https://orcid.org/0000-0003-3111-0598
ABSTRACT
Introduction
Research has found that nurses frequently report experiencing burnout and compassion fatigue. It is unclear how many nurses practice self-care skills to deal with these potential problems. Mindfulness-based interventions have been found to promote self-compassion in other contexts. This case study tested the effectiveness of a music psychotherapy technique, the Bonny Method of Guided Imagery and Music (GIM), to nurture self-compassion and promote psychological well-being in nurses.
Method
A series of GIM sessions was given to a mental health nurse. She received 21 GIM sessions over a 1-year period. To assess the effects of the GIM sessions, I analyzed transcripts from selected sessions, the mandala images created during sessions, scores from Neff’s Self-Compassion Scale (SCS) at different times during the intervention, and the transcripts of the post-intervention interview.
Results
The GIM intervention resulted in a 26% increase in the SCS score for self-compassion and positive qualitative changes in reported feelings and behaviors.
Discussion
The results suggest that GIM can be an effective intervention to nurture self-compassion and enhance psychological well-being of nurses struggling with burnout and compassion fatigue. If further research confirms that GIM reliably enhances nurses’ resilience, it could be used to retain nurses in the profession.
Introduction
Burnout and compassion fatigue are two prevalent phenomena in nursing professionals. The syndrome of burnout, first introduced by Freudenberger (Citation1974), is described as a set of symptoms relating to emotional exhaustion, such as negative job attitudes, negative self-concepts, and loss of concern and feeling for patients (Keidel, Citation2002). Similarly, compassion fatigue, introduced by Joinson (Citation1992), describes the feeling of exhaustion as a direct consequence of working with patients. Exhaustion from dealing with the suffering of others can reduce the capacity for compassion; Figley (Citation1995) has termed this phenomenon “the cost of caring.” Compassion fatigue has also been interpreted as a secondary form of traumatic stress (Figley, Citation2002).
Figure 1. Music: Holst: Planets, Venus.
Figure 2. Music: Fauré Requiem Op. 48, in Paradisum; Wagner: Lohengrin, Prelude to Act 1.
Research on avoiding burnout and compassion fatigue has identified self-compassion as a possible protective factor (Duarte et al., Citation2016; Gracia-Gracia & Oliván-Blázquez, Citation2017; Upton, Citation2018). The concept of self-compassion was introduced by Neff, who described it as “being touched by and open to one’s own suffering, not avoiding or disconnecting from it, generating the desire to alleviate one’s suffering, and to heal oneself with kindness” (Neff, Citation2003a, p. 87). As it applies to nursing, self-compassion encourages nurses to not only compassionately care about their clients’ suffering but also be kind with themselves. Practicing self-compassion has been shown to alleviate stress and burnout and increase resilience (Neff, Citation2003b; Gilbert, Citation2009; Neff & Germer, Citation2013).
Although self-compassion has clear potential benefits, it may not come naturally to many nurses. Nurses are often critical or judgmental toward themselves in response to mistakes and failures in their clinical performance (Durkin et al., Citation2016). Consequently, many nurses may need to cultivate the practice of self-compassion.
Neff (Citation2003a) emphasized that mindfulness is the key component to enhance and engender the other basic components of self-compassion. The practice of self-compassion involves intentionally entering a conscious state that focuses on the present moment in a non-judgmental way (Kabat-Zinn, Citation1994). This mindfulness is a form of “meta-awareness” (Neff, Citation2011, p. 86), which refers to being aware of one’s own awareness. It allows all sorts of awareness, including bodily sensations, visual perceptions, sounds, smells, tastes, emotions, and thoughts, to come and go on a conscious level. In other words, it enables one to perceive and recognize all of one’s senses on a conscious level and beyond, although the state is temporary. According to Neff, transformation and change can occur during this state of awareness.
The underlying mechanism of this transformation and change can be understood from Wilber’s theory of the spectrum of consciousness. Wilber (Citation2007) describes a conscious state as “unfolding waves of consciousness.” It progresses from the stage “me (egocentric)” to the stage “us (ethnocentric)” and then to the stage “all of us (world-centric)” (p. 34). This is analogous to what self-compassion does to the self, progressing from connecting self to others and then to the community. In Wilber’s integral psychograph, people can recognize their own strengths and weaknesses and thus plan accordingly. They can adjust their patterns of thoughts, feelings, and behaviors. Changes can happen when a person becomes aware of their states of consciousness and bodily experience. He emphasizes that the person will grow and develop by walking through these higher states one by one, without skipping any part of the sequence (Wilber, Citation2007). When experiencing the peak experience of these higher states, people report feelings such as a sense of oneness with all of nature or merging with a cloud of radiant luminosity.
Bonny Method of Guided Imagery and Music (GIM)
Transformation is a part of the result of this higher-state training involving techniques such as meditation and mindfulness training. The Bonny Method of GIM is another technique that involves the states of consciousness and focuses on the present moment. It allows a person to explore consciousness by freely and spontaneously generating images while listening to music (Bruscia, Citation2002). By addressing all aspects of the self, GIM allows higher-state training to occur. Music fuels the spiral movement of the self, enabling the self to explore, expand, and encounter (Goldberg, Citation2002). It also allows the self to gather various new states of consciousness and brings them to the center for integration. Music thus serves as an accelerator to facilitate this self-exploration, which builds up self-compassion.
Music is a key factor that distinguishes GIM from other self-compassion practices. In directing the GIM experience, music is considered as a co-therapist that gives continuity to facilitate this process of inner exploration (Dimiceli-Mitran, Citation2016). The therapist (also called the guide) is trained to choose pre-designed classical music programs meticulously, being mindful of the musical form and structure. After assessing the client’s conditions and needs, an appropriate music program based on the Iso principle is selected (Davis et al., Citation2008). Therefore, the elements of the first music piece in the program match with the emotional state of the client at that moment.
The GIM technique aims for more than increased mindfulness and self-compassion. It involves a transpersonal dimension, in which the sense of self expands and evolves toward a wholeness. This is a state that allows “a sense of being connected to everyone and everything as an integral part of a larger whole” (Vaughan, Citation2000, p. 43). This process expands one’s understanding of the self to increase one’s capacity for the unknown and deepen one’s integration with self-compassion. Therefore, GIM does not just awaken self-awareness of the known part of the self. It emerges organically in all dimensions, naturally uncovering the hidden part of the self, i.e. the shadow, which is not easily identifiable on the conscious level (Vaughan, Citation2000). The shadow is a dark, unexpressed aspect of the psyche, thus the opposite of the mask that the self assumes in conventional social roles. In this sense, GIM allows one to reach oneself more comprehensively than self-compassion. This is captured by the word “transpersonal,” which means beyond personal or normal human experience.
Furthermore, imagery in GIM goes beyond the normal spectrum and can include memories, emotions, feelings, and any visual, auditory, olfactory, gustatory, kinesthetic, or body-based senses. According to Dimiceli-Mitran (Citation2016), the imagery may be transpersonal; it can be beyond normal human experience or spiritual in nature, such as contact with a spiritual guide or wisdom figure, etc. In this sense, GIM images offer more than mindfulness does when entering an altered state of consciousness.
GIM for promoting self-compassion
The treatment outcomes of GIM share properties associated with self-compassion. GIM evokes similar desirable transpersonal outcomes such as compassion, love, allowance, intuition, spontaneity, and inspiration (Vaughan, Citation2000). Another similarity is that the process of GIM encourages people to avoid making judgments or setting standards. GIM allows every experience to be observed, without avoiding or pursuing anything, and helps clients to recognize the interrelatedness of all phenomena. The GIM process allows clarity to emerge, resulting in a clearer vision of the self. Gratitude can be an emotional outcome of GIM, which is important for fostering the well-being of one’s self. These similarities in outcomes suggest that GIM could be used to develop self-compassion.
The specific techniques used in GIM are also similar to the techniques for developing self-compassion proposed by Neff (Citation2003a). Neff’s approach has five features: emotional safety, mindfulness, nonjudgement and welcoming attitude, desired well-being and connection. These features are present in different components of the GIM experience. A typical GIM session comprises four parts: prelude (20–30 min.), induction (10 min.), music experience (30–50 min.), and postlude (20–30 min.).
During the music experience phase of the GIM session, music serves as a container to provide emotional safety. Neff (Citation2003a) argues that emotional safety allows one to see one’s self clearly and experience being free of self-condemnation. In addition, one can more accurately perceive and adjust maladaptive patterns of thoughts, feelings, and behavior (Brown, Citation1999).
The nondirective GIM approach fosters the practice of mindfulness and present moment in self-compassion. The induction phase of GIM includes a guided relaxation and a starting image before the music experience. The starting image may invite an openness to all senses with statements such as, “Allow yourself to notice any color, any sound, smell, or taste” and “Be aware of any textures around you, notice your feelings and bodily sensations.” This is an invitation to enter into the present state of consciousness. The guide may intervene with questions such as “What do you notice?” and “What are you experiencing?” to help attune the client, or the “traveler,” to the present moment.
During the music experience, the GIM guide holds a nonjudgmental but welcoming attitude, similar to coaching the practice of self-compassion. The guide engages in a dialogue with the client/traveler, thus supporting the imagery experience. In fact, the guide acts as a companion to the traveler but does not direct the traveler’s experience; the guide only deepens where the traveler is at in the present moment. This means that the guide avoids any judgmental wording while inviting the traveler to be with his or her present emotional state, whether it is positive or negative. The invitation to “Let yourself feel this as deeply as you can” enables the client/traveler to be present with the feeling fully. This process can then continuously guide him or her to have nonjudgment, an understanding of his or her pain, inadequacies, and failures (Neff, Citation2003a). Instead of being harsh and unkind toward one’s self, this process matches with what self-compassion does in acknowledging any suffering, failure, and inadequacies. In a sense, this process helps avoid disassociation of the experience, and allows one to see the related experience of self and other without overidentification.
The GIM guide also promotes the desired well-being for oneself, which is another feature of the practice of self-compassion, by inviting the traveler to welcome whatever comes at the moment. Interventions by the guides might be statements like: “Let yourself stay with happiness” or “Allow yourself to stay here as long as you need,” when the traveler is experiencing positive emotions. With these kinds of statements, the guide is encouraging the traveler to have compassion with himself or herself through gentleness and patience (Neff, Citation2003a).
Finally, in the postlude phase of the GIM session, the guide encourages the traveler to integrate the music experience, exploring its meaning and its relevance to the current life situation after connecting to the self. Being self-compassionate allows connections to the self and others (Neff, Citation2003a). One can recognize that suffering is something all humans experience. In this way, one can see related experiences of the self and others without distortion or disconnection. Overall, GIM allows a person to practice what self-compassion brings to him or her.
Because of what GIM potentially offers to nurses, music therapists have previously studied the effect of music-guided imagery on self-reported burnout and low job satisfaction in nursing personnel (Brooks et al., Citation2010). Unexpectedly, there was a discrepancy between the quantitative and qualitative results of that study. The quantitative analyses found no statistically significant effects. However, the qualitative data reveal positive, long-lasting outcomes and effects of GIM (Brooks et al., 2010). The positive effects reported by the subjects included evoking positive emotions, activating memories and associations, heightening awareness of the participants’ bodies, facilitating clarity about work-related and personal issues, eliciting a sense of wholeness, and promoting the development of insights about the self and coping strategies. The study by Brooks et al (2010) provides a motivation for further research on using GIM sessions to support nurses.
Beck has conducted further research on the effectiveness of GIM, including a randomized controlled trial (Beck et al., Citation2015) and two case vignettes to investigate the impact of GIM on clients taking stress leave (Beck, Citation2015). These studies did not focus solely on nurses and/or focus on the modified versions of GIM. Nonetheless, both studies provided qualitative data to show an improved sense of self-care, mood, and hope for the clients’ future work life.
Motivated by the positive qualitative results of these previous studies a series of GIM sessions was given to a nurse to determine whether GIM can be an effective intervention to cultivate self-compassion and bring transformation and significant change to a nurse. This study specifically tested whether GIM can enhance a nurse’s coping skills to deal with the issues of burnout and compassion fatigue more thoroughly. No previous study has investigated the use of GIM to cultivate self-compassion in nurses and help them cope with burnout, so the results could expand the existing literature in nursing and music therapy.
Method
The aim of this study was to describe the transformational process of an individual nurse receiving GIM sessions for approximately 1 year and identify key impacts of self-compassion.
Ethical Considerations
The researcher did not have access to a formal ethics review committee. This study followed the principles of the Declaration of Helsinki. Informed Consent was obtained from the research participant prior to her engagement in GIM sessions.
Participant
The participant was a mental health nurse, who was recruited in March 2018 and participated in this case study until February 2019. This study also fulfilled the completion of the author’s GIM training program, was approved and closely monitored by the training supervisor. All of the sessions were conducted in a private setting. In the initial intake interview, the participant was verbally informed about the approach in GIM intervention and had an opportunity to ask questions. As most locally trained nurses are not familiar with GIM, this participant could not initially decide on her degree of commitment to the research, which would likely last for a whole year. Hence, the assessment scale was used only from the 12th session onwards.
Data collection and tools
The qualitative data included all of the mandala images, transcripts of sessions, and transcript of the interview. The sessions and the interview were audio-taped and/or video-taped to enable transcription. All sessions were conducted mostly in Chinese and translated into English for the transcripts. At the end of each session, photos of each mandala image were taken as records. An interview was conducted by the author following the completion of all GIM sessions. The quantitative data consisted of a single tool, the Self-Compassion Scale (SCS). The SCS findings were documented twice for comparison. The 26-item (long) version of the SCS developed by Neff was used in this case study (Neff, Citation2003b). This instrument, with a Cronbach’s alpha coefficient of 0.92, includes six subscales: self-kindness, self-judgment, mindfulness, common humanity, isolation, and overidentification. The participant was instructed to rate how well each item described her experience using a 5-point Likert scale, ranging from 1 (Almost never) to 5 (Almost always). The SCS has been validated internationally and used in several nursing studies (Durkin et al., Citation2016; Gracia-Gracia & Oliván-Blázquez, Citation2017; Upton, Citation2018).
Procedures
The length of the GIM sessions ranged from 90 to 120 minutes. Generally, each session comprised a prelude (20–30 min.), induction (7–10 min.), music experience (35–50 min.), and postlude (30 min.). At the mid-point and at the end of this study, a modified GIM session, with a shortened music experience (3–10 min.) using nonclassical music, called Focused Music Imagery (FMI), was used to review all of the mandala images as a summary for self-reflection. A list of music used in the selected program relevant to this research is documented in Appendix A.
Data analysis
All of the transcripts were reviewed and analyzed, with the mandala images used as a point of reference. Phenomenological analysis following the method of Giorgi (Citation2011) was used to explore the experiences of and impacts on the participant as a result of the GIM sessions. The themes of transformation, changes, and transpersonal experience were identified as the key outcomes as they can reflect the impact of GIM on the participant’s work and personal life. The pivotal, insightful, or breakthrough parts of the session, reflecting core components in self-compassion, were marked for a thorough review and analysis. Subsequently, I identified particular music pieces or programs, observed the mandala image and its description, summarized the session, and finally made comments on the participant after postlude. The results of the SCS and interview were additional data used to evaluate the occurrence of self-compassion practice.
Participant background
Georgia, aged 25 years, was a single Chinese woman, who had just started a new position as a clinical consultant (mental health nurse) at the emergency room of a local hospital. During the initial sessions, she lived with her parents and a younger brother and had started studying for her first year of a Master’s degree in Law, which she intended to finish within 1 year. She had been practicing nursing for approximately 3 years after graduating with a Mental Health Nursing degree. She had a good relationship with her mother, despite the latter’s tendency to be worried and anxious, but was distant from her father because of his gambling issues. She had a stable relationship with her boyfriend and was planning to get married. Her mother and her fiancé were the most important people in her life.
Her main reasons for seeking treatment were that she was feeling lost and wanted to find a clear direction in her life. She was studying for a Master’s degree in Law, looking for opportunities to change her career. However, she was not confident about this new potential profession. She had also been impacted by her parents’ unsatisfied marital relationship since her younger years. She worried about its impact on her own family in the near future.
Prior to treatment, she did not practice any specific self-care strategies or participate in any religious practices. For example, she did not practice mindfulness or meditation regularly and had taken only one mindfulness class. Lacking a particular religious belief, she only followed her family’s practice of worshipping the goddess Guanyin. Initially, she described herself as tough and claimed that she believed only in herself. She tended to reflect on and blame herself for issues/problems, preferring to tackle the problems directly, rather than seeking help from others. Her strengths included good problem-solving skills and being flexible. She did not play any musical instruments.
Results
In certain sessions or parts of sessions, the feelings, thoughts, and behavioral changes in Georgia’s professional and personal life became apparent. These strongly evidenced transformations and changes may have arisen from her self-awareness, transpersonal experience of traveling during the sessions, and building of self-compassion through the practices. After the postludes, the author made comments interpreting the discussions that had taken place in the session, affirming the development of self-compassion in her life.
Theme 1: Strengthening her professional life
One outcome from the initial sessions was that Georgia began to feel refreshed and experienced relief from work-related stress. These changes were observed in the transcripts and mandala images in the following sessions.
Relief from work-related stress
The focus during the initial GIM sessions was work-related issues and their impact on her life. She had been attempting to gain confidence at her workplace but felt lost in her search for the right direction in her career development. Despite a deliberate attempt to record happy events and successful moments at work in a journal, many entries were complaints about heavy workload, short staff/patient ratio, and difficulty meeting the continuing education requirement for her professional development.
Initially, Georgia’s internal state was chaotic. This can be seen in the mandala image from Session 1. In contrast, the mandala image from Session 5 shows a clearer picture of her search for her career path. In the ninth session, she recognized her burnout from working intensively and identified consequences, such as forgetting her client’s case information right after reading it. Georgia’s struggles with her work as a nursing professional are evidenced in the mandala imageries of Sessions 1 and 5.
Session 1.
Mandala Image (): The image contains a marble stone bridge in the middle. There is a lake on one side of the bridge and a car with two headlights driving on a highway on the other side. The Northern Lights can be seen above her, like a blanket covering her. There are houses with lights next to the lake, but it is a dark night.
Summary: In the postlude, Georgia interpreted her imageries as follows. On one side of the bridge is a peaceful, safe, and comfortable home environment with no worries, whereas on the other side is the highway where she needs to walk cautiously to avoid being hit by oncoming cars. This highway side signifies life-and-death scenarios at her workplace. It represents the dangers she encounters in her work environment or the achievement she wants to pursue. In reality, she strives hard to survive her work life. Although she wants to challenge herself to walk out of this darkness, she dares not. It is her desire to find a stable life; she needs to first understand the outside world before she steps out of her comfort zone, which is her profession, nursing.
Comments after postlude: Through this image, Georgia became clearer about the bigger picture of her life and her response toward events in her workplace. She identified home as an “emotionally safe” place.
Session 5.
Mandala Image (): The image depicts Georgia lying down in a swamp next to a forest. In the earlier part of this session, a white horse appears and then disappears. In this image, it has returned and is waiting for her on her side. Georgia is surrounded by a frog, butterflies, and long grass. Rain is dropping on the pool, making water ripples.
Summary: The white horse is the thing Georgia is searching for, such as achievements at work. She is struggling with the horse because it shows resistance to her, not letting her ride on it. After feeling exhausted and frustrated from these failed attempts, she chooses to rest in the swamp. Once she lets go of the idea of controlling the horse, the horse returns and becomes approachable. The white horse symbolizes her decision to achieve something new in her career. In reality, she is preparing to step out of the nursing profession and search for a new profession. The root that grows out of her body may be the resistance she has to nursing, which keeps her anchored to the ground.
Comments after postlude: The metaphor of the white horse allows Georgia to understand the process of her search for a career direction. She now has a clearer picture.
Theme 2: Strengthening her personal growth
Music has penetrated her inner being. It has enhanced not just her own self to build up her inner resources but has also been outwardly adjusting her responses toward significant others.
Building resilience in self-portraits
Another obvious outcome is the progress in building her resilience, which is observed in her self-portraits. In , the mandala images from sessions 4, 11, 16, and 18 illustrate how GIM empowers Georgia to know herself and discover her unknown side for the first time. Then, her ego becomes stronger in a way that makes her boundaries more distant from external negative influences and lets her focus on building her own resources by resting. She continues to grow by expanding her capacity to understand others’ pain and suffering.
Table 1. Sessions related to self-portraits
Transformation and changes in her interpersonal life
Another impact of GIM on Georgia is that she became clear about her own desires, which improved her relationship with her fiancé and her family. She could step back to reflect on what she needs to change to allow transformation. Selected sessions in show the process of Georgia regulating herself in response to significant people in her life. Consequently, improved interpersonal relationships with her in-laws to be, fiancé, and mother were observed.
Table 2. Self-clarity for interconnectedness
As the sessions progress, significant transformations and changes are evidenced in the transcripts of sessions 12, 19, and 20. The imageries somehow ease her into practicing the changes and transformations in her imagination (Shum, Citation2019). This is a natural process. The lessons of letting go of her past, stepping out of her comfort zone, restoring her well-being, and rectifying potentially negative emotional response are seen to be learned.
Session 12.
Music: Brahms: Symphony No. 1, Allegretto
Mandala Image: She is dancing on a path in the darkness. Then, she decides to tear off the black cloth and discovers colorful flowers behind it.
Summary: Georgia stays in her comfort zone where no one can see her. While she is struggling with that, she is surprised by the new world that appears after she tears off the cloth that was in the darkness. In this session, she demonstrates stepping out of this darkness, her comfort zone. By doing that, she suddenly realizes that she can change her environment. Her insight is to review her current path instead of searching for a new path. She can revisit and gain new perspectives on the old path. She does not feel the urge to change her career, in contrast to the first several GIM sessions. She begins to appreciate her present working situation in nursing; she perceives it as good.
Comments after postlude: This GIM session supports her to develop a strong self-ego, so that she can step out of her comfort zone and welcome any surprises and changes with open arms. This insight supports her to continue in her nursing profession.
Session 19.
Music: Mozart: Ave Verum Corpus; Vaughan-Williams: Symphony No. 5, Romanza-Lento
Mandala Image: She is lying on grassland. There is a tree growing out from her body trunk, with her roots merging into the ground, as well as a lot of grass and flowers growing around her body.
Summary: Georgia tends to hide herself underneath a cover whenever she wants to avoid anything in reality. She has absorbed nutrients from the roots, which have turned her body into a tree that draws small creatures to rest on it. She has become part of the earth and the mountain range, contributing to the universe. In this way, she feels blessed for being a tree, finding this space to rest, so she can regain her energy to help others by offering small creatures a place to rest upon.
Comments after postlude: This GIM session offers her transpersonal experiences to restore her well-being, bringing healing power to herself and others.
Session 20.
Music: Gabriel Pierne’s Concertstück for Harp
Mandala Image: She is wearing a red scarf, spinning with a balanced posture on an icy lake. The icy surface starts to crack and break up, with a green fish swimming underneath the ice.
Summary: Georgia is in a life transition; she is moving to a new home and preparing herself for marriage. In her imagery, she has a fun time spinning on the lake while others observe a crack in the ice. When the ice actually breaks, she perceives it as a positive experience, considering it as no big deal. She has learned to adapt to the changes. Her insight is that she can let things be where they are. This actually brings her into an adventure mode, and she becomes playful and excited. She reports that she verbalizes her desires and needs to her fiancé, not hiding her thoughts and emotions; she also appreciates his compliments to her for doing a good job for the home.
Comments after postlude: This GIM session allows her to rectify potential negative emotional responses. Instead of fear, she changes and transforms her feelings and behaviors. Georgia demonstrates a transformation experienced through the imagery and is exercising her behavioral changes in reality.
The final image is from a modified GIM session, using the music “Sheep may safely graze” by Bach, arranged by Kobialka. This image manifests her self-acceptance, showing how much she accepts the way she looks at the present. She is no longer suppressing her desire of wanting to eat cotton candy and is holding it proudly.
Results of SCS assessment
The results of the SCS before the 12th session (August 2018) and after the 21st session (February 2019) are listed as follows in . The overall score for self-compassion before the 12th session is 3.13 and that after the 21st session is 3.94. The 25.9% increase in the score, showing an improvement in practicing self-compassion, is supported by the interview at the end.
Table 3. Result of the SCS in the 12th and 21st sessions
Interview
An interview was conducted by the author after 21 GIM sessions. Georgia reported that GIM helped her to cultivate self-compassion. She became more aware of her emotions and clearer about herself. In this interview (Appendix B), she acknowledged her positive responses to the GIM sessions. She answered, “What benefits me the most is that whenever I am not clear about my thoughts and feelings, the imagery guides me to realize what my thoughts are” (Personal communication, January 2019). Once she developed clarity about her issues, she knew what she wanted and communicated her thoughts to others.
Instead of using the escape mode, she was able to confront her negative emotions and develop positive perception over issues. For example, she said,
I accept and confront my negative emotions, such as anxiety, helplessness, and the feeling that I am not good enough. Previously, if I felt that I would want to kick those emotions out and did not want anyone to notice it. Now, I would face it positively and even seek help from others to manage them. (Personal communication, January 2019)
She gained the ability to find her own solution through her imageries. Consequently, she reported gaining confidence to face her challenges.
Discussion
Self-compassion serves as a motivation for change (Neff, Citation2011). Similarly, GIM is an approach that promotes clarity to discover what is needed for change. Instead of blaming others because of shame and self-judgment, GIM made it easier for the participant in this study to identify areas of improvement and tap into concern for the well-being of others. Selected sessions show how the participant recognized interconnectedness and togetherness, rather than isolation.
Self-compassion is the attitude that allowed her to stop judging herself so harshly. She could forgive herself and others and let go of her anger and resentment. She learned lessons of letting go of the past, adopting a welcoming attitude, restoring well-being through transpersonal experience, and subsequently changing her response to unexpected, undesirable life events. In reality, after she acknowledged her negative emotions, she could seek help from her friends to manage her situation. The non-directive approach of GIM enabled the participant to adopt her own approach to confront the core issue and find her own solution, which came from within.
The SCS results show that the score for overall self-compassion increased by 25.9% while she was receiving GIM sessions. The transpersonal experience may have given her insight and enabled her to cultivate more self-compassion at her own pace during the second half of the 1-year period. Therefore, the results of the SCS at the midpoint and at the end of that 1-year period capture this phenomenon. In fact, when comparing the SCS results in this case study with those from a brief meditation intervention by Albertson, Neff, and Dill-Shackleford in 2014, a remarkably higher percentage increase is evident. In that study, a randomized controlled trial of meditation intervention on self-compassion in women, the mean results were 2.65 at the pre-test and 3.15 at the post-test, showing an increase of 18.8%. (Albertson et al., Citation2014).
A higher score in the SCS suggests that one experiences a greater level of happiness, optimism, life satisfaction, perceived competence, and motivation (Neff et al., Citation2005, Citation2008, Citation2007) as well as lower levels of anxiety, stress, depression, rumination, and fear of failure (Neff et al., Citation2005; Macbeth & Gumley, Citation2012; Raes, Citation2010). Together with the transcripts and images, the score from the SCS reflects the positive impacts of GIM on the present participant; her responses and behavior changed accordingly. The findings suggest that self-compassion was cultivated along the way while she was receiving the GIM sessions. She developed a perspective different from that at the beginning, particularly in terms of the decision of staying in the nursing profession. It is also possible that the effectiveness of GIM resulted from the intervention being performed early. A study by Beck et al. (Citation2015) on coping with work-related stress affirmed that early GIM intervention is more effective than late intervention.
The interview at the end of this case study reflects the overall benefits she gained from the GIM sessions. The qualitative data show that the participant had become more aware of her feelings and bodily expression. This enabled her to realize her own needs when interacting with others. She was able to deal with negative emotions when they arose. GIM has indeed been beneficial to her not only to cultivate her self-compassion but also to enhance her overall psychological well-being. GIM can be an effective treatment for work-related stress, as this study shows the possible long-lasting and substantial impact of GIM on well-being.
This outcome is similar to that from another study by Beck et al. (Citation2015). However, unlike that study, the present case study did not use a sophisticated biopsychosocial framework to generate large data on biological stress symptoms, such as cortisol, testosterone, and melatonin levels. This study’s quantitative emphasis on self-compassion does, however, offer longitudinal data to reveal a key phenomenon, self-compassion, reflecting the merits of GIM. Those receiving GIM for work-related stress in Beck et al.’s study were able to return to work and had not taken further stress leave on follow up. Similarly, the participant in this study stayed in the nursing profession, instead of switching career paths.
Limitation of the study
The initial assessment using the SCS was conducted before the 12th session, instead of before the first session. If the SCS had been used prior to the first GIM session, the results may have shown more significant findings, indicating that time is required to nurture self-compassion. One needs to be patient with the process of building self-compassion. Due to the intermittent unavailability of the participant for sessions, the duration between each GIM session fluctuated from a week to a month. However, transformations and changes in a person can happen naturally and in their own time. The data collected may not have captured all of the phenomena that are pertinent to this topic. All of the session transcripts were translated into English from Chinese by the author. Some meanings and descriptions may not have been expressed completely accurately by the words used in the translation. Last, the questions asked in the interview were all set under the assumption that GIM would be effective.
Conclusions
GIM is a powerful tool for self-care. It involves the engagement of all five senses of a person through the expression of thoughts, feelings, and emotions derived from the elicited images while interacting with music and the therapist. In this case study, the development of self-compassion in a mental health nurse receiving GIM sessions could be tracked over the course of approximately 1 year. Although this nurse intended to journalize her positive work experiences, the journal did not serve as a supportive mechanism for encouraging her professional well-being. The types of interventions and the lengths of treatments necessary to support nurses dealing with their ongoing job stress and compassion fatigue are open for debate. GIM is an effective intervention that nurtures self-compassion, which is shown not only to heal burnout, compassion fatigue, related stress, and anxiety but also to promote healthy habits and attitudes to obtain happiness, motivation, and life satisfaction. In this case study, the participant changed her perception from being burnt out to being appreciative of the nursing profession. Both the objective and subjective findings from this case study further show how valuable GIM sessions can be as an effective self-care practice for nurses.
GIM is an effective and practical method for supporting nurses, enhancing their coping skills against job-related stress. The findings from this study suggest that the practice of GIM can build self-compassion as an intangible asset to many nurses. Nurses should be encouraged to experience GIM as a means of nurturing self-compassion, which leads to enhanced job satisfaction and management of burnout and compassion fatigue. It can be a preventative measure when done early, before nurses start taking sick leave for stress. To increase nurses’ coping skills and enhance their resilience to stay in the nursing profession, offering GIM sessions can potentially be an effective strategic policy to retain nurses in the profession. It could certainly be encouraged as a job benefit offered by employers when recruiting nurses, especially in the current context of a shortage of nurses.
Disclosure statement
No potential conflict of interest was reported by the author.
Additional information
Funding
Notes on contributors
Wei Wah Angela Shum
Angela Shum has been a registered nurse for more than 10 years, working in health care setting across different countries and cities, including Hong Kong, Canada and USA. Her nursing clinical experience has been extensive in various settings, including hospital, nursing home and university. She has worked with clients in the area of oncology (bone marrow transplant), surgery, medicine (cardiology) as well as gerontology (Dementia/Alzheimer).
After she earned her master degree in expressive therapy (specialize in music therapy and mental health counseling), she worked as a music/rehabilitation therapist at the Provincial/State hospitals in both Canada and USA. She has experiences working with clients having needs in dementia, forensic psychiatry, problem gambling/addictions, stroke/traumatic brain injury and developmental disabilities. Presently, she is residing in Hong Kong with a passion of educating psychiatric nurses about music imagery, GIM & expressive arts therapy/(FOAT) and promotes these in health care or other settings.
References
- Albertson, E. R., Neff, K. D., & Dill-Shackleford, K. E. (2014). Self-compassion and body dissatisfaction in women: A randomized controlled trial of a brief meditation intervention. Mindfulness, 6(3), 1–11. https://doi.org/10.1007/s12671-014-0277-3 [Web of Science ®], [Google Scholar]
- Beck, B. D. (2015). Guided imagery and music with clients on stress leave. In D. Grocke & T. Moe (Eds.), Guided imagery & music (GIM) and music imagery methods for individual and group therapy (pp. 131–140). Jessica Kingsley Publishers. [Google Scholar]
- Beck, B. D., Hansen, A. M., & Gold, C. (2015). Coping with work-related stress through guided imagery and music (GIM) randomized controlled trial. Journal of Music Therapy, 52(3), 323–352. https://doi.org/10.1093/jmt/thv011 [Crossref] [PubMed] [Web of Science ®], [Google Scholar]
- Brooks, D. M., Bradt, J., Eyre, L., Hunt, A. & Dileo, D. (2010). Creative approaches for reducing burnout in medical personnel. The Arts in Psychotherapy, 37 (3), 255–263. https://doi.org/10.1016/j.aip.2010.05.001 [Crossref] [Web of Science ®], [Google Scholar]
- Brown, B. (1999). Soul without shame: A guide to liberating yourself from the judge within. Shambhala. [Google Scholar]
- Bruscia, K. E. (2002). The boundaries of guided imagery and music (GIM) and the Bonny Method. In K. Bruscia & D. Grocke (Eds.), Guided imagery and music: The Bonny method and beyond (pp. 37–61). Barcelona Publishers. [Google Scholar]
- Davis, W. B., Gfeller, K. E., & Thaut, M. H. (2008). An introduction to music therapy: Theory and practice (3rd ed.). American Music Therapy Association. [Google Scholar]
- Dimiceli-Mitran, L. (2016). Accessing strength from within: Music imagery and mandalas. In J. K. Edward, A. Young, & H. Nikels (Eds.), Handbook of strengths-based clinical practices: Finding common factors (pp. 164–178). Routledge. [Google Scholar]
- Duarte, J., Pinto-Gouveia, J., & Cruz, B. (2016). Relationships between nurses’ empathy, self-compassion and dimensions of professional quality of life: A cross-sectional study. International Journal of Nursing Studies, 60, 1–11. https://doi.org/10.1016/j.ijnurstu.2016.02.015 [Crossref] [PubMed] [Web of Science ®], [Google Scholar]
- Durkin, M., Beaumont, E., Martin, C. J. H., & Carson, J. (2016). A pilot study exploring the relationship between self-compassion, self-judgement, self-kindness, compassion, professional quality of life and wellbeing among UK community nurses. Nurse Education Today, 46, 109–114. https://doi.org/10.1016/j.nedt.2016.08.030 [Crossref] [PubMed] [Web of Science ®], [Google Scholar]
- Figley, C. R. (1995). Compassion fatigue as secondary traumatic stress disorder: An overview. In C. R. Figley (Ed.), Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized (pp. 1–20). Routledge. [Google Scholar]
- Figley, C. R. (2002). Compassion fatigue: Psychotherapists’ chronic lack of self-care. Journal of Clinical Psychology, 58(11), 1433–1441. https://doi.org/10.1002/jclp.10090 [Crossref] [PubMed] [Web of Science ®], [Google Scholar]
- Freudenberger, H. J. (1974). Staff burnout. Journal of Social Issues, 30(1), 159–165. https://doi.org/10.1111/j.1540-4560.1974.tb00706.x [Crossref] [Web of Science ®], [Google Scholar]
- Gilbert, P. (2009). The compassionate mind. Constable. [Google Scholar]
- Giorgi, B. (2011). A phenomenological analysis of the experience of pivotal moments in therapy as defined by clients. Journal of Phenomenological Psychology, 42(1), 61–106. https://doi.org/10.1163/156916211X567497 [Crossref], [Google Scholar]
- Goldberg, F. (2002). Holographic field theory model on the Bonny method of guided imagery and music (BMGIM). In K. Bruscia & D. Grocke (Eds.), Guided imagery and music: The Bonny method and beyond (pp. 359–377). Barcelona Publishers. [Google Scholar]
- Gracia-Gracia, P., & Oliván-Blázquez, B. (2017). Burnout and mindfulness self-compassion in nurses of intensive care units. Holistic Nursing Practice, 31(4), 225–233. https://doi.org/10.1097/HNP.0000000000000215 [Crossref] [PubMed] [Web of Science ®], [Google Scholar]
- Joinson, C. (1992). Coping with compassion fatigue. Nursing, 22(4), 116–118. https://doi.org/10.1097/00152193-199204000-00035 [Crossref] [PubMed], [Google Scholar]
- Kabat-Zinn, J. (1994). Wherever you go there you are. Hyperion. [Google Scholar]
- Keidel, G. C. (2002). Burnout and compassion fatigue among hospice caregivers. American Journal of Hospice and Palliative Medicine, 19(3), 200–205. https://doi.org/10.1177/104990910201900312 [Crossref] [PubMed], [Google Scholar]
- Macbeth, A., & Gumley, A. (2012). Exploring compassion: A meta-analysis of the association between self-compassion and psychopathology. Clinical Psychology Review, 32(6), 545–552. https://doi.org/10.1016/j.cpr.2012.06.003 [Crossref] [PubMed] [Web of Science ®], [Google Scholar]
- Neff, K. D. (2003a). Self-compassion: An alternative conceptualization of a healthy attitude toward oneself. Self and Identity, 2(2), 85–102. https://doi.org/10.1080/15298860309032 [Taylor & Francis Online] [Web of Science ®], [Google Scholar]
- Neff, K. D. (2003b). The development and validation of a scale to measure self-compassion. Self and Identity, 2(3), 223–250. https://doi.org/10.1080/15298860309027 [Taylor & Francis Online] [Web of Science ®], [Google Scholar]
- Neff, K. D. (2011). The proven power of being kind to yourself: Self-compassion. Harper Collins Publishers. [Google Scholar]
- 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. https://doi.org/10.1002/jclp.21923 [Crossref] [PubMed] [Web of Science ®], [Google Scholar]
- Neff, K. D., Hsieh, Y., & Dejitthirat, K. (2005). Self-compassion, achievement goals, and coping with academic failure. Self and Identify, 9(3), 225–240. https://doi.org/10.1080/15298860902979307 [Taylor & Francis Online], [Google Scholar]
- Neff, K. D., Pisitsungkagarn, K., & Hsieh, Y. (2008). Self-compassion and self-construal in the United States, Thailand, and Taiwan. Journal of Cross-cultural Psychology, 39(3), 267–285. https://doi.org/10.1177/0022022108314544 [Crossref] [Web of Science ®], [Google Scholar]
- Neff, K. D., Rude, S. S., & Kirkpatrick, K. (2007). An examination of self-compassion in relation to positive psychological functioning and personality traits. Journal of Research in Personality, 42(4), 908–916. https://doi.org/10.1016/j.jrp.2006.08.002 [Crossref], [Google Scholar]
- Raes, F. (2010). Rumination and worry as mediators of the relationship between self-compassion and depression and anxiety. Personality and Individual Differences, 48(6), 757–761. https://doi.org/10.1016/j.paid.2010.01.023 [Crossref] [Web of Science ®], [Google Scholar]
- Shum, A. (2019, December 25). Nurse: use GIM sessions to manage job stress. [video file]. https://youtu.be/mE_1LC9s_04 [Google Scholar]
- Upton, K. V. (2018). An investigation into compassion fatigue and self-compassion in acute medical care hospital nurses: A mixed methods study. Journal of Compassionate Health Care, 5(7), 1–27. https://doi.org/10.1186/s40639-018-0050-x [Crossref], [Google Scholar]
- Vaughan, F. (2000). The inward arc: Healing in psychotherapy and spirituality. Shambhala. [Google Scholar]
- Wilber, K. (2007). The integral vision. Shambhala. [Google Scholar]