Enhancing Trauma Therapy with Compassion – with Dennis Tirch, PhD

We’re helping people to begin from a place of cultivated mindful awareness, flexible, focused attention, and an enhanced willingness to turn towards difficult experiences. We’re helping them to build this capacity, this embodied compassionate capacity, which can allow them to have a more effective container for these difficult states of mind and be oriented to moving towards the suffering. It’s inherent – a sensitivity to suffering, plus a willingness and a commitment to do something about it.

So we’ll often begin, before engaging in exposure, with some compassion-focused imagery. Breathing compassion in for the self, breathing compassion out for others, memories of compassion flowing in or out, and even the compassionate self or compassionate other exercise, having people being grounded in a preparatory state of mindful compassion at the beginning.

Then, we engage in the exposure, the way you might in traditional cognitive behavioral therapy exposure. The kind that I’ve done for almost 30 years now, I guess. Sheesh. With just this added piece of checking in about how willing the person is like a lot of third wave CBT, “How willing are you to experience this distress? How willing are you?” Then at the end, the exposure session ends, we return to this compassionate other or compassionate self, grounding and reflecting on it.

I can tell you from our anecdotal clinical experience, it really helps people approach the exposure in a way that kind of has reduced our dropout rates. It’s not sort of this bare-bones, dive in headfirst, go into the deep end thing, but it’s also not avoidant or just sort of like soft.

In fact, it actually can intensify the degree of distress people are willing to expose themselves to because they’re already grounded in an experience of safeness. They’re already grounded in a sense that they’re willing to turn towards the difficult stuff. They care. They have that mama bear energy. They’re willing to charge in and they do.

Here’s a really brief example, modified to protect the identity of the client I work with.

This was a person who had a medical trauma and they were misdiagnosed and went through a lengthy series of very painful procedures with unsupportive medical staff and some family members who were invalidating and unsupportive. They were undergoing a great fear for their actual life, even though they probably weren’t in as much danger physically as they believe themselves to be, and going through like exhausting and painful medical procedures in an unsupportive environment. So, the narrative exposure involved reflecting on and recounting the narrative of those days and weeks and what they experienced.

The initial session, I guess you could say was a sort of preparatory session where we laid out some psychoeducation about trauma memories and about shame, return to the three-circle model, all that. Then we talked about exposure, the rationale for exposure and the rationale that, rather than trying to extinguish this experience emotionally, we’re trying to cultivate a new way of being with it, a new way of responding and a new way of relating to this memory.

From there, we described what memory would be chosen first from a hierarchy of trauma memories. And this session was a longer session. In this case, it was a 90-minute session. That isn’t always possible, but it was possible for this person in this setting. We began with about 5-10 minutes of slowing down, centering, rhythm breathing, embodied compassion, compassion imagery and imagining this compassionate other having a hand on their shoulder in this person same kind of image being there, present, caring, supportive.

“Are you ready? You’re willing to do this. I’ll be here for you if you need me. Go ahead and have this memory.”

At that point, the person opened their eyes and I took some notes on the experience as well as we had a recording going. They spent time going through this narrative telling the story. From time to time I would ask questions. I would ask them to elaborate. I would ask for their perspective. I would ask if they had a sense of how much time had elapsed. Anke Ehlers and David Clark’s work in that area make a point of time code being inserted into a trauma memory. They said they drew that from work on the kind of affective neuroscience and memory. So, I guess even though I don’t keep that as the main process I’m targeting, it’s still there. It seems to be helpful.

Then after that period of going through the memory – sometimes it takes more than one session even to recount the memory – but they’ll take that recording, they’ll transcribe it, and we both sit in a subsequent session and we review that memory. I should mention at the end of each individual session that begins with the compassionate other or compassionate self, we leave enough time at the end of the session to return to that grounding, coherent breathing, and evocation of mindfulness and compassion as a way to create this container. And the debrief, time then after that for a debrief, so that the therapist can model and embody a compassionate presence and that the therapeutic relationship can serve as a social reinforcer and as a platform for the further cultivation of compassion and secure attachment dynamics.