Tag Archives: sexual abuse

Counseling survivors of human trafficking

By Lamerial McRae and Letitia Browne-James October 9, 2017

Millions of human trafficking victims exist across the globe. In the United States, hundreds of thousands of victims experience trafficking. As society expands and evolves, human trafficking perpetrators find new ways to recruit and victimize others. The evolution of perpetration ensues because of increases in accessing technology, shifting state and federal laws, and changing criminal investigation methods within communities. Human trafficking continues to evolve into a new way of enslaving human beings, stripping individuals of basic rights and freedoms, while skirting the legal issues of slavery and ownership.

Human traffickers often recruit individuals by offering the fantasy of increased happiness, stability, relationship success and financial freedom. Human traffickers, often referred to as “pimps” or “playboys,” may recruit a female or male victim with promises of a better quality of life, including, but not limited to money, security and safe shelter. These perpetrators often present as charming and recruit their victims using lies and manipulation. They prey on victims from vulnerable populations, including those with low socioeconomic status (SES), biological females, children and adolescents, immigrants and LGBTQ+ youth. The fact that these vulnerable populations often remain dependent on others or experience institutionalized marginalization allows for perpetrators to paint the picture of a better life, both in terms of finance and social support. Thus, counselors must understand the cycle of perpetration and victimization to pinpoint potential victims among clients.

As a starting point, counselors must understand the nature of the phenomenon and seek ways to identify potential risk and protective factors. Counselors must learn to assess and address possible victimization with effective rapport building and intervention. For example, youth may display delinquent behavior (e.g., truancy, sexual misconduct, drug use) as a symptom of coercion and threats by a perpetrator. Perpetrators often experience greater ease when recruiting teenagers because of their tendency to be influenced by others. Sadly, when teenagers fall victim to a human trafficker, they are subjected to the victim-blaming phenomenon.

Thus, to build therapeutic rapport from a nonjudgmental framework, counselors need to understand the true source of teenagers’ behavior rather than labeling them as inappropriate or delinquent. As counselors increase their understanding of risk and protective factors, the profession may be able to conceptualize human trafficking as a systemic problem from a broad perspective.

 

Risk and protective factors

Several risk and protective factors exist for those falling victim to human trafficking. Risk factors include the following demographics and experiences. Risk factors, which are not limited to the list provided, may change over time with the help of counselors.

  • Low SES
  • Previous or current substance abuse
  • Social vulnerability (e.g., children, females, LGBTQ+ individuals)
  • Limited education.

Protective factors, referred to as strengths in counseling, include the following demographics and experiences. Counselors must foster protective factors and strengths in clients to reduce the risk of falling victim to trafficking.

  • Education
  • Family stability
  • Strong social support networks
  • Mental and emotional health

Counselors should understand these risk and protective factors to assess potential risks for human trafficking and to focus on increasing protective factors in counseling. For example, counselors may use a family counseling approach when working with survivors to increase their connections to loved ones and family. Throughout the process of recruiting and selling human trafficking victims, counselors may notice several risk and protective factors playing a role in the process.

 

Human trafficking business model and counseling implications

Human trafficking remains a mysterious and misunderstood phenomenon. Because of a lack of understanding about the effects of human trafficking on our society, counselors are charged with educating themselves to best address and assess individuals for victimization.

Counselors should recognize that survivors of sex trafficking require additional techniques (to those used with other clients) to build rapport with them and to reduce the mistrust that they commonly have about people. To best serve survivors, treatment approaches need to remain centered on survivors, empower them, provide safety and involve a multidisciplinary approach. In addition, professional counselors working extensively with sex trafficking survivors hold legal and ethical responsibilities to provide appropriate services and identify strategies to overcome barriers to their treatment, including specialized and intensive training.

To begin, counselors must understand the human trafficking business model to conceptualize the systemic issue and the moving parts that contribute to the continuing cycle. To highlight some of the societal and professional impacts, consider the parallel of the human trafficking business model to the process of manufacturing goods. The human trafficking business model includes the following stages of grooming and distribution:

1) The supplier recruits the victim.

2) The manufacturer grooms the victim.

3) The retailer determines price and then markets the victim.

4) The retailer sells and the consumer purchases the victim.

The human trafficking business model is a sophisticated process, not always linear in nature, and it functions as a well-established industry. Thus, the need exists to explore each of the model to better understand how to help victims and break the cycle.

Stage 1: Supplying victims. The supplier, also known as the initial human trafficking perpetrator, displays high levels of mental health concerns (e.g., antisocial personality traits) and shows little concern for the basic human rights of others. When victims enter this stage, counselors may find that these individuals report troubles at home, low SES, depression, anxiety and truant behavior. These factors contribute to their need to survive. Unfortunately, this may result in a perpetrator using charm or manipulation to attract the victims. Perpetrators remove victims’ identification, passports and other valuables to trap them in the world of human trafficking.

Clinical assessment is vital at this stage and remains an ongoing process. Counselors may want to ease survivors into telling their stories, paying special attention to the therapeutic relationship. Thus, the most valuable interventions at this stage include active listening and reflection. When administering specific assessment instruments, counselors will want to measure attitudes about victimization and perpetration and prevalence rates of violence. Counselors must use both open- and closed-ended questions to directly address potential victimization. Nonverbally, counselors will want to avoid direct eye contact and limit their use of touch because of victims’ trauma and abuse history.

Stage 2: Grooming victims. This stage involves moving human trafficking victims from the supplier to the manufacturer. Perpetrators continue to display high levels of antisocial behaviors and major mental health concerns; survivors present with mental health concerns such as depression, anxiety and addiction. Substance abuse concerns usually present when perpetrators force their victims to engage in substance use to coerce and control their behaviors, often resulting in addiction.

Counselors must use clinical assessment and maintain that ongoing process. In addition, because survivors have been manufactured as a human trafficking product, their levels of abuse and mistrust often appear high when they present to counseling. Therefore, counselors must focus on the therapeutic relationship as victims provide information about their experiences in trafficking. Counselors should pay special attention to reducing the stigma of substance use and mental health concerns, especially considering that victims develop these concerns because of coercion and violence.

Stage 3: Marketing victims. This stage involves moving survivors from the manufacturer to the retailer. At this stage, human trafficking perpetrators focus on the marketing and sales aspect of their exploitation. For example, based on the quality of their goods (i.e., victim age, appearance) and market demand, perpetrators determine the price for selling each of their victims. At this stage, survivors present with major depressive, dissociative and addiction disorders.

At this stage, counselors again use clinical assessment to understand the survivor’s story while maintaining a trustworthy therapeutic relationship. As previously stated, severe mental health concerns present because of the violence and abuse that victims experience. Thus, counselors need to use evidenced-based practices to treat depression and dissociative symptoms. Some of the most helpful interventions to treat these mental health concerns include grounding and relaxation techniques.

When focusing on grounding, counselors must engage the client’s physical world to assist the person in becoming present in the moment. For example, counselors may ask clients to locate an object in the room and provide an in-depth description. Relaxation techniques to practice include deep breathing and mindfulness meditation. Both types of techniques allow clients to practice coping skills during sessions that can translate to their everyday life experiences.

Stage 4: Selling victims. As retailers push survivors toward the consumers, the perpetrators continue to focus on marketing strategies and targeting potential consumers. Perpetrators often target large events (e.g., the Super Bowl, national political conventions) to take advantage of the crowds and high demand for paid sexual services. Those paying for the sex services, the consumers, exhibit low levels of depression and anxiety. These consumers often report avoiding relationship concerns or other mental health concerns, resulting in a desire to seek out sexual activity.

Because survivors have been a part of ongoing abuse and a cycle of victimization that they cannot break, counselors must use a systemic approach to providing services. For example, counselors need to provide information on shelters and building connections with family. Counselors may incorporate the use of technology and location services, safety words and discussing location with loved ones at all times.

 

Case example         

Toney, an 18-year-old multiracial, cisgender male, moved away from his caregivers’ home about one year ago and currently lives with a friend. He moved because of safety issues in his home and within the nearby neighborhood. When Toney was 16, his father died during a gang-related shootout at their home. Thus, Toney often felt afraid of engaging in a similar lifestyle and enduring similar consequences. Toney’s mother suffered from a severe substance use disorder that led to eviction from their rental home because she could not afford the rent. Toney and his mother became homeless.

While Toney was homeless, Kevin, a childhood friend, suggested that Toney come live with him temporarily as long as Toney obtained a job and contributed to the rent and utility bills. One day, Toney answered the front door, and a young adult male appearing to be about Toney’s age attempted to sell him a magazine subscription. Toney disclosed to the salesman that he was financially strapped. The young man told Toney about the large sums of money he made while selling magazine subscriptions and offered to put him in contact with the owner. Toney was intrigued by the idea of alleviating his financial troubles, and the young male immediately scheduled a meeting with the owner for later that night.

That evening, Toney met with the young salesman and the business owner in an abandoned parking lot, bought their sales pitch and decided to go to work. The business owner told Toney that he would need to move six hours away to another state because there was a high demand for work there and he would not have to pay any rent or utility bills. The business owner promised Toney the opportunity to travel and see many areas of the country while working in the job.

Thus, Toney left a day later to live in a weekly hotel in a new city with his new manager and several others. Upon arriving, the manager took them to a warehouse to pick up the product. They all began working the next day.

After a few weeks, Toney began grasping the reality of his situation. The job of trying to sell magazine subscriptions was strenuous and exhausting. He often worked 10- to 12-hour days while receiving limited rest and food. When Toney voiced concerns about the number of work hours he put in each day, his manager threatened him. The threats later escalated to physical assault when Toney again voiced his concern and when the manager perceived him to be underperforming at the job.

No matter how hard Toney tried, he could not meet the daily sales goal that the manager set for employees. When Toney failed to meet the daily sales quota, the manager either denied him his nightly meal or forced him to sleep outside of the hotel on the streets. As a result, Toney rarely ate and often did not receive the money he had earned while working. He was told that he would receive the money once the team had completed its sales goals for the area and had moved on to another city.

One day, while trying to sell magazines to a homeowner who declined to buy anything, Toney became agitated and started crying. He told the homeowner that he was in trouble and begged her to help him get home, across state lines. The homeowner had recently watched a documentary on human trafficking and invited Toney to use her phone to call the authorities.

The police arrived and took Toney’s statement about his work experiences. Fortunately, the responding officer had recently attended a departmental training on human trafficking, and she took Toney to the police station for further questioning and support. The officer connected Toney with a local nonprofit organization that provided multidisciplinary services, including professional counseling, to survivors of human trafficking. The organization offered shelter and provided Toney with career development services to help him obtain legitimate work. The shelter’s ultimate goal was to move Toney back to his hometown.

In counseling sessions with Toney, the counselor focused on direct questions to assess the nature of the human trafficking Toney had experienced. For example, “Did anyone threaten you or your loved ones?” and “Did you have difficulty leaving the work that you did selling door-to-door merchandise?” While initially reluctant, Toney eventually responded with answers that indicated his victimization. For example, he reported that his manager used threats and power and control tactics (such as denying Toney food, money and shelter) to force him to work.

Following assessment, Toney received counseling services focused on recovering from the abuse he had endured. Toney felt validated because he was not alone while accepting that he had fallen victim to human trafficking. The counselor and Toney focused on crisis intervention and stabilization in the beginning, which included discussions about adjunct services and basic needs assessments (e.g., food and clothing, job obtainment). Next, the counselor and Toney addressed the trauma, focusing on decreasing anxiety-provoking cues and scaffolding into addressing more severe cues and triggers. All the while, Toney and the counselor developed several grounding and relaxation techniques to use both in their sessions and in Toney’s real-world experiences.

One of the most valuable grounding techniques made use of a rock that Toney could hold whenever he felt distressed. The counselor taught Toney how to become present, while holding the rock, through discussions about the texture, shape and weight of the rock. Discussing these tactile experiences allowed Toney to focus on the here-and-now rather than attempting to escape feelings and thoughts.

Toney and the counselor also used a breathing method in which Toney would take a deep breath through his nostrils for at least three seconds and exhale through his mouth for three seconds. They determined that he needed to take at least three deep breaths during the exercise so that he could calm down.

In the final stages of counseling, Toney and the counselor developed an action plan to help him avoid falling victim to trafficking. That does not mean, however, that Toney took responsibility for the actions of others. Toney and the counselor reviewed the different needs he may have and how to meet those needs in a helpful manner.

While focusing on the trauma from human trafficking victimization, the counselor worked with Toney on obtaining a job at a local fast food restaurant. They chose this restaurant so that he could easily transfer to another store in his hometown once he felt comfortable with the transition. After three months, Toney finally returned home and moved back in with his friend, Kevin. He remained employed as a fast food line cook and began seeking education at a local culinary institute.

 

 

****

Lamerial McRae is an assistant professor at Stetson University and a licensed mental health counselor in Florida. Her research and clinical interests include counselor identity development and gatekeeping; adult and child survivors of trauma, abuse and intimate partner violence; marriages, couples and families; LGBTQ issues in counseling and human trafficking. Contact her at ljacobso@stetson.edu.

Letitia Browne-James is a licensed mental health counselor, clinical supervisor and national certified counselor. She is a clinical manager at a large behavioral health agency in Central Florida and is in the final year of her doctoral program at Walden University, where she is pursuing a degree in counselor education and supervision with a specialization in counseling and social change. She has presented at professional counseling conferences nationally and internationally on various topics, including human trafficking.

 

****

 

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.

 

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.

 

****

 

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

 

****

 

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.

Becoming shameless

By Laurie Meyers April 25, 2017

You should be ashamed of yourself.” How many of us have heard — or perhaps even used — that phrase? Being on the receiving end of such a pronouncement is never pleasant. More important, experts firmly believe that attempting to wield shame as an instrument of change is both ineffective and harmful. In fact, many clinicians say that shame is intertwined with an abundance of issues that typically bring clients to counseling. Furthermore, it often stands as a significant barrier to healing.

In her book I Thought It Was Just Me (But It Isn’t), Brené Brown defines shame as “the intensely painful feeling or experience of believing we are flawed and therefore unworthy of acceptance and belonging.” The research professor at the University of Houston’s Graduate College of Social Work believes that shame has become a kind of silent epidemic in society that serves to isolate us and thus damages our sense of connection to others.

Thelma Duffey, the immediate past president of the American Counseling Association, agrees. One of her main initiatives as president focused on issues surrounding bullying and interpersonal violence, both of which can leave people struggling with a deep-seated sense of shame. “I see shame as a deeply painful feeling that people experience when they feel exposed, inadequate or especially vulnerable,” she says. “Unforgiving and powerful, shame can leave many people feeling unworthy and incapable.”

Bullied into shame

The practice of actively shaming others, particularly through bullying behaviors, is all too common in our culture, says Duffey, a practicing licensed professional counselor and licensed marriage and family therapist for more than 25 years.

“Bullying can trigger feelings of shame, leaving people feeling defenseless, embarrassed and confused,” she says. “Some feel such a strong sense of self-consciousness and become so preoccupied with avoiding shame-inducing situations that they withdraw from others, which can lead to an excruciating form of isolation.”

Without the consistent presence of love and support in a person’s life and the provision of a realistic viewpoint from others, there is no counterbalance to shame’s narrative.

“Imagine holding a broken mirror of yourself and believing that the distorted image is what you truly look like,” Duffey says. “Your perception would be off, wouldn’t it? Now imagine you are holding a broken mirror that reflects a distorted image of who you are as a person. If you believe this distortion, it won’t be easy to feel good about yourself or to connect with other people who love you. It will probably lead you to see the world as an unsafe place. In all likelihood, you’ll have to create ways of coping with these images just to survive. Too many times, these coping strategies ultimately keep us from the very connections we desire.”

Duffey says there is an antidote. “I believe that developing a sense of self-compassion is at the core of conquering shame,” she says. “Unfortunately, self-compassion is not always easy to come by, particularly when a person has been mistreated, publicly mocked or hurt, as is generally the case with any bullying situation. In fact, introducing the idea of self-compassion can actually make people wince when they live with feelings of shame, because it sheds light on their self-loathing perceptions.”

Counselors can use a variety of methods to help clients develop self-compassion, but a strong therapeutic bond is the most essential ingredient in that process, says Duffey, who is also a professor and chair of the counseling department at the University of Texas at San Antonio. One of the interventions she uses is Emotional Freedom Techniques (EFT).

“EFT has been described as a type of psychological acupressure that can help unblock distressing situations,” Duffey says. “The idea is to restore balance to the body’s energy field to move negative emotions that can keep us stuck. I also see it as a way for people to center themselves when they are in their uncomfortable emotions and to connect with themselves in a more soothing way.”

Duffey says that EFT in its traditional form has a sequence that involves identifying the problem — for example, shame — and then having clients ask themselves how they feel about the problem right now. Clients then rate the level of intensity of the problem, with 10 being most intense and zero being least intense. Next, the counselor and client come up with a “setup” statement that acknowledges the problem and follow that with an affirmation. Clients then repeat the statement and affirmation while performing a kind of “psychological acupuncture” that involves taking their hands and tapping five to seven times on the body’s “meridian” or energy points.

“A person experiencing shame and with memories of bullying might say something like, ‘Even though it is not always easy for me to see my own value, I deeply and completely love and accept myself,’” she says. “Or, ‘Even though I can still remember the horror of being made fun of, excluded and shunned, I can be on my own side now. And I am not alone. In fact, I am working on loving and accepting myself.’”

Once a person connects with the problem and the idea of loving, self-compassionate affirmations, he or she can use those affirmations to process all sorts of experiences, Duffey says. “The idea, of course, is not about thinking positively or practicing self-delusion,” she notes. “Rather, it is about really being honest about what hurts and confronting these feelings, [and then] offering affirmative statements of hope and compassion while tapping into the body’s energy using acupressure points.”

Duffey recommends the website thetappingsolution.com for those who would like to learn more about EFT.

The trauma-shame connection

At the ACA 2017 Conference & Expo in San Francisco this past March, licensed mental health counselor Thom Field presented “For Shame! The Neglected Emotion in PTSD.” In the session, he explained that shame is a significant component of posttraumatic stress disorder (PTSD), particularly in cases of interpersonal trauma, such as child abuse and intimate partner violence.

Because PTSD’s most common symptoms — hypervigilance, nightmares, flashbacks, intrusive memories and physiological hyperarousal — are all related to fear of external danger, experts in the trauma field have traditionally focused on fear as the primary emotion in PTSD, noted Field, a member of ACA. Using this assumption, therapy techniques for PTSD have focused on methods such as exposure therapy, he said. In exposure therapy, clients are asked to revisit the trauma multiple times because repetition has been shown to help lessen the physical and emotional effect of these memories.

However, new research suggests that trauma survivors often also fear being rejected and exposed as weak. This fear engenders a sense of shame, said Field, an associate professor and associate program director of the counseling master’s program at the City University of Seattle. He explained that the shame is fueled by a persistent negative self-appraisal in which clients who have experienced interpersonal trauma often berate themselves with statements such as “I am weak — an easy target”; “Something is wrong with me if I can’t prevent these things from happening”; or “Why didn’t I do something?” Trauma survivors often feel inadequate, inferior or powerless to affect their own environments, he added.

Field believes that counselors must understand the role of shame to help many of these individuals who are living with PTSD. “Shame is an emotion that arises when a person feels inadequate or corrupted by an irredeemable act or a contaminating event,” Field explained. “The person feels undesirable and unattractive and fears the perceived judgment of others.”

It is also important for counselors to differentiate shame from guilt, Field noted. He defined guilt as regret for a specific action that is bound to external circumstances. It is a feeling connected to what one has done rather than — in the case of shame — what one is, Field emphasized. Whereas guilt can motivate prosocial actions such as reparation, shame usually motivates self-protective actions such as withdrawal or lying to protect secrets, he pointed out.

Among the factors that increase feelings of shame in those who are experiencing PTSD or interpersonal trauma are the attribution of responsibility (such as the perception that having HIV or AIDS is that person’s “fault”); the level of visibility and an inability to “hide” (because of circumstances such as physical disability or disfigurement); and being marginalized, Field said.

Feelings of shame may prevent some people with PTSD from seeking counseling, and even those who do seek counseling may deny the presence or impact of trauma if a counselor asks them about it directly, Field said. Harboring a sense of shame may also make it difficult for clients to trust others, he added, so counselors must take care to proceed slowly and focus on developing the therapeutic alliance. These clients need to be made to feel safe enough to reveal their secrets and process their fear of rejection, humiliation and judgment by others, he emphasized.

An important step in the process is for counselors to facilitate client autonomy with what Field termed “pre-questions.” For instance, a counselor might say, “It seems like it might be helpful to revisit this event. How ready are you to face that?”

“If you dive in [yourself as the counselor], it feels [to the client] like it’s not voluntary,” Field explained. When counselors press the processing of shame before clients are ready, it can cause clients to, in essence, feel shame about their shame.

Counselors should also let clients know what to expect when they decide to share their trauma. For instance, Field said, “The client is going to feel physiological symptoms.”

Through client mirroring and active listening, counselors can help establish a sort of holding container for these clients’ emotions. This takes away the pressure of having to “do” anything with those emotions, allowing clients to feel safe simply “sitting” with their feelings until they are completely ready to process them, Field explained.

Like Duffey, Field thinks that self-compassion is essential to overcoming shame. The ultimate goal is to teach clients to accept their current and past experiences without self-judgment, he said. Field recommended that counselors use some of the exercises developed by psychologist and self-compassion researcher Kristin Neff. These include having clients imagine how they would treat a friend who was in the same circumstance, writing letters to themselves from a place of compassion, changing critical self-talk through reframing, keeping a self-compassion journal and practicing loving-kindness meditation.

The lasting shame of abuse

For clients who were sexually abused as children, the sense of shame is almost primal, says ACA member David Lawson, who has worked with trauma victims for more than 25 years. Time after time, women in their 30s and 40s have sat in Lawson’s office and insisted that it was somehow their fault that they were sexually abused as children.

“They say, ‘There must be something wrong with me.’ ‘I’m bad.’ ‘I’m contaminated,’” says Lawson, a counseling professor at Sam Houston State University in Texas who has conducted extensive research on trauma. “I’ve even had several people say, ‘I must be evil in some way for this to happen to me.’”

When parents are the perpetrators of sexual abuse, the abuse survivors’ sense of shame is particularly strong, Lawson says, because humans are wired to seek attachment with parental and other caregiving figures. To maintain this attachment, child victims must rationalize the abuse. As a result, these children often tell themselves that they are bad rather than accepting that the parent is not good, Lawson explains.

Another factor that contributes to these children’s feelings of shame is the perceived “benefits” they received from their abusers, Lawson says. He recounts the story of a female client in her 20s.

“She was abused from the ages of 5 to 16 by her father [until] her mother finally left the father. Years later she came into therapy, and I said, ‘Tell me about some of the best times in your life.’ She said that they were with her father: ‘At times I felt like I was my father’s girlfriend.’ There were benefits for her. He would buy her things and take her places, which he did not do with her siblings. Then, at night, the abuse would happen.”

The woman went on to confide to Lawson that the worst times in her life were also with her father. “He would tell her, ‘No one else will love you. You are worthless. No one will have you but me,’” Lawson says.

Abusers often use this technique, aware that if their victims feel there is nowhere else they can go and be accepted, there is a greater chance they will stay in the only place they seem welcome. This “acceptance” increases victims’ sense of connection to their abusers, Lawson says.

These patterns are distinct and specific to what Lawson calls the “trauma subculture.” The behaviors and beliefs of survivors of sexual trauma are so antithetical to most people’s expectations that outsiders — including many counselors — often find their reactions difficult to understand, he says.

“One of the hardest things for my students to get over is the way that [sexual trauma survivors] look at the world and the way they think about themselves,” Lawson says. “We just want to run over and hug them, but that just ramps up their shame because they don’t believe that they’re worthy.”

Early in his career, Lawson learned how premature sympathy and acceptance could backfire. He told a client that the abuse the client had suffered was not his fault, and the client got quite angry with Lawson, rejecting his help because he genuinely thought that Lawson didn’t know what he was doing.

What Lawson learned with that experience is that in immediately trying to correct clients’ beliefs about their abuse, counselors threaten to take away a major part of the identities that clients constructed as a way to survive. Today, Lawson urges counselors to move slowly with these clients and first work toward establishing a strong therapeutic bond.

“It may take many sessions just for them to feel comfortable,” he says. “These people don’t trust anyone, so to think that they’re going to trust in a few sessions is naïve and counterproductive.”

Start by accepting these clients where they are and reflecting on the dilemma they are facing, Lawson advises. “On the one hand, they feel an enormous amount of allegiance. On the other hand, they have strong feelings of hate,” he explains.

After counselors have established a relationship, they can introduce the idea of talking about the client’s experience. A counselor could say, “Talk to me about your relationship with your father and how you came to the conclusion that you’re not worthy of anyone else’s love,” Lawson suggests. He adds that counselors must give clients time to reflect and reconstruct how they came to their conclusions about self-worth.

Lawson says that once he asks those kinds of questions and lets clients unpack and narrate their experiences at their own pace, they are usually able to begin seeing how their erroneous, negative self-beliefs were shaped by what happened to them. He cautions, however, that intellectual understanding is not the same as emotional acceptance, which can take additional time. Lawson notes that some experts view this kind of shame as an annihilation of self. Survivors may feel that there is no part of themselves that is worth forgiving, he explains.

In the process of helping clients see themselves as redeemable, fully acknowledge the abuse that happened to them and grieve what was lost, counselors should be supportive, but they must also modulate their affirmation to a level that the client can handle, Lawson cautions. “If we’re too warm and nurturing, the client takes that and rejects it and sees us as incompetent because we don’t understand,” he says.

For that matter, trauma (and shame) may not be the stated concern that brings survivors of sexual abuse into counseling in the first place. Instead, the presenting issue may be depression, anxiety, relationship difficulties or something else, Lawson says. “I deal with whatever they present with and try to help them get some relief from those things,” he says.

But along the way, Lawson introduces the idea of addressing and processing the trauma with clients. He may approach it in a very general way at first, perhaps by asking clients to talk about the trauma as if it happened to someone else.

Lawson may also use a “lifetime line.” He starts by asking clients to pick a year of their lives and talk about everything they can remember about it — good and bad. By doing this, clients are not only processing trauma, but also remembering that there were positive events in their lives too, he says. Lawson also has clients write down all the positive memories to help remind them, as they construct their life narrative, that the abuse does not encompass their entire life.

Lawson says he finds narratives, either written or spoken, vital in treating clients’ shame. By showing compassion for their narratives, counselors can help clients start to feel compassion for themselves, he says.

Shame beliefs

Gray Otis, a licensed clinical mental health counselor in Cedar Hills, Utah, believes that shame is typically a component in traditional mental health disorders such as depression and anxiety. In fact, he says, shame likely underlies most issues for which clients come to counseling.

“Typically, the individuals who come for treatment have strongly held negative core beliefs about themselves,” says Otis, who has extensive postgraduate training in trauma treatment. These negative core beliefs are not just about behavior, he adds, but actually inform people’s sense of who they are.

Otis, whose counseling approach is centered on positive behavioral health, thinks that these beliefs stem from incidents that evoke a sense of shame in the person. Such events typically take place in childhood or adolescence, but adults can experience them too. These incidents may or may not be described as “traumatic.” Negative core beliefs can be caused by an accumulation of painful events, such as consistently being criticized as a child or going through a divorce. The resulting beliefs can take many forms, Otis says, but they generally revolve around reinforced themes — for instance, a person growing to believe that he or she is stupid, unworthy, undeserving and unlovable.

Otis believes the key to addressing clients’ mental health issues is uncovering and dispelling their shame-based negative core beliefs. The difficulty counselors may face in unraveling a client’s core beliefs will vary depending on the person and the complexity of his or her presenting issues. However, Otis says he finds it relatively straightforward to uncover many of these beliefs. When he asks clients to identify some of the things they believe about themselves that are not positive — Otis directs them to use “I am” statements — they can usually identify five or more negative beliefs, he says.

What is particularly potent about the beliefs underlying these “I am” statements is that people tend to perceive them as being inherent, unchangeable personal traits, Otis says. Many of these core beliefs are subconscious, he adds. By helping clients bring them to the surface and recognize that they are beliefs, not traits, counselors can assist clients in replacing negative beliefs with positive core beliefs.

Otis does this by having clients explore the origins of one of their negative beliefs, asking them when they started believing this internalized truth about themselves and what happened that contributed to that belief. Otis then asks clients to focus on one of their most distressful experiences and “freeze” it, as if it were a photograph. He then urges them to describe the emotional sense of the experience, identify their degree of distress and state the shame-based negative core belief (such as “I am never good enough”).

The next step is for clients to specify the positive core belief they desire. Otis then helps them identify life events that reinforce the new, positive core belief. He asks clients to remind themselves of these reinforcing events daily as a way to continue strengthening their positive belief. Next, Otis has clients revisit the experience that engendered the negative belief, and he talks with them about how the event was misinterpreted.

Otis says he also uses methods such as sand tray therapy, eye movement desensitization and reprocessing, and cognitive behavior therapy not only to help clients develop more positive beliefs but also to become more resilient. He emphasizes, however, that the most important factor when working with shame-based negative core beliefs is a strong therapeutic alliance.

Ultimately, he says, helping clients rid themselves of persistent shame is what opens the door to healing.

 

****

 

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

Letters to the editor: ct@counseling.org

 

****

 

 

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.

Counseling survivors of sexual assault

By Brooke Bagley and Joel Diambra August 26, 2016

My journey (Brooke Bagley) of developing a five-phase model of counseling began in 2013 as I was completing my master’s-level graduate program and transitioning into a therapy position at a local area sexual assault center where I had worked since 2010. For the past three-plus years, I have listened to horrific stories, learned to establish rapport, identified helpful strategies, Bagley_Diambraempowered my clients, observed healing, prompted restoration and marveled at my clients’ resilience. All the while, I was unintentionally and unknowingly developing an effective counseling model.

During the past two years, I’ve also been receiving supervision toward licensure from Joel Diambra, the secondary author of this article. I discovered (or uncovered) “my” model of counseling when he recognized that I had a sequential pattern to my counseling and asked me to begin identifying what I was doing and the reasons I was doing it. Thus, I began to reflect on my counseling practice and, over the course of several weekly licensure supervision meetings, we crafted a five-phase model — my way of counseling survivors of sexual assault toward healing and restoration.

Just the thought of counseling someone who has been sexually assaulted may be daunting for many counselors. I think it’s fairly natural for most counselors to feel professionally inadequate when they knowingly encounter their first client who has been sexually assaulted. Although my five-phase model is based in foundational counseling theories and skills, I offer it here as one guide for counseling clients who have experienced sexual assault. Perhaps it will provide a road map for other counselors serving similar clients.

 

Phase 1: Assessment and education 

Phase 1 primarily consists of effective assessment skills, identification of presenting problems and initiating the first steps toward building rapport and developing language (matching age-appropriate terms, paralleling word usage, avoiding trigger words, etc.) that is most effective for the client. The amount of time spent in this phase typically ranges from one to three sessions depending on the client’s trauma history, presentation and comfort with therapy, and assessment of the client’s basic needs.

During this phase, it is imperative for counselors to maintain a high level of empathy to create an environment of acceptance and comfort. Many survivors of sexual assault struggle with feelings of shame, guilt, embarrassment and defectiveness, and have a decreased level of trust in others who are outside their identified support systems. To facilitate an environment that feels supportive and safe, I use the client’s own language, focus on appropriate and accurate reflections, and allow the client to emote without much intervention on my part.

The psychosocial assessment covers basic client-related information familiar to most mental health providers. This assessment provides insights regarding a client’s familial, medical and work-related history, in addition to current issues and past functionality. I complete the assessment to focus more on trauma-related history, both specific to sexual trauma and complex trauma (any previous trauma-related incidences a client identifies as having experienced). This focus is helpful in gauging client resilience, gaining insight into a client’s threshold for stress and obtaining increased awareness of potential maladaptive cognitive patterns the client might possess related to any current situations or traumas. At this point, the initial narrative (the client’s first retelling of the traumatic experience) is established, and I am able to incorporate the client’s language into future interactions to help in developing rapport and trust.

Phase 1 also consists of a psychoeducational focus that is helpful in increasing the client’s confidence in pursuing and maintaining therapy services. After completing the psychosocial assessment, I file the assessment in the client’s chart to review later in the therapeutic process and provide the client with trauma-related materials on normative responses that may be experienced in all facets of the client’s functioning (cognitive, emotional, physical, mental, social, etc.) At this time, I walk the client through a trauma symptoms checklist that includes emotion-, behavior- and cognitive-related questions. These questions and the corresponding answers offer insights into the client’s level of affectedness, while simultaneously educating the client on how and why certain symptoms have manifested.

Phase 2: Rapport and strengths

Building rapport and identifying strengths are major components of allowing successful trauma processing and resolution to occur. In phase 2, I encourage clients to take a break from our immediate focus on the sexual trauma and to instead explore their perceived strengths. This action facilitates the instillation of hope. This phase deviates slightly from other trauma-focused therapies by offering clients allotted time to engage in intrapersonal exploration that is separate from their trauma. This approach is geared toward a focus on what they still have versus what they feel they have lost.

Rapport building starts with intentional focus on empathy versus sympathy and the utilization of unconditional positive regard. This is accomplished by allowing clients to clarify their self-perceptions, identify as “survivors” or “victims,” and so on. This is the perfect time to incorporate the language or narrative the therapist has picked up from clients in the initial sessions. This conveys to clients that they were heard and listened to and, thus, are being cared for. I often explain the difference between empathy and sympathy during this phase to help clients identify which felt most supportive and when. This is also helpful to clients outside the counseling office because they are better able to identify those in their lives who provide this level of support and others who are less able to support them.

During the second phase, survivors of sexual abuse often report a reduced perception of control, diminished trust in others, a negative view of self and decreased feelings of worth related to being loved, cared for and valued. In this phase, I encourage clients toward increased positive views of self and self-confidence and the ability to seek support from individuals who can provide it. This skillset and a more positive perception of self are helpful over the course of the therapeutic journey.

Additionally, I explore clients’ past coping successes — activities they have previously engaged in that have been helpful in decreasing general stress — and work with clients towards creating a coping skills “kit” for emergency access. This provides go-to coping strategies when future trauma-related escalation occurs. When packing their kits, clients have included such items as adult coloring books, chocolate, scented oils, music playlists, the contact information of support people and so on.

Phase 3: Cognitive intervention

In phase 3, I explore clients’ cognitive processing. We work to identify thought patterns that lead to self-deprecating perceptions and triggering responses. I often alternate between the cognitive distortions focus of cognitive behavior therapy (CBT) and the emotion-incorporated theory of rational emotive behavior therapy (REBT).

During this phase, I recall the initial assessment (initial narrative of recent trauma) and work with clients to identify how they retell their history and describe their current functioning. Using a predeveloped checklist of common cognitive distortions, I work with clients in session to identify which distortions they are experiencing. Once clients are aware of these patterns, I encourage ongoing mindfulness activities to increase recognition of these cognitive distortions outside of therapy.

For example, I often give homework in the form of thought logs to help clients record triggering events, thought responses and actions taken. For clients who are less engaged in homework, a simple rubber band on the wrist is used to help clients heighten and maintain awareness. They do this by snapping the rubber band every time they experience a trigger. The hope is that if they find themselves snapping recurrently, they will in turn pay more attention to their maladaptive thoughts and can then better self-identify and later verbalize these patterns in therapy. Some of the cognitive distortions that clients commonly report to me include: “I am damaged”; “I will never be the same”; “I should have done something different”; “Nothing good ever happens to me.”

Once we identify negative thought patterns and triggers, we begin working toward positive and realistic reframes while continuing to focus on coping skills from the previous phase. I encourage clients to share their perceptions of their situations and, together, we begin to break down these thought patterns to help them process their experiences differently. For instance, a client might state, “My family seems uncomfortable when I bring up my assault. They must think I am overreacting.” In this case, we would work to create a healthier, more adaptive reframe such as, “My family may appear uncomfortable when I bring up my assault, but maybe it is because they are not sure how best to support me.”

This provides a reevaluation of the client’s perception. The hope is that clients will then recognize the potential in their support systems and, incorporating increased self-confidence from the previous phase, will feel comfortable conveying and eliciting more effective and efficient support from friends and family members.

Phase 4: Emotion focused

Phase 4 is primarily focused on emotion-based responses and interventions, along with the incorporation of mindfulness. I purposefully separate this from and have it follow the cognitive phase because I have found there are residual and intense emotional responses that often outweigh clients’ abilities to rationalize or self-soothe. Clients with complex trauma or a lack of effective coping skills often report numbness, a sense of disconnect from their bodies, intense and seemingly uncontrollable anxiety responses, and self-harming or self-medicating behaviors in various forms. In this phase, I primarily use Gestalt-based interventions to help clients better understand mind-body communication as it relates to emotional response.

The Gestalt interventions I use with clients are primarily focused on bodily sensations and reexperiencing physiological reactions. For this focus, I teach and encourage clients to practice body scanning on a regular basis but especially when experiencing more intense emotional reactions. The purpose is to have clients become better acquainted with specific aspects of their emotional functioning and the associated feelings linked to their bodies. This interventionBranding-Images_survivors allows in-the-moment understanding of how certain emotions manifest physiologically and encourages an increased awareness of clients’ specific responses to emotions in triggering conditions.

I ask clients to walk me through a recent trauma-related episode, having them focus on what they felt bodily versus emotionally or cognitively. Many clients report feeling like anxiety manifests in their digestive tract (stomach, bowels) in the form of cramps and intense aching or, alternatively, in the form of pressure in the temples of the head or behind the eyes.

Some clients will report a complete disconnect when they experience intense emotional reactions. They become physically numb and feel no sensation — much like physical denial. Clients who disconnect are more prone to self-harm. They tend to revisit this unhealthy form of coping even if it has not been in active state for them for some time.

A common practice I use for working with this trauma response is based in mindfulness. I encourage clients to engage all five of their physiological senses by directing them to pick different therapeutic items up in my office (essential oils, stones, stuffed animals, mints, wall art, etc.) to smell, touch, taste, listen to and focus on visually. Once this senses-based intervention has been practiced within the therapeutic office, I encourage clients to continue using this intervention at home. A more severe tactic of grasping ice has been found to be helpful for clients who have tendencies toward self-harm. The ice allows for a physiological stimuli or shock to the body that engages sensation centers in the brain similar to those engaged in cutting, burning, etc. The hope is that these clients will choose items that are pleasing to them over items that are unpleasant, thus creating more positive experiences that involve bodily sensations.

Phase 5: Trauma narrative

The final phase in this model is focused on the trauma narrative. It is at this point in the therapeutic process that clients are displaying and self-reporting more stable emotional and cognitive-related responses to stress and more effective use of healthy coping skills.

I encourage survivors of sexual assault to begin writing out their trauma narratives, which occurs in session. Retelling their stories has been empirically proved to decrease the severity of the trauma response. It also allows clients to apply new meaning to their experiences and incorporate new and positive self-views and language. I do not recommend writing trauma narratives outside of the therapy session, however, because clients with a recent trauma can still be easily triggered. This is especially true when the narrative directly engages their previous trauma.

Once an initial narrative is written, I have the client read it out loud two separate times within the same session, or sometimes over the course of two sessions depending on the client’s responses to the narrative work. The first time, clients read their accounts of their trauma verbatim. From there, we are able to explore and process their reactions to the narrative and gauge their level of trauma response. I then ask clients to reread their narratives in the third person, as though they are telling someone else’s story. This allows them to take a bird’s-eye view of their trauma experience and perceive it differently, which often results in clients permitting more empathy and understanding for themselves.

Implications and model tenets 

My experience with this model in treating survivors of sexual assault has been favorable. Using this five-phase model, I have maintained a high client retention rate of 70 percent and a low cancellation rate of approximately 25 percent (compared with a typical rate of 40 percent within our center) over the past 18 months. Most clients report an overall increase in functionality after three sessions. These same clients have engaged in trauma work sooner in the therapeutic process than have our clients treated without the five-phase model.

Tenets of this model include effective assessment skills, a focus on client history and complex trauma, empowerment and encouragement of clients, an empathic strength-based approach and the incorporation of CBT/REBT and Gestalt-based interventions.

 

****

 

Brooke Bagley, a national certified counselor, is a therapy team leader/supervisor and clinical mental health therapist at the Sexual Assault Center of East Tennessee. Contact her at brookelynnbagley@gmail.com.

Joel Diambra is an associate professor of counselor education, associate department head and director of graduate studies in the Educational Psychology and Counseling Department in the College of Education, Health and Human Services at the University of Tennessee in Knoxville. He is a licensed professional counselor-mental health service provider. Contact him at jdiambra@utk.edu.

Letters to the editor: ct@counseling.org

 

****

 

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.

Going beyond ‘no means no’

By Laurie Meyers August 25, 2015

Survivors and activists have sought for decades to shine a light on the issue of sexual assault on college campuses with everything from Take Back the Night events to No Means No education campaigns. A Columbia University student who graduated in May made national headlines when she spent her senior year carrying a mattress with her everywhere she went on campus to represent the dorm room bed where she alleges she was raped as a sophomore. The alleged perpetrator was NOallowed to remain on campus.

And yet the debate about how best to address sexual violence on campus rages on. For that matter, researchers can’t even seem to agree on how often sexual assault occurs on campus. On the one hand, the 2006 federally funded Campus Sexual Assault Study of more than 5,000 women and 1,000 men at two large (unnamed) universities found that 1 in 5 female college students had been sexually assaulted. However, a 2014 Department of Justice report based on the answers of 160,000 respondents in the National Crime Victimization Survey found that an estimated 0.6 percent of female college students had been sexually assaulted.

Experts have pointed out significant shortcomings in both surveys, but some recent data, gathered in the first quarter of the year and released in June, aligns with the 2006 study. These findings come from a joint Washington Post-Kaiser Family Foundation poll of more than 1,000 randomly selected recent college graduates. The poll defined sexual assault as five types of unwanted contact: forced touching of a sexual nature, oral sex, vaginal sexual intercourse, anal sex and sexual penetration with a finger or object. One in 5 of the female respondents reported having been sexually assaulted in college. Five percent of the poll’s male respondents also reported being sexually assaulted while in college.

Regardless of the numbers, few would argue that any sexual assault is one too many. Counselors who are on the front lines of prevention efforts on college campuses say that decreasing the number of sexual assaults can’t be accomplished simply by raising awareness but must also be accompanied by widespread behavioral and cultural change. That is a complex and daunting task, but the counselors we spoke to — who are engaged in research or are working with campus programs — believe that current campaigns to reduce sexual violence through education sessions, campuswide activities and, in some cases, even the theater, can bring about lasting change.

A holistic approach to prevention

For decades, prevention efforts failed to address all of the factors that contribute to sexual assault, instead placing the onus on individual women and what they should do to prevent being assaulted, says Laura Hensley Choate, an American Counseling Association member who researches and writes about women’s and girls’ issues. Until relatively recently, she adds, little thought was given to also addressing perpetrators or potential perpetrators in prevention efforts.

As researchers began focusing on college men’s attitudes and behaviors, it quickly became apparent that most of these men didn’t have a clear understanding of consent. In fact, many still believed that, in certain cases, women “were asking for it,” Choate says. Another significant finding also emerged. Although prevention efforts consisting of short-term education programs sometimes temporarily changed men’s attitudes, they did not change behavior. Any lasting change would need to involve long-term education.

ACA member Brittany Talley, coordinator of the Campus Violence Prevention Program (CVPP) at Southeast Missouri State University in Cape Girardeau, Missouri, agrees with that assessment. She has found that although many students — women included — have learned that “no means no,” they don’t really understand that a woman’s decision to consent to sex is completely independent of what she is wearing or whether she has slept with the person in the past.

In the presentations that Talley gives, she also emphasizes that a literal “no” isn’t the only way of communicating that a person doesn’t want to have sex. “We talk about what ‘no’ might [sometimes] sound like — ‘I don’t really feel like it’ or ‘I don’t really want to,’” she says.

Not surprisingly, alcohol is another huge component in many campus sexual assaults. “There is huge misunderstanding about alcohol use and consent. Some students don’t realize that if you are too drunk to drive, you are too drunk to consent [to sex],” says Talley, a provisionally licensed professional counselor.

Talley addresses these myths and misunderstandings in a talk that all freshmen and transfer students are required to attend when they arrive on campus. The 35-minute education session focuses on dating and sexual violence, including how prevalent it is, what constitutes violence, how to get help and how outsiders can help. Talley also hands out cards with a help number and information on what to do after a sexual assault.

In addition to giving presentations and workshops to classes and student groups, Talley has coordinated a number of highly visible awareness events on campus. Part of the goal in these campaigns is to help engage bystanders because she believes that they play a crucial role in preventing sexual assault and violence. For instance, she says, if students at a party or bar notice that someone is being plied with drink after drink, they should step in or get help.

This past fall, the CVPP participated in RAINN (Rape, Abuse and Incest National Network) Day, an annual event devoted to sexual assault education. Most vividly, umbrellas are designed and displayed by participants to draw attention to the issue of sexual assault. The umbrellas can be decorated in any manner the participants wish but must include at least one mention of RAINN somewhere in the design. In addition to making its own umbrella, the CVPP invited various student organizations to submit umbrellas. This was done not only to raise awareness but also in hopes of getting more student organization members involved in prevention efforts, Talley says. On RAINN Day, 20 student organizations displayed umbrellas. Some organizations used serious themes, while others designed their umbrellas as emblems of support. For instance, the group made up of criminal justice students designed an inside-out umbrella because sexual assault turns a person’s life inside out, Talley notes.

The CVPP has coordinated other efforts as well, including the clothesline project, in which T-shirts bearing the stories of survivors of sexual assault were hung up on a clothesline on campus, and “Sexy Time Talk,” in which students lead discussions that focus on the characteristics of healthy and unhealthy relationships.

Only time will tell whether activities such as these will have a significant effect on the sexual assault rate on campus, Talley says. In the meantime, students and staff are reaching out to assist survivors who want help but haven’t been able to take that step, she says.

“One of the most common ways I hear of a case is through other students or a staff member,” she says. “They may ask me to reach out to a particular student, or professors might walk students over or have me come to their offices.” CVPP is part of the university’s counseling and disability services, and in addition to her prevention efforts, Talley counsels survivors of sexual assault.

ACA member Jennifer Sharp oversaw a sexual violence peer education program known as PHREE (Peers Helping Reaffirm, Educate and Empower) at Penn State from 2009 to 2012. “PHREE members worked with the [university’s] Center for Women Students to develop a variety of events designed to support survivors of sexual and relationship violence, provide accurate information about violence and raise awareness,” says Sharp, a national certified counselor (NCC).

PHREE coordinates educational presentations at residence halls and sororities on topics such as dating violence, healthy relationships, sexual assault and consent. It also uses creative, often performance-based events to raise awareness. During Sharp’s time, PHREE members engaged in the university’s participatory theater project, Cultural Conversations, which focuses on social justice issues. PHREE’s performance was on body language. Various participants acted out representative scenarios, and then audience members and performers engaged in a discussion of the issues.

During Sharp’s tenure, PHREE also planned and assisted with activities for sexual assault awareness months that included “survivor speakouts” and poetry/spoken word events that emphasized themes of sexual assault and survival.

Sharp is now an assistant professor of counseling at Northern Kentucky University, where she helped secure a grant to fund the Norse Violence Prevention Project. “The grant essentially provides funding to coordinate and strengthen existing resources for survivors of sexual assault, relationship violence and stalking,” she says.

Sharp is also implementing the Norse Violence Prevention Peer Educator program, which is based in part on the knowledge she gained while working with PHREE. Peer educators are currently being trained to advocate and offer support for survivors of trauma.

Providing services, support and a sense of safety to survivors

Even if the number of sexual assaults on college campuses is reduced significantly, there will always be survivors. Some of those who have experienced sexual violence will seek counseling to help them process and move beyond these devastating events.

Survivors who seek help immediately or shortly after the assault and those who seek help later face many of the same issues, but there are differences in their presenting issues and primary needs, says Sue Swift, a licensed professional counselor (LPC) at the Collins Center, a community center in Harrisonburg, Virginia, that provides mental health, crisis, medical, support and legal services to survivors of sexual assault and violence. The center also uses advocacy and education in its efforts to help end sexual violence in the community.

“When we work with survivors immediately after an assault, we have the primary goal of stabilization and re-establishing at least a basic sense of safety,” Swift says. Establishing safety is especially important in cases of campus sexual assault because the survivor may attend classes, socialize or even live with the person who committed the assault, note counselors who work at on-campus facilities.

When a survivor comes into the Maxine Platzer Lynn Women’s Center at the University of Virginia right after an assault, counselors first determine whether the student’s living situation and general physical environment are safe, says ACA member Charlotte Chapman, an LPC who serves as the director of counseling services at the center. It is also important to start establishing a sense of emotional safety by ensuring that the survivor has a support group or safety net in place.

“A lot of people will say, ‘I don’t want my parents to know,’” Chapman says. “We’d prefer that they use family as a source of support, but that’s not always what they want. … We talk to them about tapping into [support] resources on and off campus.”

Sometimes their best friends aren’t on campus with them, especially if the survivor is a first-year student and hasn’t yet formed strong social bonds, Chapman notes. In such cases, counselors at the women’s center will talk to the student about how to access her or his network of friends through methods such as Skype.

Survivors of sexual assault need help to feel safe because of the range of frightening emotions they are experiencing, Swift points out. “Often, survivors at this stage [immediately or shortly after an assault] are feeling overwhelmed, vulnerable and fearful,” she says. “Counseling can help [survivors] sort through and reduce anxieties [and] develop plans for getting support and taking tiny steps forward.”

“With these acute clients, we might spend a good amount of time normalizing their reactions and feelings but also helping them with grounding techniques and coping skills to deal with the anxiety and stress they are probably feeling,” Swift continues.

Counselors at the Collins Center may also help survivors of sexual assault access resources such as law enforcement, medical assistance and campus services (when appropriate) if they haven’t already done so, she says.

On the other hand, Swift says, survivors who come in for counseling years after an assault are in various stages of distress or healing. Some survivors may seek counseling after a triggering event, while others arrive ready to talk after years of burying their feelings, she says. Regardless of the circumstances that bring them in, these survivors have all had time to tell themselves a “story” about their assault — a story that may include distortions and inaccuracies, Swift says.

“Survivors often blame themselves in some way for what happened or feel badly about themselves,” she explains. “They may feel the assault defines them. Their self-esteem and relationships may suffer.”

It is important for counselors to understand that survivors often have a deep sense of shame. They feel as if the assault was their fault or that they could have prevented it, even when they know intellectually that this isn’t true, say Swift and her colleagues at the Collins Center.

Counselors can be effective at helping survivors of sexual assault work through these feelings, Swift says. She and her colleagues at the Collins Center have found that a supportive approach that allows survivors to set the pace works best. Typically, Swift and her fellow counselors begin by helping these clients to develop coping skills and providing them with psychoeducation about trauma. Most survivors will need help correcting cognitive distortions about themselves and their assault, such as blaming themselves, Swift says. These clients may also benefit from grief work to help them mourn the losses they’ve experienced as a result of the assault, she continues.

“Support groups can also be very healing,” Swift asserts. “Being together in a group, even informally, with others who understand your pain is transformative for many.”

If a client cannot find a support group that offers a good fit, bibliotherapy involving the stories of other survivors can be an extremely helpful alternative, she says. “Many survivors think they are ‘crazy’ until they hear their thoughts and feelings expressed by another survivor,” she adds.

Caution! On campus, confidentiality may not apply

This past January, a University of Oregon student who alleged that several members of the basketball team had raped her sued the university for mishandling her case. Although the players were eventually dismissed from the team and suspended from the school, the survivor alleged that the university had delayed its investigation to ensure the players could remain on the team for the remainder of the season.

As part of a counterclaim — which has since been dropped — the university requested that the campus counseling center release the student’s treatment records.

The incident served as a glaring reminder that counselors who work in campus mental health centers need to ensure that their clients understand that, in certain cases, their records and confidentiality may not be protected. The state of Oregon claimed that it had a right to the student’s records under the federal Family Educational Rights and Privacy Act (FERPA), which allows an educational institution to access student records to defend itself against lawsuits.

“FERPA covers educational records and only educational records. Treatment records for mental and physical health are specifically excluded,” says Perry Francis, who served as the chair of ACA’s Ethics Revision Task Force. However, he explains, the student’s lawsuit in this case specifically mentioned emotional distress, and in Oregon, the law says that if mental health is included as part of a lawsuit, defendants have the right to defend themselves with access to the records. This is an area in which counseling ethics and law collide, notes Francis, a professor of counseling and coordinator of the counseling clinic at Eastern Michigan University.

“Legally, short of a court order, we [the counseling clinic] are not going to release a student’s records,” he says. Counselors do have to follow the law, but before releasing anything, the counselor should discuss it with the student to make sure he or she understands, adds Francis, a past president of the American College Counseling Association (ACCA), a division of ACA. The counselor should also talk to the student’s attorney to discuss what the order specifies and how the counselor or counseling center might limit the information they release. It may be that not all of the records are germane, notes Francis, an LPC and NCC.

M.J. Raleigh, a past ACCA president and the director of counseling and psychological services at the University of North Carolina at Pembroke, confirms there are times when she and her staff have had to release information, but they take actions to limit it.

Anne Marie “Nancy” Wheeler, the risk management consultant for ACA’s Ethics Department, says a counselor who has been asked for a client’s file might be able to provide only a summary of the file rather than the entire file.

“If a counselor receives a subpoena, in many states, the counselor can see if a summary will suffice,” she says. “This is sometimes addressed by state statute, or sometimes the client or counselor can file a motion to quash or a motion for a protective order, which would lead to a court order from the judge. If there is an actual order from the judge, the scope of that order will determine whether a summary or the entire record can or must be released.”

So where does this leave survivors who come to college counseling centers? Raleigh and Francis emphasize the necessity of informed consent for all clients who seek services at a college or university counseling center at every stage of the counseling process, beginning with the intake form. Counselors need to make sure clients understand that there may be circumstances under which the center won’t be able to keep records confidential, they say.

Michelle Wade, an ethics specialist with the ACA Ethics Department, says that counselors who are compelled to release client information should work through an ethical decision-making model. This will help them look at all possible options and outcomes of releasing client information to determine the best course of action that causes the least amount of harm to the client.

“Professional counselors should be aware that they may be called upon to disclose confidential client information under a variety of circumstances, and legal requirements may dictate compliance with such requests,” says Erin Shifflett, director of the ACA Ethics Department. “However, it is imperative that counselors consider their ethical obligations as well. Prior to disclosing any information, counselors should develop a rationale for the disclosure which explores the ways in which the client may be impacted by the release of confidential information and ways to mitigate any potential risks.”

 

****

 

To contact the individuals interviewed for this article, email:

 

****

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

Letters to the editor: ct@counseling.org