result of early developed attachment issues are also thought to be fundamental to the treatment of self criticism, thus providing protection against depression because individuals with poor self-soothing skills are also likely to be highly self critical of themselves.
Compassion focussed therapy is increasingly being used to tackle issues arising as a result of shame and harsh self-criticism that often develop as a consequence of abusive and neglectful early environments. There is also a recognition that such a mechanism can lead to depression. However, the number of RCTs that have investigated the efficacy of CFT is zero as a result of its emerging status. The RCT method is considered the gold-standard for research in healthcare. Using this methodology CBT has a more robust evidence base for its efficacy in depression. However, the difficulty expressed by client appeared to revolve around shame and self-criticism, with low mood as a response, and so CFT was thought to be a suitable addition to pure CBT. Further, Gilbert (2010) argues that individuals with high levels of shame and self-criticism often find it challenging to engage in therapies such as CBT in which there is a greater focus on evaluating the validity of thoughts. This is because such individuals often endorse their self-critical shaming thoughts as true and find it difficult to argue against them. This is the hallmark of the difficulty for the case to which this study pertains. However, basic CBT skills are germane to CFT, but the combination provides a way of targeting the underlying issues and not just the responses. In addition a study which lacked randomisation but compared CBT alone to cbt and cft together found that the CBT and cft together showed better results for depression (Beaumont, 2012).
In fact, there is a growing evidence base to suggest that compassion has an inverse relationship with mental health problems (Macbeth and Gumley, 2012). Indeed, the Macbeth and Gumley (2012) study found high effect sizes for the connection between compassion and mental health. The trend in the evidence base is to demonstrate that a lack of self- compassion is associated with a large number of psychological difficulties (Schanche et al., 2001). However, such studies are unable to provide primary causal evidence of the connection and so it has been suggested that CFT could provide a helpful lens through which to conduct CBT work, especially as the techniques have the strength to overcome the obstacle created by shame and self-critical processes (Gilbert, 2006). That is, the evidence base indicates that the techniques derived from CFT are facilitative of the greater success of CBT, thus augmenting CBT for such individuals. This specific proposal was investigated in a study in which CBT and CFT were combined and researchers promulgated the idea that CFT could help better engage those individuals with high levels of shame and self-criticism thus providing a valuable augmentation of CBT (Gale et al., 2014). In fact it has been argued that CFT might provide a specific response for those who are high in self-criticism (Kelly et al., 2010), which is pertinent in this particular client’s case.
Further support in the literature for CFT is provided by studies in which using a measure developed to measure self compassion has also been shown to negatively correlate with depression and to positively correlate with well-being (Neff, 2004). Further, individuals scoring highly on this measure of self- compassion were also less likely to respond to personal set-backs with rumination, which has been implicated in the development of depression (Leary et al., 2007). Further, studies have shown that he lack of a developed ability to resist the attacks of the inner critic is positively associated with depression. These individuals often become supplicant to such attacks and thus respond in a way that is likely to foster problems like depression. Further, such individuals are also more likely to respond to such thoughts as though there is an inherent truth in them (Sturmain & Mongrain, 2005). This is often because early trauma, and subsequent attachment related difficulties can lead to a sense that there is something fundamentally ‘defective’ about the individual, which is true in this case. In fact, this process is thought to lead to the development of schemas, which are at a level higher than automatic thoughts and core beliefs. In fact, such information is often held in cognitive-emotional networks, thus providing a way of understanding that such information ‘feels right’ to the person and arguments against it are often resisted. Therefore, the use of CFT with CBT targets the inner critic at the outset, which is thought to be at the centre of the maintenance of such networks.
Therefore, the combination of CBT and CFT was thought to be a more powerful defence against the problem that this client is vulnerable to. In fact, Greenberg et al. (1990) found that the lack of an ability to defend against early developed self criticism is a risk for depression. The combination of CBT and CFT, however, was employed because a fundamental premise of CBT is that providing challenges for negative automatic thoughts can help improve mood (Tarrier, 2006). However, more recent research has shown the importance of accessing other modalities in which emotion-based information is stored (Padesky, ). This provided a further justification for the combination of CBT and CFT. Additionally, there is mounting evidence from neuroscience about the development of a problem with self-criticism that leads to detecting threats in the responses of others to one’s self (Gilbert, 2010). Therefore, the combination of CBT and CFT was used to target this issue as the threat system is implicated in the activation of primary emotions of fear, disgust and shame, all of which are prevalent in this case.
Thus, this integrated assignment presents a case for whom shame and self-criticism were particular problems. Further, subjugation to and acceptance of the self-criticism was high, partially due to a cohort effect of age, partially due to gender-specific issues, but in the main because of an invalidating early environment in which harsh criticism was the norm and love was seldom expressed. This led to the development of an over-compensatory strategy to attempt to always make others happy and to try harder if this appeared to fail to lead to greater acceptance of the client. Underlying this was also an attachment difficulty in which insecure attachment led to fear of abandonment, and also a fear of a lack of love within relationships. Thus CFT combined with CBT was thought to be a helpful response as the problem appeared to not only reside at a cognitive level, but also deeply emotional level, with much imagery of events in which the client had experienced shame and harsh treatment. In fact, during the formulation process the client engaged well in ’emotional bridging’. As mentioned earlier there were also cultural messages about the importance of doing the ‘right’ thing for a woman, which appeared to mean becoming a supplicant and generally invalidating one’s own wishes and desires, and taking the blame for issues.
Once the formulation sessions had been completed, I suggested that we attempt a combination of CFT and CBT, and client agreed. In fact, she seemed to become buoyed by the idea and said that her mood had lifted at the thought of hope that things could improve.
During the subsequent session, however, I attempted to complete BDI which appeared to show a huge improvement in mood in recent weeks, since beginning of therapy. Client explained that having explanations that she does not have a character fault and the psychoeducational information provided had had the impact of lifting her mood. We also completed the CORE. Thus, we measured mood on a simple mood rating scale of 0-10 at the start and end of sessions which showed improvements. We used behavioural measures of improvements to demonstrate whether the therapy is helpful. This showed improvements early on, with greater levels of activation.
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The intervention thus involved using the Mary Wellford book of CFT. During the intervention we developed a compassion specific formulation of difficulties and saw how this had contributed to the vicious cycles that had developed. The client also began to spot and tackle her self-critical thoughts and challenge them. One specific example of a vicious cycle is provided in the appendix that demonstrates how self-blame leads to issues remaining un-tackled. We also developed an understanding and description of the ‘inner critic’, which transpired to be an image of her father. We thus completed an imagery exercise in which we shrank her father’s image to a small size in relation to her and also altered his voice so that it was less audible. Interestingly, following on from this client began to imagine being able to turn down the volume on the inner critic so that she could challenge the voice and also give self-soothing messages about herself. This appeared to help quite dramatically. As a result of having developed this foundation client agreed to try a behavioural experiments early on in which she would talk to her husband about clearing some of the stuff at home. We also role played client being able to use some interpersonal effectiveness skills so that she would not be waylaid when requesting her husband to make changes. We then also looked at the pros and cons of her coping strategies as they generally involved avoidance.
One of the process issues that was consistently present was that the client had subjugated to the demands of the inner critic. However, when downward arrow was completed client appeared to have a good ear for her words, which revealed to her the extent of her general level of self-blame. In fact, making downward arrow explicit to the client seemed to be an effective way of eliciting collaboration. This also led to ‘penny drop’ moments which appeared to thus elicit engagement with the idea of working on the inner critic. We also made explicit the gender related and cultural specific issues of the era in which she grew up to help us understand why the voice of the inner critic might have been easily absorbed into her consciousness. This appeared to improve engagement quite substantially.
Another process issue that arose quite often was that as a result of having a strong inner critic, client would often suggest within sessions that I would know better. This clearly is a demonstration of the client’s responses outside of therapy. Therefore, I used this in the immediacy to demonstrate this so that she could reflect on how she might be responding in general. This also led to us having to tackle the issue that for too long she had been a supplicant to her husband and this had in effect meant that she had not tackled his lack of a response to the hoarding and had also sought his permission for many aspects of her life. For example, she had given up a career as a nurse so that she could be at home more often. This had led to much poverty in their lives as she earned far more than her husband. This brought much sadness to the fore at the thought of being made to endure poverty. This was quite a challenging experience in session as there is a realisation in the sessions that she has been expected to endure hardships at the behest of others. We needed to acknowledge and sit with so that she could also develop the idea that she needn’t avoid all such emotion. We also used this to draw a vicious cycle of emotion to demonstrate what usually happens when there is strong emotion. This is provided in the appendix.
Personally a process issue for myself was that I worried I would not have enough time to help this person, especially when reference was made to her age and the lack of therapy that had been offered in the past. This often led to me wanting to cover too much and so I needed to be mindful of pacing issues. Thankfully the client was someone who could be described as ‘psychologically minded’ and this means that the client often experienced many ‘penny drop’ moments about the dynamics that had been fostered in her life. I also found that she also was quite conversant about the generational issues, in respect to the role of women and so we were also able to use this as grist to the mill. However, as a result of the pressure to help client there was one session in which when a deep thought arose about something, I moved too rapidly to use it as an example to explore it within the model rather than exploring it more fully in its own right and I would do this differently next time.
In supervision sessions my supervisor supported the formulation and use of CFT and CBT in the way that I had presented to him. As a result of the training of the supervisor in mood based models and CAT, I received lots of additional information about the control of mood and how this is impacting the client. For example, extreme control of mood had led to sleeping during the day and waking during the night so that the client was less exposed to triggers for the inner critic, particularly in terms of self-belief in the ability to cope. In fact this diurnal rhythm also seemed to be a response to the lack of interaction between the client and her partner in general during the day. However, this way of managing mood had led to severe avoidance which is demonstrated on the cycle provided in the appendix. The supervisor and I thus agreed that the sleeping was not a biological response to low mood, but in fact a behavioural coping mechanism and mimicked a learned-helplessness-like response. The supervisor and I also discussed the importance of early intervention on a behavioural level, so that therapy is measurable. We agreed that we would take a sessional mood rating, use a session rating and personal scale and the CORE. We agreed that the BDI might be a difficult measure to complete as many of its facets are based on a biological mood model, many factors of which we had been unable to identify with this client in the assessment, formulation or intervention sessions. However, I agreed that I would attempt to complete the BDI as well.
It was interesting that the BDI revealed a low score at the outset. Client said that she felt activated by the formulation sessions because it seemed that her difficulty was being understood. In supervision, we were also able to explore the role of the client’s Christian background in the BDI outcome. For example, factors such as suicide and hope were managed through a belief in Christianity. I also explored how inappropriate it had felt to use the BDI as the terminology was negative. Further, it felt like an invalidation to say that this client does not have a problem due to low score on BDI. This also reinforced using CFT and CBT, since the evidence base for CBT would be stronger for a purer depression.
Further, the BDI did not reveal risk issues. However, I took this to supervision and my supervisor explained that within the mood model of CBT, we would not class depression as a biological response. It was also explained to me that the control of mood is more relevant than the mood itself, which is often a response. However, we also hypothesised that the excessive sleeping during the day could be leading to a lack of focus on low mood, leading to an artificially inflated mood. We also agreed that working on the inner critic in the sense of working on self-efficacy was therefore more important as the formulation showed that this is a fundamental issue. The supervisor agreed and said that in fact this person has strengths we should also focus on.
In an ideal world it seems to me this couple would enter therapy together, and receive a systemic intervention. However, it was made obvious to me at the outset that the client’s partner had a different view of the client’s problem and in fact appeared to blame the client for the difficulty by stating that the problem resides in her. It also transpired in many of our conversations that the client’s partner was not self-reflective and did not appear to believe that his contribution to the problem is significant. To some extent, in therapy we focussed on reinforcing this state of play by focussing on the client alone. One of the ethical issues raised was therefore whether therapy would help energise the client, just to find that things hadn’t changed systemically. However, the difficulty in terms of the development of the inner critic preceded her relationship with her partner and so there appeared to be a good justification to focus on this. Nonetheless, it was difficult to focus on relational issues and their current contribution to the difficulty, as this was just the kind of meta-thinking that the client had in fact attempted to avoid. However, the client had a huge strength in being able to bring these issues to the session which we were then able to explore in a candid and honest way. This reminded me of this client’s strengths and how resilient she had in fact been to have coped with this in the best way that she could, given that her systemic issues tended to reinforce a view of her defectiveness. This is why it was important to focus on inner critic as this provides a way of explaining that the problem is not that of defectiveness of the individual. Firther, this helped lift mood and create and foster hope at the outset and enabled us to develop an effective therapeutic relationship, and so indicated that we were along the correct lines. Following one of the first sessions, for example, the client went out to purchase carpet, which is something she would otherwise allow her husband to purchase alone. Therefore, the choice of modality in terms of CFT and CBT appeared to be the right one in this regard.
Ethically, one of my concerns was whether an inevitable focus on the relationship would lead to much distress when many of the client’s efforts to change things are rebuked by the partner. The elephant in the room appeared to be that had the client had this therapy some years ago she might have made the choice to exit from the relationship. Therefore, I wondered if putting the problems on the table (brought to sessions by the client herself) was unethical as it felt we were not by any means leading to positive change in the relationship per se. Further, I was mindful throughout that one of the common criticisms of Psychology emanating from critical Psychologists is that perhaps we enable clients to feel better in and about bad environments thus leading to a greater acceptability of the environment itself. Thus, one of the issues of importance to me was the acknowledgment of the oppression issues such as the role of a woman and how to sensitively tackle this. I have yet to resolve this with myself, however I managed this issue by ensuring that the agenda items were brought by the client herself so that we tackled what she invited me to help her tackle. This meant that her relationship with her partner was often at the forefront. However, I also thought it could be invalidating to suggest we park this because of the partner’s poor responsiveness. However, the formulation showed that an important role for myself was to equip the client with the tools to tackle the self criticism, leading to a fulfilling life in which she at least does not blame herself for problems in the relationship and thus does not sleep all day due to avoidance.
One of the factors in terms of service delivery I have been able to reflect on is to ensure that the service does not neglect such clients who have not been on the receiving end of the more harrowing versions of abuse such as sexual abuse. Therefore, I have provided feedback about this to my supervisor. Additionally, I think that such clients because of their age might experience prejudice leading to the suggestion that Psychology at this stage in their life would not be helpful or lead to good outcomes. Further, I think that it is important that we heed some of the criticisms provided by critical psychiatry which tell us that often we respond to oppression through reinforcing the oppression by using overtly medicalised versions of distress and not acknowledging the sociocultural reasons for distress. In fact, the service response in terms of psychiatry has been to focus on ‘depression’, the medication for which the client has been taking for ten years. This also provided justification to look more deeply at the problem. In response to this I wrote a letter to update the psychiatrist in which I sensitively provided the psychological formulation so that this could be considered as part of their diagnosis, though it could be argued a diagnosis is unnecessary. It is also interesting that the client’s access to the Psychological service was via the partner’s complaints and frequent phone calls. I think that it would be important that we ensure that such clients receive a helpful initial formulation when they are taken into the service so that they themselves are able to demand services. One of the positive points about the way in which the Psychological services are configured around a trauma informed approach is that every client is given four sessions of formulation development, which therefore leads to responding more often to the underlying issues and reduces the ‘revolving door’ problem. In fact, it has been proposed that at a future review this client might be discharged from secondary care as a result of our work to embolden her protection against the inner critic and thus depression.
The work differed from ‘textbook’ practice in terms of not focussing on the medical labels given to the client e.g. depression which then entails accessing CBT in primary care. However, the justifications for this were as a result of the developed formulation showing the problems with inner criticism and shame based problems as a result of early trauma. The evidence base was then consulted to consider what it suggests for this kind of difficulty, which revealed the value of CFT as a response to this.