International Society for Traumatic Stress Studies

Combating Self-Criticism and Judgment in Veterans

Posted 27 July 2013 in StressPoints by Katie Dahm, MS

Post-traumatic stress disorder (PTSD) has received immense empirical attention and clinical focus since the start of Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF) and Operation New Dawn (OND). Due to high prevalence rates among returning military service members and veterans, this condition has become known as one of the “signature injuries” of these wars (Hoge et al., 2004, Sayers et al., 2009; Tanielian & Jaycox, 2008). Prevalence rates estimate around 15 percent of U.S. service members develop clinically significant levels of PTSD upon returning home (Hoge et al., 2006; Tanielian & Jaycox, 2008). Recently pioneered in the research by Kristin Neff (2003a), self-compassion is a powerful and relevant construct that directly targets the avoidance and negative emotional states related to posttraumatic reactions. 

Stemming from the Buddhist notion of compassion, self-compassion is being open to experiencing one’s pain and suffering, directing feelings of kindness inwards in moments of distress, and recognizing that all humans experience suffering (Neff, 2003a). In addition, a lack of self-compassion has been conceptualized to include self-judgment, isolation, and an over-identification, or clinging to, negative thoughts and feelings. A growing body of literature is finding that higher levels of self-compassion are strongly associated with psychological health and life satisfaction, while lower levels of self-compassion have been linked to depression, anxiety, avoidance, and other negative mood symptoms (MacBeth & Gumley, 2012; Neff, 2009; Neff, 2003b).

Neff (2003b) theorizes self-compassion as being comprised of three elements: self-kindness, common humanity, and mindfulness. Self-kindness suggests that in the face of adversity or perceived shortcomings, one responds with caring and understanding instead of with harsh criticism or judgment. People who are self-compassionate turn comfort inwards when experiencing difficulties rather than “soldiering on” to try and take control of the situation (Neff, 2009). Common humanity involves perceiving one’s suffering as part of a broader human experience, rather than occurring in isolation. When people are faced with difficult and challenging times, they often feel alone and disconnected from others. Self-compassionate people are able to recognize that everyone experiences suffering and can connect with others when dealing with pain. Mindfulness addresses having a balanced awareness in the present moment of one’s experience so that distressing thoughts and feelings are neither avoided nor exacerbated. Being able to recognize that one is suffering is necessary in order to employ compassion towards the self (Neff, 2003a; Neff, Kirkpatrick, & Rude, 2007). 

PTSD is operationalized as a prolonged response to a traumatic event and manifests as symptoms of hyperarousal, avoidance of trauma-related triggers, emotional numbing, intrusive recollection of the trauma, and significant functional impairment in daily life (American Psychiatric Association [APA], 2000). In combat situations, service members may be exposed to multiple traumas over extended periods of time, and encounter physically and psychologically demanding conditions daily. When service members are exposed to longstanding and repeated trauma, it can affect not only their psychological and physical functioning but multiple aspects of overall quality of life. Additionally, recent research is highlighting the presence of post-deployment guilt and/or shame as a complicating factor for overall symptomology and treatment response for PTSD (Steenkamp, Nash, Lebowitz, & Litz, 2013).

Cognitive-behavioral treatments for PTSD have consistently shown strong empirical support, particularly exposure-based therapies (Bradley, Greene, Russ, Dutra, & Westen, 2005). While these treatments have been effective in reducing PTSD symptoms, veterans may also benefit from developing compassionate and self-soothing techniques to target any guilt or shame that could be potentially interfering with trauma-focused treatment (Orsillo & Batten, 2005). Self-compassion is a form of coping that provides the emotional safety needed to tolerate negative states. A growing number of empirical studies have provided evidence that self-compassion not only combats harsh self-criticism and judgment but also enhances emotional resiliency and promotes overall positive well-being (Neff, 2003a; Neff, Kirkpatrick, & Rude, 2007). Due to the fostering of self-acceptance, self-compassion may also address the stigma that veterans perceive in receiving mental health treatment (Hoge et al., 2004; Stecker, Shiner, Watts, Jones, & Conner, 2013). 

A relatively new and exciting area of research examines the relationship between self-compassion and trauma (Tanaka et al., 2011, Vettese et al., 2011), highlighting the susceptibility of individuals with trauma histories to exhibit low self-compassion. To date, only one study has assessed levels of self-compassion in a sample diagnosed with PTSD (Thompson & Waltz, 2008). The researchers found that individuals with greater levels of self-compassion showed significantly less avoidance symptoms. These results suggest that individuals with higher self-compassion were more willing to engage with the memories and associated negative symptomology related to their trauma. They may feel less threatened by their trauma-related thoughts and feelings and be more willing to comfort themselves during times of intense distress. These preliminary findings also suggest when managing posttraumatic symptoms, more self-compassionate individuals may be more willing to engage in exposure-based treatments.

Self-compassion seems to directly target the numbing, detachment, and avoidance commonly seen in combat veterans with PTSD (Batten, Orsillo, & Walser, 2005; Walser & Westrup, 2007). In addition, self-compassion addresses the self-criticism, self-isolation, and negative self-focus that are commonly found in individuals with not only PTSD but chronic mental health difficulties as well (Germer, 2009). Several therapeutic interventions that incorporate self-compassion are currently being implemented in Veterans Administration (VA) clinics around the country as adjunctive treatment (Vujanovic et al., 2011), such as Mindfulness-Based Stress Reduction (MBSR; Kabat-Zinn, 1990), Mindfulness-Based Cognitive Therapy (MBCT; Segal, Williams, & Teasdale, 2002), and Seeking Safety (Najavits, 2002) but little research has examined self-compassion in this population. A recent study found that self-compassion was significantly related to lower levels of PTSD, depression, and anxiety symptoms, and higher levels of functionality and overall quality of life in a sample of trauma-exposed OEF/OIF Veterans (Dahm, 2013).

Mindful Self-Compassion (MSC; Neff & Germer, 2013) is a recently developed group intervention that teaches mindfulness and self-compassion skills. MSC not only targets avoidance by focusing on acceptance of present moment experiences, but also includes self-soothing skills to help individuals better tolerate negative thoughts and emotions.  A recent randomized wait-list control study (Neff & Germer, 2013) examined the impact of the MSC program on a community sample. Results found significant post-test improvements in mindfulness, compassion for others, social connectedness, life satisfaction, happiness, depression, anxiety, stress, and impact of life events. Interventions like MSC that incorporate self-compassion are encouraged as a complement to already established trauma-focused treatments in order to enhance emotional resiliency and develop self-soothing techniques that are often absent in this population.

Research examining self-compassion and trauma is in the beginning stages and offers promising implications and future directions. As an intervention, self-compassion provides encouraging ways to relate to negative experiences and connect with others in times of suffering. Self-compassion is an inspiring treatment component that may assist in the complex adjustment and mental health concerns of our returning veterans.

References

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Batten, S. V., Orsillo, S. M., & Walser, R. D. (2005). Acceptance and mindfulness-based approaches to the treatment of posttraumatic stress disorder. In S. M. Orsillo & L. Roemer (Eds.), Acceptance and mindfulness-based approaches to anxiety (pp. 241-269). New York: Springer.

Bradley, R., Greene, J., Russ, E., Dutra, L., & Westen, D. (2005). A multidimensional meta-analysis of psychotherapy for PTSD. American Journal of Psychiatry, 162(2), 214-227.

Dahm, K.  (2013). Mindfulness and Self-Compassion as Predictors of Functional Outcomes and Psychopathology in OEF/OIF Combat Veterans Exposed to Trauma (Unpublished Doctoral dissertation). The University of Texas at Austin.

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Neff, K. D., & Germer, C. K. (2013). A pilot study and randomized controlled trial of the Mindful Self‐Compassion program. Journal of Clinical Psychology, 69(1), 28-44.

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Sayers, S. L., Farrow, V. A., Ross, J., & Oslin, D. W. (2009). Family problems among recently returned military veterans referred for a mental health evaluation. Journal of Clinical Psychiatry, 70(2), 163-170.

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Vettese, L. C., Dyer, C. E., Li W. L. & Wekerle, C. (2011). Does self-compassion mitigate the association between childhood maltreatment and later emotional regulation difficulties? A preliminary investigation. International Journal of Mental Health and Addiction, 9, 480-491.

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About the Author

Katie Dahm, MS, is currently at The University of Texas at Austin completing her PhD in Counseling Psychology. Her dissertation examined the relationship between self-compassion, mindfulness, and experiential avoidance with psychological and functional outcomes in a sample of OEF/OIF combat veterans. She is currently completing internship at the Michael E. DeBakey VA Medical Center (MEDVAMC) in Houston, Texas and was also recently awarded a Trauma/Dual Diagnosis postdoctoral fellowship at the Hines VA in Chicago, IL.