Monthly Archives: September 2017

Beyond words

By Nevine Sultan September 28, 2017

Attempting to work from a purely cognitive or emotional perspective with clients who have experienced sexual trauma is like trying to build a sturdy house without laying down a solid foundation. Facilitating recovery from sexual trauma demands the inclusion of the site of the original wounding — the body.

A clinical vignette

“Jerry” arrives seven minutes late for his intake appointment. He appears disoriented and confused.

“Please,” I say, inviting him to take a seat. When our eyes meet, he turns his gaze to the floor and explains, “I think I stopped at a gas station on my way here.”

Jerry’s face is flushed and his nostrils are fluttering. Although his head seems to be the most active part of him, I am drawn to Jerry’s feet, legs and hands. The rigidity in the lower half of his body is intense. Jerry’s left foot is twisted outward in a painfully supinated position. His hands are imprisoned beneath his thighs, and his shoulders are hunched forward. The word concave comes to mind. I feel a sense of hollowness in my core as I realize that Jerry is holding his breath like a dam straining to hold water that might cause irreversible damage if released all at once.

We talk briefly. Jerry tells me about his anxiety, the panic attacks that have besieged him up to twice daily over the past few months, his ceaseless hypervigilance, the memories that haunt him, the persistent need to wash his hands and the nights dotted with brief slumber from which he is jarred awake by horrific nightmares. “I’m also having problems with my girlfriend,” Jerry says. “I know I can trust her. It’s just … I can’t shake that feeling.”

As Jerry speaks, his voice is jittery and his lips tremble. His breathing shifts from closed to ragged. “I was out taking a walk in my neighborhood one night. A guy drove up to the sidewalk and asked for directions to the community pool.” Jerry’s pitch lowers, his articulation becomes less sharp, and he drifts inside himself. I shift in my chair to gently facilitate his return to the here and now. He looks up before continuing.

“As soon as I started talking, he got out of the car, opened the door to the backseat, and then … I don’t know. It happened quickly.” He pauses. “I woke up in a hospital. My wrists were really bruised.” Jerry scans the room with his eyes, which are filling with tears. “I couldn’t save myself.” He weeps, pulling his hands out from beneath him and rolling them up into fists.

My stomach clenches, and I feel a sting in my eyes. I am all too familiar with this narrative. Many of my clients who have suffered sexual trauma describe similar experiences of numbing and freezing and an overwhelming sense of self-betrayal. I take a deep breath and redirect my attention to Jerry, who is still sobbing. I give him a few minutes. As he recovers from his outburst, he returns to holding his breath.

“Jerry?” I say gently. He looks up. “Thank you for trusting me with that. See if it’s OK to exhale. Slowly.”

Understanding dysregulation

Every word that Jerry says matters. I note his narrative. It is significant. I also note the paranarrative — the cauldron of sensations, emotions and racing thoughts bubbling beneath the surface of his quivering demeanor. This agitated vessel is holding a fusion of fear, isolation, shame, avoidance, mistrust, physical and emotional numbing, negative beliefs, impulsivity, diminished agency and an outright inability to tolerate the present.

While Jerry’s thoughts and emotions are overly active, his body is entirely ignored. Consequently, he is caught in the unconscious frenzy of persistent fear and some terribly unforgiving stories: The world is dangerous. I will never be safe. I can’t protect myself.

The harm Jerry has endured did not compromise his thinking or his emotions alone, however. Jerry has suffered a severe wounding to his body; hence, his collapsed posture, his irregular breathing and his restricted movement, coupled with his overall sense of being overwhelmed and his inability to maintain a state of calm.

As French phenomenological philosopher Maurice Merleau-Ponty pointed out in his seminal text, Phenomenology of Perception, our bodies are the agents by which we exist in the world. They are also the receptacles of memories that, often vanished from our conscious awareness, are still deeply etched within our being. When those memories are triggered, we experience suffering at a highly existential level that transcends consciousness. Facilitating the recovery of clients who have experienced sexual trauma must include opportunities for repairing connections with all dimensions of their being.

John Hughlings Jackson, known as the “father of English neurology,” outlined a human nervous system composed of three parts: social, sympathetic and parasympathetic, which has since inspired Stephen Porges’ polyvagal theory. Jackson’s model is hierarchical: The higher elements inhibit the lower elements. When a higher element on the hierarchy fails, a lower component takes over.

The highest element of the nervous system is the social one, responsible for relational contact and communication. Lower on the hierarchy is the sympathetic nervous system, which kicks in when we experience a disturbance in our inner or outer environment, thus activating our fight/flight/freeze/dissociate response. Should we not fight or flee, we plunge into freezing, immobility and dissociation. Unless the parasympathetic nervous system is reactivated, we remain frozen, incapable of responding to our environment.

Paradoxically, nonthreatening surprise situations are likely to elicit a sympathetic nervous system response, whereas threatening situations are likely to elicit a parasympathetic response, which is why many of us freeze or dissociate when confronted with a seemingly hostile situation. A healthy nervous system is one that self-regulates through a balance of sympathetic and parasympathetic functioning — that is, an arousal-activation event is followed by a period of rest and digest. An unhealthy nervous system, on the other hand, remains in either hyper- or hypoarousal, giving rise to startle, panic, hypervigilance, restlessness and emotional flooding, or to emptiness, exhaustion, disorientation, dissociation and emotional numbing, respectively. Clients who have not resolved traumatic events are often stuck in hyper- or hypoarousal.

In the aftermath of a traumatic event, survivors are likely to develop generally maladaptive coping symptoms that offer temporary relief from dysregulation. These coping symptoms include various process and substance addictions, obsessions and compulsions, and self-harm. Regardless, clients suffer the following interruptions:

  • Physical/perceptual (inaccurate kinesthetic reactions to perceived threat, anxiety, dissociation, collapse)
  • Contextual (difficulty perceiving and making sense of surroundings)
  • Emotional (fixation on fear, rage or sadness)
  • Cognitive-behavioral (intrusive, racing thoughts; memory loss; self-destructive patterned behavior)
  • Spiritual/existential (loss of sense of self)

Jerry tends to cycle between hyper- and hypoarousal, as evidenced by his frequent experiences of hypervigilance and panic attacks, and his often collapsed and frozen posture. When agitated, he attempts to manage his dysregulation in a number of maladaptive ways, including engaging in impulsive (e.g., breaking up and making up with his girlfriend repeatedly) and compulsive behaviors (e.g., continually washing his hands).

Although traditional cognitively and emotionally oriented psychotherapy approaches may help Jerry ease some of these coping behaviors, they do not include methods for addressing his dysregulation. Working with Jerry’s physical process allows me to help him identify when he is in hyper- or hypoarousal and bring himself back to what leading neuropsychiatrist and interpersonal neurobiologist Daniel Siegel refers to as one’s “window of tolerance,” or the zone in which our arousal state is balanced.

Honoring the somatic narrative

The somatic approach to healing trauma was inspired by a phase-oriented model for treating trauma and dissociation that was established in the early 20th century by French psychotherapist Pierre Janet. The somatic approach requires an understanding of how nervous system dysregulation is activated as a consequence of trauma and which parts of the body and brain are involved. The counselor uses this information to help clients create a sense of safety, to facilitate clients’ use of internal resources to regulate arousal and enhance self-efficacy, and to help clients address traumatic memories and explore novel ways of being in the world. Interventions include focus on nonverbal experience, kinesthetic awareness and reshaping body movement.

In the aftermath of his traumatic assault, Jerry’s ability to organize his experience was compromised, resulting in dysregulation of arousal, challenges tracking his surroundings and increased cognitive and emotional processing. This sent his thoughts and feelings into overdrive, making it difficult to control his impulsivity. With his inability to self-regulate, Jerry is virtually incapable of remaining connected with his present moment, and specific trauma-related (and sometimes neutral) stimuli can trigger an immediate impulsive response.

According to Pat Ogden, the pioneer behind the popular attachment-based somatic approach to healing trauma known as sensorimotor psychotherapy, a primary task faced by counselors working from a somatic approach is to help clients create a balance among the various processes used to organize experience. This is done using a bottom-up model that views human experience as an initially sensory process that informs emotion, which then informs thought and behavior. Focusing on the here and now is especially important when using a body-centered approach because it allows the counselor to address how a past event is manifesting in the present.

Finally (or perhaps first and foremost), when working with the somatic dimension, high levels of therapist presence and attunement are needed to support a therapeutic alliance with appropriate boundaries that is built on safety and trust.

Creating shared space

Essential to facilitating Jerry’s connection with his physical process is my personal embodiment — that is, my ability to be in contact with and present in my own body. By anchoring myself in my body and my present-moment experience, I am better able to create an empathic space for our encounter.

I use my sensory experiences to inform the therapeutic process and guide me toward a well-rounded understanding of how Jerry exists in the world based on how he exists in the therapy room. Understanding the experience of my body when I am in contact with Jerry helps me reach out within our intersubjective space with the deepest respect for his pace while acknowledging that I am affected by his experience. From this place of compassion and empathy, sharing and being, and phenomenological engagement, an integrative somatic process begins in which I serve as a bridge between Jerry and the rest of the world.

“When you are ready,” I say to him in gentle invitation.

Organizing the client’s experience in the here and now

I listen to Jerry’s verbal narrative. I also attune to the story his body is telling and how my own body is receiving that. What body postures does Jerry fall into as he recounts specific parts of his story? What gestures accompany certain words, phrases or recollections in the here and now?

Such physical manifestations are indicative of how Jerry’s body has encoded certain events implicitly. Jerry is physically manifesting content from his implicit (unconscious), somatic memory of the traumatic event that may or may not be congruent with his declarative (conscious) memory. Keeping in mind the fallibility of declarative memory, working from a somatic approach supports access to Jerry’s implicit memory, which offers us additional insight into his experience.

Attending to Jerry’s somatic narrative, I notice that his fists hold the highest energy. My own fists are wound so tightly that I can feel my nails digging into my palms. I also notice that I am holding my breath in anticipation. I release my breath, unfold my fingers and share some observations with Jerry in the form of brief contact statements designed to enhance his awareness.

I also pose exploratory questions. “I’m noticing that as you talk about feeling incapacitated in the moment you were grabbed, your hands are balled into fists. Would it be all right to bring your attention to your hands for a moment?” Helping Jerry consciously connect with the most reactive part of his body invites his capacity to self-witness and be self-aware. This activates the prefrontal cortex that, according to body-centered trauma expert Bessel van der Kolk, is responsible for emotion regulation, cognitive and social behavior, and decision-making.

As Jerry accesses his past experience in the here and now from a nonreactive place, he is better able to observe it, recognize that it happened in the past, notice how it is manifesting in the present and identify new ways of understanding it. Next, we work to identify the emotions that arise with the declarative and implicit memories of the experience and any thoughts that accompany the physical and emotional manifestations.

“What are you sensing in your fists right now?” I ask. “Examples of sensation are tingling, tightness, cold, heat.”

“They’re stuck,” Jerry says. “I can’t do anything with them.”

I ask Jerry to name the feelings that accompany that sense of stuckness. “Examples of feelings are anger, sadness, guilt, fear. ‘I feel …’ Can you fill in the blank?”

Jerry stares at the ground. “I feel … angry.” He begins to weep inconsolably. “I’m so, so angry.” He drops to the floor and curls into a fetal position. I give him a few minutes to be where he needs to be, to experience being balled up and angry.

“I’m so mad at myself. I didn’t save myself. Who does that?” I recognize that I didn’t have to invite Jerry to reflect on any thoughts accompanying the emotion and the sensation; the thoughts are emerging on their own.

Minutes later, Jerry is still holding his fists, but his tears are subsiding. I grab a box of tissues and sit on the ground near him, close enough to offer the nonphysical support he may need. I pull out a tissue and drape it gently over his left fist. He flinches and opens his eyes, looking straight ahead.

I wonder if it might be helpful to invite some awareness around how he is organizing this experience. “What are you holding inside your fists, Jerry? And what is that doing for you?” Jerry continues to look out into the ether. “Your fists,” I prod gently. “If your fists had a voice and could speak, what would they say? ‘I …’ Can you fill in the blank?”

Jerry is silent for a few seconds. “I … I am …”

“Yes, Jerry. Keep going,” I encourage him.

“I am … very angry,” he offers meekly.

“Is that what the anger inside of your fists sounds like?” I nudge gently. Jerry shifts slightly in his fetal position and then stops. “What does your body need to do right now?” I ask. “Expand? Contract? Walk away? Move closer? Is it OK to explore that need?”

“I think I need to move,” Jerry says. Without further invitation, he sits up. His upper body is still collapsed, and he seems undecided. I invite him to attend, once again, to what his body needs. Jerry inhales a little more deeply, expands moderately with his intake of breath, tightens his fists further and bellows, “I AM SO ANGRY!”

“Say that again,” I urge. “Give your fists the voice they need.”

“I AM SO ANGRY!” he screams, over and over. Twenty times. Thirty times. “I WILL NEVER LET ANYONE DO THIS TO ME AGAIN!” Jerry says even louder, holding his fists chest high and shaking them like he has someone by the collar.

Once Jerry has experienced a full release of energy, his tight fists unfold, although with some reservation. “Would it be OK to let go of the rest of that?” I invite.

Jerry’s eyes close, and I realize he may be unwilling to let go. I offer a compromise. “You don’t have to let go of your anger forever,” I say. “Maybe you can leave it in a safe place so that you can have it back whenever you want it.”

Jerry seems open to this idea. After some deliberation, he looks at a print hanging on the wall behind me and says, “I think I’ll leave it behind that picture.”

Jerry and I have just worked through a process of using an implicit memory (balled-up fists) connected with his traumatic incident to initiate a recalibration of his nervous system. This process involved:

a) Creating a shared space facilitated by my presence

b) Helping Jerry identify different facets of memory (implicit and declarative)

c) Using contact statements to help Jerry recognize the orienting patterns he is using to organize his experience (“I’m noticing …”)

d) Inviting Jerry to name his sensory, emotional and cognitive experience (“What are you experiencing …?”)

e) Allowing Jerry’s body to tell its narrative (“If your fists had a voice and could speak …”)

f) Exploring modification of Jerry’s orienting patterns (“What does your body need right now?”) and experimenting with new ways of being

g) Restoring empowering actions (“Give your fists the voice they need.”)

The next step involves making sense of our process. The hope is that Jerry will use his new understanding of his experience to make new choices informed by the here and now.

Creating meaning and energizing change

“What was that like for you?” I ask.

“I don’t know,” Jerry says. “I feel like a heavy load has been lifted.” I nod. “From these,” he continues, raising his hands.

I acknowledge and affirm Jerry’s reflection. “Those fists were holding on pretty tight. What did it mean to hold tight?”

“I think … I felt in control.”

“Can you say more about that?”

“Yeah. Like I wasn’t going to lose it, I guess.”

I feel that Jerry and I are in a safe enough place for my next question. “What would happen if you allowed yourself to completely lose it?” Jerry clenches. “OK to exhale?” I invite.

Jerry releases his breath slowly. “I don’t know.”

“Jerry?” I invite him to make brief eye contact with me. “I’m not sure I buy that.” I smile gently. “What would happen?”

Jerry thinks but maintains eye contact. “I mean, I just lost it, right?”

I offer a perspective: “Seems like you trusted yourself with that too.”

“I did,” he says solemnly.

“What is it like for you to trust yourself?” I ask. “‘I …’ Can you fill in the blank?”

“I feel pretty big right now.”

“Hmm. What does big look like?” I invite. “Can you show me?” Jerry lifts his body and expands his chest. Although he does this slowly and with seeming caution, I am aware that he has given himself permission to explore a place beyond his wound. I open the door for a final inquiry that will help Jerry take what he has learned about resourcing himself outside of the therapy room: “What might you do with that bigness, Jerry?”

Working through roadblocks

Accessing and working with certain memories in the here and now is not always a straightforward process. In Jerry’s case, he sometimes exhibits an aversion to being in the present. For example, although Jerry shows relative ease connecting with his anger, in a later session he experiences great difficulty accepting his shame.

Jerry’s resistance manifests, initially, as indirect eye contact and fixation on the ground. Once we begin exploring this and Jerry identifies the emotions and thoughts connected with it, he manifests an outburst of physical agitation that is marked by twitching in his chair until he falls to the ground.

I invite Jerry to remain seated on the floor and connect with the ground (using a process we call grounding), which helps him feel connected to and supported by something outside of himself. Next I ask him to explore his center of gravity by way of a process called centering, which brings his attention back to his physical experience. Finally, I suggest containment, a self-holding exercise designed to facilitate self-regulation and awareness of one’s boundaries and overall physical presence.

Because of their focus on the physical, these exercises shift clients’ attention from the self-destructive emotional and cognitive narrative to their internal resources. With this, the counselor is tasked with pacing the session so that the client is not overwhelmed. Introducing these safety-enhancing exercises is often helpful as sexual trauma clients experience the need to recalibrate from the potentially overpowering experience of confronting their trauma.

Establishing a time frame for the therapeutic process

Clinicians working from a somatic approach are highly aware of the challenges of creating time parameters for their therapeutic work. On the other hand, it is not uncommon for clients to ask, “How long will I be in therapy?” My response is that it depends on a number of factors, including:

1) Whether the traumatic event was a single, first-time incident or is recurring

2) The client’s developmental history (i.e., milestones, attachment patterns)

3) The client’s current coping strategies

4) Systemic factors (i.e., family, community and broader social support)

5) Client openness to working with the body

6) Therapist consistency and the quality of the therapeutic alliance

That said, somatic therapy tends to be time intensive, unlike, say, brief solution-focused or cognitive-behavioral work. Jerry attended weekly 80-minute therapy sessions for approximately 10 months, followed by biweekly 50-minute sessions for three months. He is currently coming in for monthly 50-minute check-ins.

Although Jerry has not forgotten his traumatic incident, he has learned how not to be hijacked by memories, how to self-regulate when confronted with somatic, emotional or cognitive triggers and how to tap into internal resources (including his body) to address present-moment needs.

Closing reflections

Embracing a somatic approach in working with Jerry’s sexual trauma engages his verbal and nonverbal narratives, opening a door to reshaping his way of being in the world and catalyzing new intentions and experiences. It also helps us focus on what is versus what was or what might be.

Working in the present enhances Jerry’s awareness of who and how he is in the world, what he does and how he does it, and how remaining stuck in the past or allowing himself to be hijacked by the future are choices he can modify as he works to reconnect with his window of tolerance. Being aware brings present-moment possibilities and options center stage. The emphasis is no longer on irreversible past or anticipated future experiences but on what is happening in the here and now.

Thus, clients take responsibility for their needs, feelings, thoughts and actions. Taking responsibility and ownership of situations and experiences is, in itself, a holistic, anchoring and awareness-enhancing behavior. With it comes an increased ability for clients to push the boundaries that are stifling their self-expression, identify immediate needs and engage in self-mobilization, creative experimentation, somatic expression and self-regulation, all of which are at the heart of an existence that has made peace with its past and is grounded in the present. As clients’ awareness is ignited on a holistic level, they are empowered to decide whether their patterned behaviors still serve a purpose and how those behaviors can be modified to meet present needs.

How we inhabit our bodies reflects our way of being in the world. Through our bodies, we sense and experience, receive and perceive. Exploring the physical body and its manifestations of past sexual trauma helps clients integrate the physical, emotional and cognitive dimensions of their experience. Sensory-kinesthetic exploration brings history to life in the present and anchors it here, where it is more accessible.

Conscious engagement with the body’s innate knowledge permits clients to access their own strengths in the process of healing. How empowering and transforming for our clients who have suffered from sexual trauma to recognize that their well-being exists within their own bodies — the very site of their original wounding.

 

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Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

Nevine Sultan is an assistant professor of clinical mental health counseling at the University of St. Thomas in Houston and a licensed private practitioner specializing in trauma, dissociative disorders and grief. She embraces an embodied phenomenological approach to counseling and psychotherapy, research and teaching. Contact her at nevine.sultan@gmail.com.

Letters to the editor: ct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Stories of empowerment

By Lindsey Phillips September 26, 2017

In 2009, writer Chimamanda Adichie gave a TED Talk on the danger of reducing people to a single narrative, using her own personal stories to illustrate the complexity of individuals. In one of those stories, she revealed how her college roommate in the United States had a single understanding of Africa — one of catastrophe. Adichie, a middle-class Nigerian woman, did not fit this single-story narrative. To her roommate’s surprise, Adichie spoke English, listened to Mariah Carey and knew how to use a stove.

Adichie points out that people are impressionable and vulnerable in the face of a story. Stories are powerful, she says, but that power is dependent on who is telling the story and how it is told. “Power is the ability not just to tell the story of another person, but to make it the definitive story of that person,” Adichie says.

Storytelling can also be used to empower people, which is one of the primary functions of narrative therapy. In many ways, the story of narrative therapy began in the late 1970s through shared stories and conversations between Michael White and David Epston. This counseling approach assumes that culture, language, relationships and society contribute to the way that individuals understand their identities and problems and make meaning in their lives.

The narrative approach also separates the person from the problem — a technique that allows clients to externalize their feelings. “The spirit of externalizing the problem is so that the client doesn’t see that as something that they can’t change,” says Kevin Stoltz, an American Counseling Association member who is an assistant professor of counselor education at the University of New Mexico. Moreover, this approach places clients as the experts in their own lives (see sidebar, below).

Don Redmond, an associate professor of counseling at Mercer University in Atlanta and director of the university’s Center for the Study of Narrative (CSN), points out that White and Epston’s original vision of narrative therapy was not prescriptive. “It really is in some ways theoretical, even though there are specific techniques that you can learn. It really is about celebrating and appreciating each person’s unique story and helping them frame it in a way that is more self-affirming and less self-defeating,” he explains.

(Re)writing memories

Narrative therapy can help clients release the burden of painful memories. Cheryl Sawyer, professor of counseling at the University of Houston–Clear Lake, started using narrative therapy in part because of an aha moment she experienced while watching a scene in the movie Harry Potter and the Goblet of Fire. In the scene, Hogwarts headmaster Albus Dumbledore shows Harry the Pensieve, an object that stores thoughts and memories.

Sawyer specializes in trauma counseling and often works with children who are refugees or who have been abused. She wanted to help her child clients release their traumatic memories, so she created a narrative project in which children create memory books. As Sawyer explains, the memory books operate like the Pensieve, allowing the children to unpack their trauma and give it a safe place to live.

Children do not narrate the episodes of their lives chronologically, Sawyer notes. Instead, their level of trust determines where their stories begin. If they trust the counselor, she says, they will reveal more intimate details (e.g., “I was beaten up at my birthday party”) rather than offering only the generic version (e.g., “I received presents”).

Because children’s narratives typically are structured but not sequential, it can be hard to discern cause and effect, says Sawyer, a member of ACA. To overcome this, counselors can have child clients place events from their stories on a timeline. This technique allows clients to see the cause and effect, understand their own behavior and possibly project what might come next based on the patterns they notice.

In Stoltz’s experience, Adlerian theory and early recollections (an Adlerian process in which counselors instruct clients to remember actual events from their early life) work well with narrative therapy. This is because they help people understand their self-concept and self-identity and make meaning out of the experiences embedded in their lives.

In a classical Adlerian sense, early recollections are defined as memories before age 10, Stoltz says. “The time frame … is somewhat artificial in some aspects, but in other aspects, it’s good to understand the very core of when those first experiences started to come out for people — what they remember, what they really think is poignant that … shapes their beliefs and their worldview,” he says. Childhood memories are often distorted by one-dimensional thinking because people’s perception in childhood is different than in adulthood, he adds. Re-storying involves recalling these early memories and reinterpreting them with an adult mindset that is capable of higher cognitive exploration.

Stoltz is currently applying guided imagery to career narrative stories. As he explains, clients often have a fictional or real-life person they admired when they were young because the person’s traits or behaviors matched the way they thought the world should operate. Often, they used this hero narrative to move through life, Stoltz says.

For example, with one client who presented a heroic memory of Spider-Man, Stoltz noticed a pattern: The client kept using the word conflict in his narrative. In discussing this pattern, they discovered that the client no longer wanted to let his responsibilities be an excuse for shying away from conflict. So, they worked together to determine how the client handled conflict currently, how the client wanted to handle it in the future and how the client’s role models handled conflict.

“Guided imagery is a way of projecting that hero data onto a future career decision or a career transition. And it makes it more lifelike in the session for the person. It begins to allow them to purposefully imagine and really begin to apply that self-concept to the next step in their career,” Stoltz says.

Stoltz uses narrative data from the career construction interview to develop individualized scripts, including ones focused on supporting client identity, meaningfulness of work and aspects of adaptability and skills. “The narrative approach is always about writing the next chapter, and this is a way of applying the next chapter to an imagined world, a daydream,” he explains.

Pictures worth a thousand words

Words can sometimes fail clients. If clients cannot or will not articulate their stories with words, counselors must be creative and find another way for clients to express themselves, Redmond says. “The more versatile a counselor can be, the better,” he adds.

Sawyer works with some clients who possess limited vocabularies because they have lived on the streets from an early age and haven’t been exposed to higher levels of language. For example, a child might say, “I’m really mad,” but that statement is insignificant compared with what he or she is actually feeling.

When children don’t have all the words they need to express their thoughts, Sawyer relies on pictures. She asks clients to draw pictures, find pictures on the Internet or even go out and take pictures that support the deeper level of emotion in their personal stories. Often, she will take a series of pictures into the counseling session and ask clients if any of the pictures express how they feel that day and why that image best exemplifies what they are feeling.

Technology is providing yet another avenue for clients to communicate their stories. Sawyer finds that children and adolescents are often more comfortable texting than talking, so she has started using technology as a tool in storytelling. She creates digital narratives by typing the clients’ stories into PowerPoint slides. Then, she gives clients the option of adding music, images or art to depict how they feel. For example, one client added a picture of his father’s death certificate, and another client added a picture of a pair of shoes she was going to send her sister before her sister was murdered.

Redmond also combines technology and narrative therapy. At Mercer University’s CSN, counseling students interview people in the community and then convert these interviews into digital narratives (approximately five-minute videos) by selecting pictures, art and music to complement each person’s narration of his or her own story. One woman whom Redmond interviewed painted and sang to express her story, and both aspects were incorporated into her digital narrative. Pairing descriptions of her artwork with actual images of it captured her essence more fully than if she had been only interviewed, he adds.

These digital narratives allow individuals not only to rewatch their stories but also to share their stories with others. In fact, one of Redmond’s goals for CSN is to create a digital library that will help individuals going through a difficult time to realize that they aren’t alone.

Taking a back seat

Narrative therapy falls under postmodern theory. “One of the hallmarks of the postmodern approach is embracing the fact that there is subjectivity with an individual’s perception and what they’ve been through and not having the counselor come in and be the expert,” Redmond says. With narrative therapy, he explains, clients are the ones verbalizing the new or modified narrative of their lives, and counselors only paraphrase or mirror what clients are saying.

Because narrative therapy is client driven, it is more important for clients to understand how they are feeling than for the counselor to understand it, Sawyer says. “[Counselors are] the tool that [clients are] using, the base that they’re using, to tell their stories for themselves,” she explains. Clients must be provided with a safe space where they can share their stories and learn to express their feelings about what happened.

As a volunteer with Bikers Against Child Abuse, Sawyer often attends court cases involving children who have been abused, and she has observed children’s frustration when lawyers interrupt or guide their stories in answer to a specific question. For Sawyer, this observation further underscores the importance of allowing clients, not counselors, to direct and narrate their stories. As she points out, counselors are facilitators for the client’s story, so their job is to listen and help the client structure the order of the story, not the content.

Stoltz has found that the process of deconstructing and reconstructing the elements of a client’s story is often challenging, particularly for counseling students. To demystify this process, in 2015, Stoltz, along with Susan Barclay, published a guidebook, The Life Design ThemeMapping Guide, that provides counselors with a process for deconstructing narrative data, developing specific themes for the career construction interview and helping clients reauthor their stories. For the past five years, Stoltz has used this technique to train students to deconstruct and theme elements together.

Taking a back seat and allowing clients to guide the session can be particularly difficult for new counselors because they want to feel that they are accomplishing something, Stoltz says. They want to sense that the client has made a decision and is moving in a direction. Drawing on James Prochaska and Carlo DiClemente’s Stages of Change model, Stoltz reminds counselors that they’re “raising awareness now. You’re in the beginning of the change model. You’re in the contemplation stage or precontemplation stage. You’re not looking for movement. You’re looking for insight or awareness, the aha moment.”

A voice for marginalized, multicultural populations

With narrative therapy, clients inform counselors about their world, values and beliefs. In fact, early recollections provide counselors with an inside view of the client’s culture, Stoltz says.

Within this dynamic, a counselor’s culture and values may differ from the client’s, but counselors should not place cultural judgment on what clients have done, Sawyer says. For example, clients might disclose that they have offered sex in exchange for food, or they may use profanity in telling their story, but counselors must refrain from passing judgment, even if they think this act or language is hideous or immoral based on their own cultural perspective. Clients must feel safe to use their own language and words to freely tell their stories, Sawyer adds.

Redmond agrees that narrative therapy is compatible with cross-cultural environments because narrative counselors do not presume to know and tell clients about their problems. He also realizes that too often, the stories of marginalized individuals remain unheard. One of Redmond’s inspirations for creating CSN was StoryCorps, an oral history project that allows people to record their stories in a studio by having a family member or friend interview them. The recordings are then archived at the Library of Congress. Through CSN, Redmond expanded the project to include marginalized populations (e.g., people who are homeless, refugees) who do not readily have someone available to interview them and record their stories.

Redmond believes the community plays a significant role in narrative therapy. Therefore, CSN’s purpose is both to allow counselors to practice their listening skills and to provide a service to the community by letting people who are marginalized know that they are valued. Even though the CSN interviews are not considered official therapy, most people would agree that the simple act of telling one’s story can be therapeutic, Redmond says.

Redmond’s personal story also played a role in the creation of CSN. Besides the fact that he has always enjoyed stories, Redmond had two professional experiences that strengthened his belief in the power of narrative therapy. First, in his role as a supervisor at Hillside in Atlanta, a facility that serves children with severe emotional behavior disorders, he discovered that the children with the most severe behaviors and who had been at the facility the longest also possessed the most strengths. This observation made an impression on him, especially considering all the negative messages directed at these children, many of whom had been abused and were in and out of foster care.

The second experience occurred when Redmond was an access clinician at a community services board. Many individuals were at this facility under court order or because they were dealing with mental health issues. While conducting intake interviews, Redmond amused himself by writing down the clients’ strengths (e.g., intelligent, strong work history, sense of humor, family support). At the end of the interview, he would tell the clients the strengths he had jotted down and then would ask if they wanted to add anything. He often witnessed powerful reactions from the clients, including those who cried and said no one had ever told them that they had strengths.

These two experiences reinforced Redmond’s belief that “people start creating negative self-stories, and they start to only believe the negative images, and then they forget about the strengths that they have.” Therefore, Redmond advises counselors never to forget to account for the strengths of their clients, no matter the difficulty of the case.

The cultural awareness gleaned from narrative therapy also applies to clients, allowing them to question their own cultures. Often, Stoltz says, the difficult part is relating the memories and stories back to the client’s present life. Some clients grasp this concept more easily than others, and some struggle to understand how childhood events are still affecting them as adults. The latter scenario is challenging. “Early memories really are a good tool to have to be able to talk to people from different cultures because [there are] stories in every culture. … Memories are a story, and [they are] a way of relating that whole story back to the person,” he says.

Validating narrative therapy

Critics of narrative therapy often question how counselors objectively measure narrative techniques, which are subjective. “I think we’re in the infancy of starting to measure these kinds of things. I think we’re just beginning to rediscover some of the things that have been helpful in mental health counseling, and we’re applying those as new techniques to the career narrative area,” says Stoltz, who served as chair of the research committee for the National Career Development Association, a division of ACA. At conferences, counselors are discussing how the narrative approach works, and they are doing outcome research that says it works, but they are not yet validating the process, he adds.

“You cannot quantify emotion,” Sawyer acknowledges. She and her colleagues attempted to measure narrative approaches by administering a pretest and posttest to children who had suffered trauma. They found a valid instrument and administered it in the children’s native language, but the formality of the instrument and the fact that the counselors had not yet established a relationship with the clients caused some clients to leave prematurely. Based on this experience, Sawyer decided not to administer the posttest and concluded that sometimes narrative therapy is not about research; it is about clients and their needs.

The best method Sawyer has found for measuring the success of narrative therapy involves having clients point to shapes (e.g., small, medium and large circles) to indicate how big their problems are both before and after counseling sessions. Using this method, she has found that narrative therapy has a positive effect because for most children, the representative shape decreases in size at the end of the counseling sessions. However, because counselors cannot account for all variables — if court is over, if the client is living in a home with 14 other children, if the client has learned to speak English and so on — it is impossible to know whether clients have improved strictly because of narrative therapy, she points out.

Redmond is a proponent of mixed-methods research because quantitative research (e.g., a Likert-type scale) provides more breadth than depth, whereas qualitative research provides the depth. In addition, they complement each other: Quantitative research can provide counselors with great ideas for qualitative research and vice versa. Redmond recommends first using quantitative research, such as a survey, because clients find it less threatening and less personal, but it will still get clients thinking about their experiences. Then, counselors can ask clients the magic question: “Is there anything you haven’t discussed that you would like to talk about?”

Stoltz has discovered that finding thematic codes for categorizing narrative data is one way to measure narrative techniques. For example, people who engage in storytelling about traumatic events in their lives tend to integrate these life events into meaningful stories and report higher life and career satisfaction.

“Preliminary evidence is beginning to show that when trained people read these stories, they come to the same conclusions,” Stoltz says. “That’s an important first step in validating …
this process.”

In addition, digital narratives may provide opportunities to quantify narrative interventions in the future, Redmond says.

Integrating narrative practices

Narrative therapy is not for the lightweight, and it is not as easy as it sounds, Sawyer says. In fact, self-doubt can prevent counselors from using narrative techniques, she points out. To avoid this, counselors need practical experience. Just taking one course or workshop or reading a book on the topic won’t mean that counselors will know how to use the approach correctly. Instead, Sawyer argues that counselor training should involve a holistic approach in which counselors expose themselves to the topic not only through courses, books and articles but also by practicing under supervision and processing all along the way.

Also, some counselors are hesitant to incorporate mental health-based approaches if their training is in another specialty such as career counseling. Stoltz, however, stresses the importance of taking an integrated perspective because people have multidimensional experiences that are not mutually exclusive. “Career counseling is often seen as limited to the career dimension, but it is really counseling with a career goal in mind,” he says.

For Stoltz, it makes sense to apply narrative therapy to career counseling because there is always a story behind one’s career. Furthermore, many people spend eight to 10 hours working every day, and work stress is a significant contributor to a person’s well-being or absence of well-being, he says. Despite this, counselors are generally not incorporating work aspects into mental health, he points out.

Thus, Stoltz argues that counselors “need to rethink [their] specialization construct.” Unfortunately, it is easy for counselor educators to design courses that address a certain standard (e.g., a career counseling course, a trauma course, a multicultural course). However, when counselor educators create stand-alone courses, students often move from one course to another without integrating those courses, Stoltz says. To avoid this, he incorporates basic counseling skills alongside career counseling because students must learn to respond to content and meaning before they can help a client deconstruct a story.

Sawyer’s counseling program at Houston–Clear Lake integrates narrative therapy into the curriculum by introducing narrative therapy as a counseling tool and working narrative techniques into multiple courses. “It is not the only way to counsel but … like how everybody knows how to do Rogers, everybody knows how to do Gestalt … all of my students know how to do CBT [cognitive behavior therapy] and trauma-focused CBT, and they all know how to do narrative counseling,” she says.

Stoltz agrees with expanding counseling areas, but he also worries that as counseling training becomes broader, counseling programs are finding it difficult to retain depth. Counseling students need to understand both the academic jargon and the practical training associated with those terms, he stresses. “Re-storying needs to be accompanied with a practical, pragmatic application of what that looks like and what that process is,” he says.

Stoltz is helping to bridge this gap by incorporating experience work in his classroom, which is a technique modeled after Mark Savickas’ pedagogical practice. For example, a counseling student might do a case study and follow someone through a career intervention, or a career story, and present this constructed story to the class.

Redmond finds that counseling students infrequently have many opportunities to train specifically in narrative therapy or narrative studies. Currently, students in his program are introduced to narrative therapy under the umbrella of postmodern approaches in a counseling theories course, but his goal is to have students do more specialized work in narrative therapy in the future. As a step toward achieving this goal, he will be working this fall on a proposal for a narrative certificate program.

Authoring the next chapter

Stoltz acknowledges that misinterpretation or a unitary interpretation of a client’s story is one of the pitfalls of narrative therapy. “[Counselors] feel like [we’ve] got the inside track on this because [we] have this psychological knowledge, this counseling knowledge, and [we] have to be careful with that,” he warns.

Often, counselors will make up their mind about what the story means to the client. But the counselor’s job is to test, not to interpret, Stoltz says. Counselors should make the client aware of what they see and test that theme or theory with the client while still respecting that it is the client’s story, he explains. The client is the one who has to live the life and rewrite the story; the counselor’s job is to help the client accomplish this.

Adichie reminds us that “stories can break the dignity of a people, but stories can also repair that broken dignity.” Narrative therapy provides clients with a safe space to tell their stories. With a counselor’s guidance, clients can slowly reject the negative stories and stereotypes that create an incomplete or inaccurate representation of who they are as individuals and replace them with stories that empower them to take control of their lives and regain their humanity.

Stories are powerful, but the person holding the pen is the one who controls the story. Revision is key when writing a novel, and this holds true in narrative therapy as well. People first have to understand and narrate their stories in order to rewrite them and become the authors of their next chapter.

 

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Narrative approaches

As explained in the fifth edition of Counseling and Psychotherapy: Theories and Interventions, edited by David Capuzzi and Douglas R. Gross and published by the American Counseling Association, narrative therapy is based on the following beliefs:

1) Clients are not defined by problems they present in counseling.

2) Clients are experts on their lives, so in counseling, judiciously seek their expertise.

3) Clients have many skills, competencies and internal resources on which to draw when impacting change and growth.

4) Therapeutic change occurs when clients accept their role as authors of their lives and begin to create a life narrative that is congruent with their hopes, dreams and aspirations.

 

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Lindsey Phillips is a freelance writer and UX content strategist living in Northern Virginia.
She has 10 years of experience writing on topics such as health, social justice and technology. Contact her at lindseynphillips@gmail.com or through her website at lindseynphillips.com.

Letters to the editor: ct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Nonprofit News: Preparing for your successor starts with the founding of your program

By “Doc Warren” Corson III September 25, 2017

Most of us have seen it happen. The founder of a nonprofit program retires or dies after decades of dedicated service and sacrifice, and their life’s work turns to shambles in no time because of drastic changes made by those who replace them.

Sometimes it starts subtly, with a tweak or two to the mission statement. Other times it’s like a battering ram and might include the sale of once vital property, the handing over of the nonprofit to a larger program, the abandonment of core values and missions or the dissolving of the program altogether.

In other cases, the driving force behind a nonprofit is neither the board of directors nor even the founder(s) but rather one or two key members of the program. Once they have gone, the heart and possibly the soul of the program goes with them.

This does not need to happen, however. In this article, I’d like to offer some key ways to ensure a positive outcome once you are gone from your nonprofit program. It is NEVER too early to plan for your departure. In fact, in the program I founded, that planning started in the design stage, far before the first client arrived, before the location was selected and while the writing of our bylaws and other founding documents was taking place.

Be clear about your mission and direction. When training new staff and board members, use your mission and direction plans as the framework for every major decision. Otherwise, the mission statement is little more than something that is written in the founding documentation and then forgotten. When new programming is suggested, discuss how it would further the mission (or not). Make your short-, mid- and long-term direction clear. The best way to ensure a smooth transition is by educating your workers thoroughly while you are still active in your nonprofit program.

Select board members who love your program and what it has become but who are not afraid to challenge you. Find folks who share your passion but not ones who will follow you without question. This is not a place for sycophants. As the director of a counseling-based nonprofit, you will be challenged during discussions and you will likely lose a vote from time to time. That is a good thing, so long as it is productive.

Beware, however, of board members who might say, “I never really got what the founders wanted. It just didn’t make sense. But I took the position because it was good for my career.” Once these folks take charge, your program may never be the same.

I once spoke with a person put in charge of a low-income housing program who said he never understood why the program owned property. He set about divesting the program of ALL of its real-estate holdings “with the understanding that the new for-profit owners would keep costs affordable for all income levels.” Since its incorporation, the foundation of the program had been the acquisition, development and maintenance of property for the express purpose of providing quality low-income rental units. In short order, this person transformed “his” program into little more than an advocacy program, which was far removed from what the founders had envisioned. If there had been a stronger board of directors that possessed a working knowledge of the founders’ goals, this scenario easily could have been prevented.

Teach your secrets to others. Are you able to negotiate better deals with certain companies than others could due to knowing more about that company’s preferences and style? If so, how do you do it? Do you know something that others might miss? Perhaps that that company requires a softer hand or more direct involvement? Whatever the case may be, if you have a secret, share it with your valued staff.

I often am called into negotiations of various types, such as when there are issues between two entities that have shared programming or to help prevent rifts between individuals or programs that could lead to legal issues or formal contract disputes. The hope is that I can bridge the gaps. Most times, I can, although some cases do indeed lead to court or other less-than-positive situations. Whatever the outcome, I always try to sit with key members of my program to go over the case study so that we can see what worked, what didn’t work and how it all turned out.

Don’t make yourself out to be the superhero; share your knowledge. Sometimes it comes down to a little observation such as “I noticed from the way that someone in the negotiations held themselves that they likely would not do well with an authoritarian approach, so I approached them as equals and asked them rather than told them how they could assist.”

By teaching your team not just the how and why of your process but also the what (What led you to this decision? What data was important? What cues do you consider important?), you can help them replicate it far into the future. This is key so that if they ever are called into a situation such as this in the future, they will have a leg up in the process due to the added insight from this experience. At times, the “student” in this situation can become the teacher because he or she may see a possibility that I missed. Either way, this process assists our entire program because of the shared knowledge. Although it’s great to feel important and to be the “go to” member of your team, it is better to help foster an environment in which the whole team becomes “go to” people. And it’s all the better if they come to emulate your style so that once you are gone, your flavor will remain.

Nurture your employees and volunteers. Show them they are vital and appreciated; don’t just provide lip service. What makes them important? What skills do they want to build? Find out and try to put them in positions where they can gain them. What do they prefer to do? Find out and try to match the needs of the program with your employees’ and volunteers’ skills and passions. When they fail, be kind and offer guidance and a shoulder as needed. The more ownership they feel in the program, the better.

Speak of future plans now. Don’t keep things a safely guarded secret. Put your dreams and goals out there. The more folks that know, the better. Pillwillop Therapeutic Farm is a direct result of me making it known to anybody who would listen that I wanted land for passive recreation for our community. It started with an offer from a lodge brother who heard about my plan and said he would let his property be used via parking passes. From there, it led to a lease and purchase. The property never was put on the market, and without me sharing my vision with others, we would never have known about it. Many things happen like this in business on a regular basis, so make your dreams known.

Don’t allow yourself to become indispensable. We’ve all seen it. An enigmatic leader appears to be able to pull off just about anything he or she attempts, often where others have failed. No one else, it seems, can do what this leader does. This is great while the leader is there, but it can be disastrous when they are gone.

Teach folks how you do what you do. Nurture them and guide them while you can so that when you are gone, they can take over in a smooth transition. In many cases, the secret is easy. When a leader was asked how victory was achieved where so many others had failed, the leader responded, “I looked at each failure to determine why I thought it failed, then compiled all the data and took a path that no one else had. Using the failures as a way to eliminate possible paths provided me with the one most likely to succeed.” The leader then gave concrete examples that were invaluable.

Don’t overreach or overspend. We often have grand goals, which is fine. But keep the bottom line in mind and be realistic. Many nonprofit programs fail because when the new guard comes in, they find that the old guard left the program with a pile of debt or discover that the work the program is doing has become so diluted as to make it tasteless.

If you want a smooth transition, leave a firm foundation. This includes a healthy debt-to-income ratio (my program has only one line of credit, which is our mortgage), equity in your properties should you ever be forced to take out credit (we had about 55 percent equity at closing) and realistic growth. Although we have built our main program slower than projected (we have about half of our building remodeled, whereas we had hoped to have it all redone), we have done so without a line of credit or debt, which leaves us in a very strong position.

Delegate, empower and cross-train. Don’t do it all yourself. You can delegate duties, monitor, guide and lead, but to succeed, you will need a solid team. Teach folks not only their job but the jobs of others so that should an emergency arise, you will have backups. This happened to us recently when we lost a key member of our staff temporarily due to illness. Because we were cross-trained, we possess the capability of getting the job done, at least minimally, while waiting for our team member’s return. We all are doing a bit more than normal, but thanks to the cross-training, it is working.

Use the “decade rule.” It has been said that it takes a decade to properly train your replacement as a leader. If everything ran smoothly, you could wait until 10 years prior to your planned retirement to train your replacement. But since we do not know how our health, the job market and countless other factors will be that can impact our ability and desire to work, it is a good practice to have training in place sooner rather than later. Through training, delegating, setting a good foundation and following other best practices, you are allowing yourself the decade required to allow your successor to learn the ropes well.

If you want a solid course for the future, leave a solid program when you exit.

 

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Nonprofit News looks at issues that are of interest to counselor clinicians, with a focus on those who are working in nonprofit settings.

 

Dr. Warren Corson III

“Doc Warren” Corson III is a counselor, educator, writer and the founder, developer, and clinical and executive director of Community Counseling Centers of Central CT Inc. (www.docwarren.org) and Pillwillop Therapeutic Farm (www.pillwillop.org). Contact him at docwarren@docwarren.org. Additional resources related to nonprofit design, documentation and related information can be found at docwarren.org/supervisionservices/resourcesforclinicians.html.

 

 

 

 

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Informed by trauma

By Laurie Meyers September 22, 2017

In 1995, the Centers for Disease Control and Prevention and Kaiser Permanente began what would become a landmark study on the health effects of adverse childhood experiences. Over the course of two years, researchers collected detailed medical information from 17,000 patients at Kaiser’s Health Appraisal Clinic in San Diego. In addition to personal and family medical history, participants were asked about childhood experiences of abuse, neglect and family dysfunction, such as emotional and physical neglect, sexual and physical abuse, exposure to violence in the household and household members who had substance abuse problems or had been in prison.

Researchers found that the presence of these negative experiences in childhood was predictive of lifelong problems with health and well-being. The more negative experiences a participant had, the more likely — and numerous — these problems became. Another disquieting finding was that adverse childhood experiences were incredibly common. Almost two-thirds of participants had endured at least one adverse childhood experience, and more than 1 in 5 respondents had endured three or more such experiences.

In the decades that followed, this discovery of the prevalence and devastating effects of trauma spurred the development of practices such as trauma-informed counseling, which stresses the importance of recognizing and treating trauma and, most importantly, preventing additional trauma.

Drawing on basic counseling skills

According to the U.S. Substance Abuse and Mental Health Services Administration, programs, organizations or systems that are trauma informed:

  • Realize the widespread impact of trauma and understand potential paths for recovery
  • Recognize the signs and symptoms of trauma in clients, families, staff members and others involved with the system
  • Respond by fully integrating knowledge about trauma into policies, procedures and practices
  • Seek to actively resist retraumatization

In many ways, trauma-informed care involves using skills that every counselor should already possess. “Remain empathic, open, nonjudgmental and steady. Steadiness is particularly important,” says American Counseling Association member Cynthia Miller, a licensed professional counselor (LPC) in Charlottesville, Virginia, whose practice specializes in trauma. “You don’t want to overreact to things a client tells you. But you don’t want to underreact either. Screen for trauma at intake. Don’t just ask a client if they’ve ever been abused or neglected. Many clients won’t define themselves as victims of abuse or neglect, and if you ask it that way, you’ll miss it. Ask behaviorally instead.”

Miller suggests using questions such as, “Has anyone ever hit, punched, slapped or kicked you? Has anyone ever put you down, called you names or made you feel worthless? Has anyone ever touched you without your permission? Have you ever witnessed a violent or upsetting event that really troubled you?”

“If a client responds with a ‘yes’ to any of those questions, ask them if they’d like to share more about it now,” Miller continues. “Help them feel in control of what they disclose and when and how much. Don’t make the mistake of thinking you need all the details and then push to get them. You can retraumatize someone that way. Instead, ask them how they think the experience impacted them and if they think it is related in any way to their current struggles.

“At the opposite end, if they respond to everything with ‘no,’ don’t assume a trauma never happened. It may very well be that they’re just not telling you about it right now because they don’t yet feel comfortable. Stay open to the possibility and rescreen as appropriate.”

When specific questions about trauma don’t elicit answers, ACA member Rebecca Pender Baum, a licensed professional clinical counselor in Kentucky who has worked with survivors of sexual assault and interpersonal violence, often asks clients if there is anything they haven’t already told her that they think she needs to know. She has found that this approach often helps clients express concerns that they have been holding back.

Jane Webber, an ACA member and LPC in New Jersey who has written extensively about trauma and disaster, often mixes less threatening questions in with questions related to trauma. For example, in the midst of gathering basic background on family history, she will ask clients about events such as accidents or a history of falling. She then works up to questions about physical and sexual abuse. Webber emphasizes the importance of counselors using the same calm, steady tone of voice for all questions to prevent distressing the client.

Webber also finds it useful to tell her clients, particularly those on the younger end of the spectrum, that they can answer her questions via text during the session. She says that sometimes clients are more open to texting about things that they might struggle to express verbally.

Webber urges counselors to be intuitive with clients and look for signs of unexpressed trauma such as sweaty palms, restless movement in sessions and failure to make eye contact.

Miller says that she stays alert “for what I think of as disordered self-soothing,” which may include “substance use, self-injury or aggression. Individually, any one of them can be a clinical indicator. As a triad, they’re almost certainly covering up an untreated trauma.”

A different focus

At first, it may seem strange to treat every client as if he or she is a trauma survivor. However, clinicians who use trauma-informed counseling say that the practice is also about changing the overall focus of counseling by moving away from the “problem” approach. That approach demands, “What’s wrong with you? What did you do wrong? What’s making you act that way?” says Webber, a lecturer in the counselor education department at Kean University’s East Campus in Hillside, New Jersey. “[Trauma-informed counseling] is a paradigm shift from what is wrong with the client to what happened to the client.”

Julaine Field, an ACA member and LPC from Colorado Springs who works with traumatized children, agrees with Webber. Field explains that rather than focusing on changing a client’s thoughts or behaviors, trauma-informed care seeks to understand how people react and adapt to experiences.

A trauma-informed counselor helps clients understand where their behavior is coming from by explaining trauma’s effects on the brain and emotional regulation, says Field, a counseling professor and coordinator of the clinical mental health track in the Department of Counseling and Human Services at the University of Colorado Colorado Springs. “[Counselors] can also help [clients] understand the real importance of basic self-care, deep breathing, good eating, exercise and that a focus on wellness on a daily basis is the best way to fight the trauma impact and arousal,” says Field, who has also counseled veterans and survivors of interpersonal violence.

A recurrent — and perhaps predominant — theme when talking about trauma-informed counseling is safety. Making the client feel safe and welcome is paramount, say trauma experts. That sense of safety starts with the environment. Counselors should make sure their offices appear warm and inviting, considering everything from comfortable seating to appropriate lighting (neither too harsh nor too dim), says Pender Baum, an assistant professor of counselor education and practicum internship coordinator at Murray State University in Kentucky.

Clients should also feel that they have some control over the counseling process. “Even if you don’t know if a client has been through trauma, you can do things as a clinician that communicate to clients that they are safe and in control of what happens in the consulting room,” says Miller, an assistant professor of counseling at South University in Richmond, Virginia, who has also worked with incarcerated women.

“Let them determine where they want to sit. Ask if they are comfortable. Give them permission to decline to answer any question they are uncomfortable with and to take breaks at any time during the intake if they start to feel uncomfortable,” she suggests. “Pay attention to body language, tone of voice and other cues of emotional distress, and respond to them. Be willing to pause during a session and encourage clients to take a breath, ground themselves or stretch.”

Establishing safety

Both Miller and Webber stress that uncovering trauma is not an automatic green light for counselors and clients to start dissecting the past.

“Establishing safety is the most important and, often, the longest stage of treatment,” Miller says. “Don’t jump immediately into reprocessing, and don’t assume that everyone needs to reprocess. And remember that if you take away someone’s primary coping skill — however maladaptive it may be — you’re leaving them with nothing to soothe themselves when their emotions run high unless you teach them more productive skills.”

Webber spends substantial time helping clients build coping skills. She says that deep breathing is the fastest, easiest and most effective way to regulate emotion, but she cautions that there is no one-size-fits-all approach to this technique. Some people like to use counting — breathing in for three or four beats, holding the breath for another three or four beats, and then slowly breathing out, perhaps for six to eight beats.

However, some clients find it stressful to focus on counting, Webber says. In those cases, the counselor and client should just focus on breathing in and breathing out. She directs clients to inhale slowly and to exhale twice as slowly, noting that the slow exhale is what calms the nervous system and helps decrease a person’s level of physical agitation.

Another factor in breathing “style” is environment. Some people need to look at something specific such as a wall to focus on their deep breathing, whereas others prefer to close their eyes, Webber says. Counselors and clients should experiment with what works best. It can also be difficult to visualize what breathing from the diaphragm means, so counselors should practice their breathing in front of a mirror so they can better demonstrate it to clients, Webber advises. Because it is hard for people to learn when they feel overwhelmed, she also emphasizes the importance of teaching deep breathing and other grounding techniques to clients when they are calm.

Another grounding technique that Webber uses is anchoring in a safe place. Before asking a client to visualize a safe place, however, she says it is important for the counselor to know whether the client has experienced sexual or physical trauma. In those cases, “safety” for the client might mean hiding behind a locked door, which doesn’t provide a healthy, calm image.

“They may not have a happy place,” Webber says. “We might have to create a brand-new place [to visualize], such as a place with no people.” Counselors can help clients visualize their safe places by asking what environments are most comfortable for them.

Webber also uses tapping as a grounding technique. Tapping is a form of bilateral stimulation that helps clients desensitize feelings of trauma and stress. Webber leads clients through deep breathing and asks them to imagine something that is agitating but not overwhelmingly traumatic. Then, she instructs them to use their hands to tap their shoulders repeatedly, alternating between left and right. After about 40 taps, she asks clients to stop and smile.

Clients can also use tapping in public if they are feeling agitated or overwhelmed. Simple and inconspicuous techniques include tapping a foot on the ground three times, lifting a heel in and out of a shoe, or simply looking left and then right repeatedly, Webber says.

Even in the midst of teaching clients coping skills and grounding techniques, their safety is never far from Webber’s mind. To avoid retraumatizing clients, she monitors their level of distress in each session, giving them a scale on which 1 represents complete calm and 10 represents overwhelming agitation. Webber begins and ends sessions with the scale. She also pauses and does a quick check within the session if the client shows signs of agitation or arousal. If the client’s distress level is too high, Webber stops and does some grounding and deep breathing with the client.

All of the professionals interviewed for this article stressed the importance of counselors receiving supervision or working in tandem with a trauma specialist if needed. “When you start to feel in over your head, you’re probably in over your head,” Miller says. “That’s a good time to get supervision or to consult with someone who has more training and experience than you.”

However, there are basic principles of trauma-informed counseling that all counselors should know, Field says. These include:

  • Psychological first aid
  • Mindfulness techniques
  • Breathing techniques
  • Grounding strategies
  • Relaxation methods

“Psychoeducation about the brain and the impact of trauma on the brain is something that all practitioners can do,” adds Field, noting that simply normalizing the effects of trauma can be enormously helpful for many clients.

Helping the helper

Another tenet of trauma-informed counseling is self-care. Immersing themselves in others’ problems and pain can take a toll on counselors, and counselors who regularly engage in trauma work face an increased risk of vicarious or secondary traumatization. According to the second edition of the APA Dictionary of Psychology, burnout can be “particularly acute in therapists or counselors doing trauma work, who feel overwhelmed by the cumulative secondary trauma of witnessing the effects.”

To continue to treat clients affected by trauma with compassion, counselors must extend some of that same consideration toward themselves. A practice of good self-care can help trauma-informed counselors to safeguard their own mental and physical health.

That is a lesson Jessica Smith, an LPC with a private practice in the Denver area, learned early in her career. “My work used to define me,” says Smith, an ACA member who specializes in addictions and trauma. “If I did a pie chart of where I found meaning in my life, three-quarters of it would have been my work as a counselor when I first started out on this professional journey, but through my burnout and recovery, I’ve learned that I am so much more than this work. I care about my clients deeply, but I also love and care about myself deeply too.

“I used to view self-care as a burden — just one more thing to do. But now I see it as an opportunity to show up more fully in my life and the lives of those around me, including my clients.”

Smith now makes self-care a regular part of her day. “I start my day with meditation, journaling and movement in the form of walking, yoga or another form of exercise. I infuse self-care throughout my day through meals, writing, music, mantras, and connections and conversations with other colleagues. I have a mantra that I say before each session, which is, ‘Help me to be a conduit or reed to transmit … messages to this person in a way that they are able to receive them. Help me to remember that I cannot fix, change or save this person and that I am only one small part of their healing journey on this earth. Give me love, give me hope and give me light.’”

The creative interventions that Smith does with clients — including movement, art, visualizations, writing and breathwork — also serve as a kind of pressure valve, she says. “I’m constantly checking in with my body during sessions, especially when I’m working with [clients who have experienced] trauma, to notice, breathe into and release any areas of tightness and tension.” Smith finds that her body reflects the tension in clients’ bodies. “[I] check in with them about their sensations, then disclose mine as well in order to help model healthy body awareness and connection.”

At the end of the day, Smith clears the office by burning sage and consciously making a decision to let go of any residual trauma or distress. When she gets home, she physically “shakes off” the day before going into the house.

“I end each day with a meditation and gratitude practice where I write down three things I am thankful for that day,” Smith says. “I stretch and do heart-opening yoga poses, then go to sleep.”

Counselors need to have self-care strategies that allow them to gain distance from their work and give them the ability to check out mentally and physically from the responsibilities of being a counselor, Pender Baum says. She has learned to literally put self-care on her calendar.

“I live by my calendar, so if it is on there, it becomes just like another required staff meeting or counseling session,” she says. “It’s not negotiable. Admittedly, I can still struggle with this one at times, [but] it’s important not to let work get in the way of your me time. Get that self-care in whenever you can. It might be closing the door for five minutes and doing some deep breathing or taking a walk around the building. Something to break up the day and get you away from your office.”

It’s also important to engage in activities that don’t have a timeline or deadline and, most importantly, that are fun, Pender Baum says. “I like to kayak, watch movies with my husband [and] read to my daughter. Others might like going for a run, reading their own book [or] soaking in a bubble bath.”

Another self-care strategy that Pender Baum emphasizes for counselors is to avoid isolation. “Developing connections sometimes can involve seeking out professional development opportunities. This helps to keep you connected to the profession, learn new skills and be around other professional counselors without hearing the traumatizing stories from clients.

“For example, just this summer, my mother — a fellow counselor educator and counselor — and I attended a training on finding meaning with mandalas. We not only learned a fantastic clinical skill, but it was very therapeutic [for us] at the same time.”

Pender Baum also stresses the importance of peer support and supervision. “It’s … important to debrief after particularly difficult cases,” she says. “Have that peer support group, supervisor [or] consultant on hand that you can engage with. Have a mentor or be a mentor to someone.”

Smith participates in two therapist support groups that meet once a month. “Since I’m in private practice, isolation can be a risk, so I do these groups as well as go to lunch or coffee with at least one friend or colleague in the field each week,” she says. “I take time off each month and no longer feel guilty about doing so as I did early on in my career. I try to do a training or workshop quarterly for self-care, connection and to nurture my inner student.”

Pender Baum says counselors need to know themselves. “Give yourself permission to experience the emotions, but also set clear boundaries,” she says. “Know your limits, avoid overtime, commit to a schedule, and recognize and change negative coping skills.”

All counselors should also be aware of the signs and symptoms of vicarious trauma, Pender Baum stresses.

“Vicarious trauma can change one’s spirituality, and this can impact the way we see the world and how we make sense out of it,” she says. “Some counselors experience difficulty talking about their feelings, anger or irritation, an increased startle response and difficulty sleeping. Others might experience over- or undereating, an ever-present worry that they are not doing enough for their clients [or] possibly even dreaming about clients’ traumatic experiences. Still others might feel trapped in their jobs, lose interest in things they typically enjoy and even [experience] a loss of satisfaction and accomplishment. Some experience intrusive thoughts related to client stories and feeling hopeless.” These are all signs that counselors need to step back and focus on self-care, she says.

Other symptoms include:

  • Chronic lateness or absence from work
  • Low motivation and an increase in errors at work
  • Overworking
  • Avoidance of responsibilities
  • Conflict at work and in personal relationships
  • Low self-image

Pender Baum also urges practitioners to listen to their peers, family members, friends and loved ones if they say they are noticing a change in them. Counselors may be unaware that they are showing signs of burnout, and feedback from others can be helpful in preventing a crash from overwork and stress.

 

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Additional resources

To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association:

Counseling Today (ct.counseling.org)

  • “Coming to grips with childhood adversity” by Oliver J. Morgan
  • “The toll of childhood trauma” by Laurie Meyers
  • “Traumatology: A widespread and growing need” by Bethany Bray
  • “The transformative power of trauma” by Jonathan Rollins
  • “A counselor’s journey back from burnout” by Jessica Smith
  • “Stumbling blocks to counselor self-care” by Laurie Meyers

Books (counseling.org/publications/bookstore)

  • Terrorism, Trauma and Tragedies: A Counselor’s Guide to Preparing and Responding, third edition, edited by Jane Webber & J. Barry Mascari (fourth edition being published in 2018)

Webinars (aca.digitellinc.com/aca)

  • “ABCs of trauma” with A. Stephen Lenz
  • “Children and trauma” with Kimberly N. Frazier
  • “Counseling students who have experienced trauma: Practical recommendations at the elementary, secondary and college levels” with Richard Joseph Behun
  • “Traumatic stress and marginalized groups” with Cirecie A. West-Olatunji

ACA interest networks

 

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editor: ct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

The mental health aftermath of Harvey, Irma

By Bethany Bray September 18, 2017

Residents of the Caribbean and the southern United States are still grappling with the aftereffects of two immensely powerful and destructive hurricanes — Harvey and Irma — both of which caused widespread damage and left millions of people displaced. Rebuilding what the hurricanes destroyed will be a long and painful process, but counselors who live and work in the hardest hit areas have seen people from within and without the damaged communities come together to help each other. This sense of community and resilience will help many of those affected to recover without signs of mental health problems, but counselors also caution that some residents of the storm-wrecked areas may experience greater trauma and require more time to recover.

Maureen C. Kenny, a professor of counselor education at Florida International University in Miami, has seen Hurricane Irma spur a significant amount of anxiety in her area, from worry over whether to evacuate to the stress of having children home from school for an unknown length of time.

“For many parents, they may need to return to work but the children are not [back] in school yet, so child care is an issue. Many families are without power and still dealing with hot weather, uncomfortable living situations and limited ability to cook or eat,” Kenny, an American Counseling Association member with a part-time counseling practice in Fort Lauderdale, said in the days following the storm.

At the same time, Kenny said she’s seen community members come together to help one another, such as neighbors helping neighbors install hurricane shutters and fix generators.

“Since people are often without power for extended periods of time, they spend time outside talking to their neighbors. People are out walking dogs, kids are riding bikes and neighbors are sharing storm stories,” Kenny said. “In a strange way, it brings people together. Without electricity, people are forced outside and have more contact with one another.”

NASA satellite image of Hurricane Irma passing Cuba on Sept. 8.

Harvey was a Category 4 hurricane as it made landfall near Corpus Christi, Texas, on Aug. 25. The storm then stalled over southeast Texas for days, bringing heavy rainfall and catastrophic flooding. Irma — one of the most powerful Atlantic storms ever recorded — was a Category 5 hurricane when it razed many of the islands in the northeastern Caribbean and “skirted” Puerto Rico, leaving 1 million residents without power. The storm had dropped to a Category 4 hurricane when it made landfall in the Florida Keys Sept. 10 and began its slow march up the Sunshine State.

Forecasters are also keeping an eye on two more hurricanes, Jose and Maria, which are currently churning in the Atlantic Ocean.

The barrage of catastrophic weather has brought weeks of news coverage and warnings to evacuate or stock up on emergency supplies.

“With technology’s advance notice of hurricanes, it allows people to get ready but also adds a lot of anticipatory anxiety,” Kenny said. “Schools and businesses were closed several days before

ACA Member Maureen C. Kenny took this photo of near-empty shelves in the bottled water aisle at a Winn-Dixie grocery store in Cooper City, Florida on Sept. 6, which was four days before Hurricane Irma made landfall.

the storm actually hit. This left people waiting for the storm to hit and unsure of what exactly would happen. … As days grew closer to the storm, there were long gas lines [at gas stations], the shelves at the stores were empty and people may have not been able to get supplies.”

ACA member Jeffrey Kottler also saw people pushed to their limits during the time he spent as a disaster mental health volunteer at Houston’s George R. Brown Convention Center in the days after Hurricane Harvey. At the peak of the crisis, the facility sheltered more than 9,000 people.

Kottler, a clinical professor of psychiatry at Baylor College of Medicine in Houston, worked with psychiatry colleagues from Baylor in a tent at the convention center, offering support and a sympathetic ear. They did everything from offer psychological first aid to help people contact family members, refill medications and get a new driver’s license because theirs was lost in the flooding and chaos that followed the storm.

When a distraught person would enter his team’s tent, Kottler said his approach was to pause, calm the person down and give the person time to tell his or her story, even if that meant walking around the conference center with the person or finding a quieter place to talk.

People were overwhelmed on many levels, Kottler said. Not only were they reeling from the loss of homes, vehicles and other personal property, but they were crammed in close quarters with complete strangers.

“[The convention center] was the most chaotic environment imaginable, and people’s brains were going off like fireworks,” Kottler said. “It’s hard to describe the chaos of what it was like to be there, seeing [thousands] of beds, with dogs barking and babies crying. People were just in shock.”

“Imagine having a car, a job and a home, and then in one day, it’s all gone and you’re living with 9,000 people. Those were most of the people that I was spending time with [as a disaster mental health volunteer].”

Kottler noted that the center featured a large police presence – alongside many, many volunteers and aid agencies – for safety and to ensure that weapons, alcohol and other banned items were not brought into the facility. For some, this added to the tension of an already anxious situation.

Kottler, a keynote speaker at ACA’s 2015 Conference & Expo in Orlando, Florida, recently moved to Texas to start a new position at Baylor College of Medicine and to serve in a volunteer role (consultant and staff trainer) at the Alliance for Multicultural Services, a refugee resettlement agency. Previously, he was a professor at California State University, Fullerton.

Kottler said he has been struck by the resilience of his new hometown – from grocery store cashiers asking if he’s OK to the local American Red Cross chapter having too many volunteers.

“I am new to Houston, and I’ve just been blown away by how the city and community have come together to help each other selflessly,” Kottler said. “What I found so personally disturbing is [the realization] that this could happen to any of us.”

Many in Houston have now begun the process of clearing out damaged homes and rebuilding lives after Harvey. In Florida, some residents are waiting for utility service to be restored, one week after Irma. Residents are still displaced and emergency shelters are still open in both Texas and Florida.

In Miami, Kenny said she had power in the days after Irma, but no phone or internet service. Classes resumed at Florida International University Sept. 18 after a nearly two-week closure. Some of the school’s facilities were being used as shelter for evacuated residents of the Florida Keys, Kenny said. Professors have been advised to be flexible with deadlines and assignments.

In her role as a counselor educator, Kenny said she has also witnessed anxiety among some counseling students who are concerned about the loss of internship hours because clinical sites were closed in the storm’s upheaval. In her private practice, Kenny had numerous clients cancel appointments prior to the hurricane because they were busy with preparations or didn’t want to travel for fear of using gasoline that might be needed later.

“Thankfully, cell phones [are currently working], so you are able to check in with clients and see who can return,” she said. “Many clients – those who were able – left town and still have not returned. Thus, practice remains slow. For some clients without power, coming to an air-conditioned office for an hour to cool off and vent is a welcome relief.”

Although hurricanes are part of the reality of living in South Florida, the upheaval that Irma brought has stirred up difficult memories for some longtime residents, Kenny noted. For others, watching Hurricane Harvey’s devastation from afar was equally troubling.

“For some in South Florida, [Irma] was also a reminder of Hurricane Andrew 25 years ago. For those [individuals], it definitely brings up posttrauma issues. These are people who lost their entire homes, businesses, etc., and were fearful of the same thing happening again,” Kenny said. “Others who are living here but have lived through storms in other parts of the country were also triggered by this storm. Some [of my] clients had family in Texas [who] had just survived Hurricane Harvey and were still dealing with them when this storm was approaching. For those clients, the back-to-back storms seemed overwhelming. I had a client who was able to arrange for evacuation of a family member in Texas through Facebook. The family member was elderly and in need of medical attention post-surgery but was in a completely flooded area. A stranger responded to the request and used their boat to get the relative to a hospital. This type of kindness demonstrates how a community can come together.”

 

The road ahead

For people who are directly impacted by a natural disaster, the aftermath can be marked by feelings of loss, fear, panic, grief or guilt, said Anka Vujanovic, an associate professor and director of the Trauma and Stress Studies Center at the University of Houston. Counselors may hear clients talk about strong feelings of irritability, anger or guilt, having difficulty sleeping or a sense of wanting to do more for their community because they made it through the storm relatively unscathed.

“There may be guilt in those who are not severely impacted – survivor’s guilt of ‘why them, why not me?’” said Vujanovic, a licensed clinical psychologist and co-director of the University of Houston’s Trauma and Anxiety Clinic.

Other clients may be in shock right now and focused on the immediate needs of putting their life back together in the storm’s aftermath, Vujanovic said. Mental health struggles can surface weeks, months or even years later when triggered by another natural disaster or traumatic event.

“Once they’re past the crisis, they may have symptoms. … Once things settle down, they have their house [renovated], they’re back to ‘normal’ and life has settled down. They may feel the aftershock even months later,” Vujanovic said. “People may or may not experience symptoms until the next rainstorm with high winds, or [next year’s] hurricane season. That may trigger people and activate some of their difficult memories.”

“It’s something to check in about for practitioners, especially if they work with people who were directly impacted. Keep in mind that there may be things that crop up. Clients may not be ‘over it’,” Vujanovic said.

Counselors may see clients develop panic attacks, intensifying anxiety or depression, loss of interest in things they normally enjoy, mood fluctuations or increased substance abuse. People often use alcohol or drugs to cope with feelings of stress, loss and grief after a natural disaster, Vujanovic said.

It’s vitally important for counselors to check in with clients in affected areas to see how they’re coping in the storm’s aftermath and to monitor their symptoms. Practitioners should encourage clients to maintain social connections with friends and family and “fight the urge to isolate,” Vujanovic said.

“Take time for self-care, which can be incredibly difficult if you’re living in a shelter. Take time for appropriate sleep, exercise, social activity – whatever is important to that person,” she said.

Vujanovic’s area of research is posttraumatic stress disorder (PTSD). Although 30 to 40 percent of people who are directly impacted by a natural disaster will develop PTSD, it is important to note that a majority of people who survive a natural disaster will not develop mental health symptoms, she said.

A number of factors – from whether individuals have pre-existing mental illnesses to how much social support and financial stability they have – contribute to whether they might struggle after a natural disaster. “All of those things will go into the complex equation of who develops a problem [after a natural disaster]. These factors up the risk, but it doesn’t mean they definitely will,” Vujanovic said.

 

Businesses in Miami Beach, Florida, board up windows on Sept. 7 in preparation for Hurricane Irma.

 

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Related reading

 

Counseling Today’s August cover story, “Lending a helping hand in disaster’s wake

 

From Counseling Today columnist Cheryl Fisher, “Mental health cleanup following a natural disaster

 

 

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Bethany Bray is a staff writer for Counseling Today. Contact her at bbray@counseling.org

 

Follow Counseling Today on Twitter @ACA_CTonline and on Facebook at facebook.com/CounselingToday.

 

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.