Trauma, suicide and bullying are not new topics for most counselors, who at some point in their careers have likely worked with clients on each of these issues. However, as research and practice continue to progress, some counselors are using emerging approaches or perspectives to tackle these problems.
At the American Counseling Association’s 2015 Conference & Expo in Orlando, Florida, Counseling Today attended several sessions that presented some of these fresh approaches. We then caught up with three presenters after their sessions to get a more in-depth look at their ideas so we could share them with readers.
As far back as the ancient Egyptians, the chronicles of war have noted trauma-induced psychological symptoms. Samuel Pepys wrote about them in the wake of the Great Fire of London. Historians think that the author Charles Dickens may have experienced them after a horrific train accident. We now know these symptoms as indicative of posttraumatic stress disorder (PTSD), but until relatively recently, the cause of trauma-induced behavioral changes was thought to be purely internal and was sometimes even referred to as cowardice.
Trauma-induced psychological symptoms were not officially labeled as a disorder until 1952, in the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), which identified it as “gross distress reaction.” However, in 1968, as the memory of World War I and World War II faded, the diagnosis was dropped from the DSM. It wasn’t until scores of Vietnam veterans returned with severe psychological trauma that researchers began a deeper examination of the condition and its causes. The term PTSD officially entered the lexicon in 1980 with publication of the DSM-III. Defined, in essence, as a common set of symptoms brought on by extremely traumatic events such as combat, natural disasters, accidental disasters or personal catastrophes, PTSD has more recently gained greater recognition, both in mental health circles and the public eye, because of the struggles of veterans returning from the wars in Iraq and Afghanistan.
At the same time, many mental health experts have come to believe that another, more common, form of trauma exists that is often misdiagnosed as PTSD. Referred to as complex trauma or complex PTSD, this type of trauma is caused by repeated exposure to abuse or other traumatic events over time.
Despite the urging of many trauma experts, complex trauma was not included in the DSM-5. However, the disorder is very real and distinct from the current definition of PTSD, asserts Cynthia Miller, an ACA member who presented on “Recognizing and treating complex PTSD” at the ACA 2015 Conference.
Complex PTSD is typically the result of cumulative trauma and abuse that started in childhood. Miller’s interest in complex PTSD was first piqued when she was counseling women in the corrections system, where many of her clients — and many of the incarcerated women in general — had histories of trauma and childhood abuse.
“I got interested [in complex PTSD] in my work with the prison population, but even in my community work, I saw that histories of trauma were way more common than we realized and also at the root of so many things that we were treating,” she says.
Clients with trauma histories are often misdiagnosed not only with single-incident PTSD but also with borderline personality disorder, bipolar disorder or major depression, Miller says. These disorders — along with alcohol and substance abuse — can accompany complex trauma, but counselors need to understand that the trauma colors everything the client is experiencing, explains Miller, a licensed professional counselor with a private practice in Charlottesville, Virginia. At the same time, treating complex trauma by immediately turning to protocols for PTSD, such as eye movement desensitization and reprocessing (EMDR), prolonged exposure therapy and cognitive processing therapy, is not going to work as well and may actually result in retraumatizing the client, she says. Methods such as EMDR may be helpful for some clients later in the treatment process, Miller says, but only after they have been through an initial stabilization process.
“One of the most common mistaken impressions [when treating trauma] is that someone who has been through trauma needs to talk about and process it,” explains Miller, who is also an assistant professor of counseling at South University in Richmond. By doing this, she says, “counselors are trying to help clients, but they [may] open up trauma that neither the counselor nor the client is ready to deal with. When dealing with complex trauma, the first thing you need to do is to help them live in the present, not the past.”
Although PTSD and complex trauma share certain symptoms, they also feature significant differences — differences that are crucial for counselors to understand, Miller says.
PTSD is typically caused by a single or time-limited event. Its symptoms include intrusive thoughts, avoidance behaviors, negative alterations in mood and cognition, and alterations in arousal and reactivity.
Complex trauma, on the other hand, is caused by long-term traumatic experiences such as child abuse, intimate partner violence, community violence (including living in a society at war), experiences as a refugee or displaced person, trafficking and forced servitude, chronic illness and disability necessitating invasive treatment, and bullying. Symptoms may partially mirror those for PTSD but also feature additional severe problems such as:
- Difficulty regulating emotions
- Disturbances in attention and consciousness
- Affect dysregulation
- Altered self-perception, including feelings of guilt and worthlessness
- Difficulty interacting with other people
- Chronic dysphoria or dissociation
- Engaging in self-destructive behavior
- Difficulty with self-soothing
People who are experiencing complex trauma do not have the emotional skills necessary to address the issues they’re facing, so before moving forward, a counselor must first help the client to stabilize, Miller says. Stabilization begins with establishing a sense of safety, including addressing the client’s most basic needs.
“You really almost have to go through Maslow’s hierarchy with [these clients] to find out if food, clothing and shelter are concerns,” Miller says. “If so, how can you help the client address it? Because it’s hard for someone to build skills if they don’t have a place to sleep.”
After the client’s basic needs have been addressed, the counselor should help the individual establish a sense of safety with “self,” Miller explains. This requires the counselor to probe for self-injurious behavior, suicidal behaviors or urges, risky sexual and other behaviors, and attendance to the health and integrity of the body. Assessing for self-protective behavior is also important, Miller continues. For example, is the client locking his or her house or bedroom door at night? Does he or she go running alone at night in crime-ridden areas? Safety with others is also important, she notes. For instance, is the client in a relationship in which he or she is being abused or exploited?
The third element of safety — without which the counselor cannot help the client with the first two — is feeling safe in therapy, Miller emphasizes. The client must feel that he or she is in control of what is going on.
“There must be a mutually designed treatment plan, informed consent throughout and the promise that the therapist is not going to do anything that the client doesn’t want to do or push them into doing something that they don’t want to do,” Miller says.
As the counselor and client address safety skills together, they should also work on other stabilization elements, such as reducing the acuity of trauma symptoms, Miller says. Symptom reduction involves developing coping skills and may or may not include medication, she adds.
Miller has found that dialectical behavior therapy (DBT) is particularly effective when teaching clients emotional coping skills. DBT helps clients learn that their symptoms are not their fault but rather a natural reaction to what has happened to them. This helps remove the attendant stigma and the clients’ sense that something is really wrong with them, Miller explains.
Because complex trauma causes dissociation, dysphoria, physical agitation and cognitive distortions, grounding skills — both physical and mental — are essential for reconnecting clients with themselves and their surroundings, Miller says. For instance, when a client’s nervous system is overloaded or aroused, his or her cognition is disrupted. To help these clients ground and re-engage, Miller directs them to say their ABCs backward, name the 50 states and state capitals, or name the different makes of automobiles.
To counteract physical disruption and the dissociation that sometimes accompanies it, Miller teaches clients grounding methods that engage the senses, such as touching physical items that have texture, describing what they see in their immediate physical surroundings or listening to soothing music. She also suggests physical stretching and movement, even if it’s just having clients stomp their feet while sitting down, or the sensory experience of running warm or cool water over their hands.
Miller also uses other soothing strategies such as safe place imagery with clients who have complex PTSD. Clients imagine a place, real or imaginary, where they feel safe, and Miller asks them to put themselves there by describing what they see, hear, feel, smell and taste.
Another soothing visualization technique involves picturing a nurturing and protective figure who has made the client feel cared for. Miller says this might be a relative, a friend, a pet or even a fictional or spiritual figure, just as long as the client can envision this figure during a time of need.
Clients with complex trauma also struggle with intrusive thoughts, so Miller asks them to visualize a container — whether it is a box, a safe, a vault, a dumpster or a tractor trailer — that is big enough to hold all of the things that disturb them. “It has to be as real as possible, and they have to be able to ‘lock’ it,” she says. Miller directs clients to visualize the container, set it aside and then walk away. “When they walk away, I have them walk to their visualized safe place,” she says.
Clients who are struggling with complex trauma also need to learn to relate to themselves and to others in different ways, Miller says. DBT can help in this area by teaching clients skills for managing intense emotions and interpersonal relationships. These skills include distress tolerance, emotional regulation, mindfulness and greater interpersonal effectiveness.
After clients are stabilized and feel safe, counselors can help them to integrate their traumatic memories so that the clients are no longer controlled by these memories, Miller says. She emphasizes that the aim of integration is to resolve the traumatic symptoms without retraumatizing the client.
Miller cautions that counselors should proceed carefully, helping the client to re-evaluate the meaning of the trauma and having the client demonstrate the ability to remember experiences while still remaining physically, emotionally and psychologically intact. The re-evaluation may involve an organized recounting of events using methods such as prolonged exposure therapy, cognitive processing therapy, narrative exposure therapy, traumatic incident reduction, EMDR and art therapy, she says.
After successfully stabilizing and integrating traumatic memories, the client and counselor can then work on enhancing the client’s relationships and planning for the future, Miller says.
Miller reiterates that complex trauma is more common than most helping professionals might realize, so she recommends that counselors screen for it routinely. “Counselors should be prepared. … Clients are not necessarily going to tell them [about their trauma] right away,” she says. Even if clients do bring up traumatic experiences on their own, it’s unlikely that they will reveal everything to a counselor initially, so counselors need to create a safe space and be patient, Miller says.
Miller adds that if a counselor suspects a client is experiencing complex trauma, the counselor should ask about it — but carefully. “Ask behaviorally,” she says. “Don’t ask clients if they were physically or sexually abused. Instead, ask them if anyone has ever punched, slapped, kicked or touched [them] in a way that [they] didn’t like or want.” Initially, clients struggling with complex trauma may not recognize or be willing to identify these behaviors as abuse, Miller says.
Because the trauma focus in counselor education is typically on PTSD and not complex trauma, Miller urges counselors to seek further training through continuing education and conferences. “It’s one of those things that you can’t afford not to know about and not know how to treat because, whatever work you do, you’re going to see it,” she says.
Understanding and assessing clients who are suicidal
It’s a counselor’s worst fear: a client who dies by suicide. Yet, as any counselor knows, there is no research that can definitively tell practitioners how to prevent suicide. But what if prevention starts with acceptance rather than assessment? What if connecting with a client who is suicidal requires accepting and understanding that there are circumstances under which many people might consider suicide? These are the questions that ACA member Eric Beeson explored in his conference session, “How do I know if someone is suicidal? A discussion of suicide theory, attitudes and interventions.”
Beeson, a licensed professional counselor and lecturer at the University of North Carolina-Greensboro, thinks that accepting the validity of such feelings is key to understanding why a client believes suicide is the answer. When faced with a client expressing suicidal thoughts, many mental health professionals instead focus on immediately shutting those thoughts down, he says. Although acknowledging there are certain cases that require emergency treatment such as hospitalization, Beeson says an immediate focus on preventing suicide may actually alienate the client and hinder treatment. He believes that approach is often based in the mental health professional’s fear — not only of losing a client but also of having to deal with and consider the subject of suicide. To understand and, hopefully, redirect a client’s suicidal urges, counselors must first examine their own attitudes, he asserts.
Beeson started asking such questions early in his counseling career during a four-year stint at a hospital, where dealing with death and the aftermath of suicide attempts was a regular occurrence. “Watching the way some of the staff interacted with people after a suicide attempt, some of the judgments I saw, got me curious about people’s attitudes toward suicide and then, eventually, how … that attitude influences practice,” he says.
With more than 41,000 reported suicides in the United States in 2014, these are urgent questions to answer. Beeson, a contributing faculty member at Walden University, began his presentation by asking attendees to consider the following questions as a way to examine their own attitudes about suicide and people who die by suicide.
- How can I tell if my client is suicidal?
- Why do people attempt or die by suicide?
- Is suicide a singular event or a process?
- Can suicide be rational and/or permitted?
- What is my role when working with someone experiencing suicidal behaviors?
- Am I capable of suicide?
- Even though you would prefer another way to die, painful circumstances in life might lead to suicidal ideation. How do you estimate the probability that you sooner or later will die by suicide?
a) I am sure I never will die by suicide.
b) I hope I will never die by suicide, but I am not absolutely sure.
c) Under certain circumstances, I consider suicide as a possibility.
d) I consider suicide as a possibility for the future.
n What suicide attitudes do you think are most helpful to counseling practice?
a) More/less acceptance of suicide
b) More/less condemnation of suicide
c) More/less belief in the preventability of suicide
Beeson notes that even within the mental health field, the stigma and avoidance surrounding suicide remains strong. People who have died by suicide or attempted suicide are typically viewed as weak. This represents an empathy gap — one that counselors need to close, Beeson asserts. So, he challenges counselors to ask themselves about their personal suicide potential.
During his session, Beeson used humor to demonstrate circumstances that might cause a person to consider suicide as a viable option. In a clip from the old TV sitcom Cheers, four characters — Sam, Woody, Norm and Cliff — are preparing to sky-dive. But when the time comes to jump, they’re all petrified, realizing that they could die. Suddenly, skydiving doesn’t seem like such a good idea. However, for various reasons — to prove something, to not look like a coward, because everyone else is doing it — they each eventually jump. Cliff is the last and the most hesitant. Seemingly nothing will make him jump. But then the plane starts to sputter and the pilot says it’s going to go down. Cliff decides to take his chances — to, in essence, take control of how he will die — and jump.
Beeson asked the audience to think about which character they identified with. What might motivate them to get out of that plane? Beeson says he does this to help counselors recognize that under certain circumstances, anyone might consider dying by suicide. In turn, that helps them better understand why a client might consider suicide a viable — or even the only viable — option.
Beeson notes this is not just theoretical for him. During his time working with clients who were suicidal, he found that the more he focused on prevention, the less effective he was. However, once he started focusing on acknowledging the client’s struggle and the resilience it had taken to come this far, he was better able to take that resilience and direct it toward other methods of coping.
“I don’t know what it’s like for … any person to walk in their shoes, and who am I to say that they’re walking in their shoes wrong?” Beeson asks. “Who’s to say if I wasn’t in a similar situation, that my shoes might get a little uncomfortable? … And [if they] become more uncomfortable than I’d like to bear and I can’t find a new pair of shoes, then who’s to say that I might not take those shoes off?”
“I don’t believe that people just want to kill themselves,” he says. “It’s just that last-ditch effort to attain something that seems unattainable.”
Beeson believes counselors need to view suicidal intent on a continuum. “Suicidal is a misleading term. There’s no research to suggest that there’s any way to truly decide when someone is or is not — quote, unquote — ‘suicidal,’” Beeson says.
The better question, he asserts, is how likely is someone to die. Dying is painful and goes against the natural human instinct to preserve life. Beeson explains that research by psychologist and suicide expert Thomas Joiner posits that suicide requires overcoming that instinct and becoming capable of killing oneself. When that capability is combined with circumstances that seem intolerable, the risk of suicide is very high, Beeson explains.
Some people, such as those in high-risk, high-intensity jobs, including police officers, firefighters and emergency services personnel, already have a greater risk of death because they are regularly exposed to and habituated to it, Beeson contends. In addition, people in these jobs are routinely exposed to others’ experiences of pain. This engenders a certain comfort level with pain that also increases the person’s likelihood of dying, Beeson says.
But working in one of these high-intensity professions is not the only way that people habituate themselves to pain and the risk of death. Nonsuicidal self-injury, prior suicide attempts, intravenous drug use and prostitution have all been linked to suicidal behavior, Beeson says.
He adds that research by Joiner and others has shown that suicidal risk factors fall under three main categories.
- Mental disorders — particularly mood disorders, schizophrenia, anxiety disorders and certain personality disorders
- Alcohol and other substance use disorders
- A sense of hopelessness
- Impulsive or aggressive tendencies
- History of trauma or abuse
- Some major physical illnesses
- Previous suicide attempt
- Family history of suicide
- Job or financial loss
- Relational or social loss
- Easy access to lethal means
- Local clusters of suicide that have a contagious influence
- Lack of social support and sense of isolation
- Stigma associated with help-seeking behavior
- Barriers to accessing health care, especially mental health and substance abuse treatment
- Certain cultural and religious beliefs (for instance, the belief that suicide is a noble resolution of a personal dilemma)
- Exposure to suicide, including through the media, and the influence of others who have died by suicide
Beeson says counselors should evaluate clients for these risk factors and also look for the following warning signs.
Talk: The client talks about killing himself or herself, having no reason to live, being a burden to others, feeling trapped, having no hope or being in unbearable pain.
Behavior: New or increased episodic behavior, especially if related to a painful event, loss or change; increased use of alcohol or drugs; looking for a way to kill themselves, such as searching online for materials or means; acting recklessly; withdrawing from activities; isolating from family and friends; sleeping too much or too little; visiting or calling people to say goodbye; giving away prized possessions; and displaying aggression.
Mood: Displaying depression, anxiety, rage, irritability, humiliation or sudden calmness.
Beeson also explained that there are five levels of risk for suicide:
Nonexistent: No or few risk factors, no previous attempts and no suicidal behaviors.
Mild: A previous attempt but no other risk factors, or no previous attempts but demonstrating short-term, mild suicidal behaviors.
Moderate: A previous attempt with other notable risk factors, or no previous attempts but exhibiting ambivalent plans or preparation, suicidal desire or two other notable risk factors.
Severe: Previous attempt with two or more notable risk factors, or no previous attempts but having moderate or severe symptoms of resolved plans and preparation.
Extreme: Previous attempts with severe symptoms of resolved plans and preparations, or no previous attempts with severe symptoms of resolved plans and preparations and two or more other risk factors.
If a counselor has a client who is displaying suicidal risk factors, the first step is to ensure immediate safety, which in some cases may require hospitalization. Otherwise, the counselor and client can work to develop emergency plans that the client can follow if he or she is feeling suicidal, Beeson says.
It’s also important for counselors to establish a rapport with these clients and listen to their stories without judgment, he emphasizes. Counselors should then help clients manage their feelings by acknowledging their pain and encouraging them to use the session as a time to consider all options, including suicide, Beeson says.
Another critical factor is to guide clients in exploring alternatives to suicide by helping them envision future possibilities. Beeson says counselors should emphasize future plans by asking questions such as: How are you going to stay alive in the next week? Will you be back to see me next week? He adds that helpful behavioral strategies include drawing up a short-term positive action plan and using safety or wellness plans.
Beeson gives presentations on suicide frequently because he feels the topic is so important. “I just want to foster tough conversations about what we believe about suicide and the implications for practice,” he says. “I want people to live. That’s my goal. But I also believe in autonomy and the client’s right to choose. I think as we acknowledge that autonomy, we are better able to connect with people. I just think that one of the best ways to promote those types of interventions is to address what it is that we believe so that we can promote life-giving conversations. Then maybe we can promote that hope that the unattainable might just be attainable in some other direction.”
A playful approach to bullying prevention
Bullying prevention often focuses on punitive measures. The bully is identified, chastised and punished — with little or no consideration given to why the bullying occurred in the first place, says ACA member Ruth Ouzts Moore. And if counselors, teachers and other educators don’t address the underlying reasons, the likelihood of preventing bullying over the long term is low, she adds.
But how can counselors and educators learn the real reasons for bullying? Those who bully and those who are bullied often are too ashamed, scared or just plain angry to talk honestly about what is driving the bullying, Moore notes. That’s why she has come to believe that play, not punishment, is the best way to address and reduce bullying.
As a licensed professional counselor, counselor educator and part-time school counselor in the Savannah, Georgia, area, Moore has implemented this creative approach with young students and found it to be very effective. She described her experiences in a session at the ACA 2015 Conference.
Moore, an ACA member, began her presentation by clarifying the definition and different types of bullying. At its root, she said, bullying is an intentional, abusive act or attempt to inflict injury or discomfort on another person. She further explained that bullying can take the form of physical, verbal, relational or cyber abuse.
Bullying is fueled by the imbalance of power between the person doing the bullying and the person being bullied. Moore, a core faculty member in the mental health counseling graduate program at Walden University, noted that research suggests targets of bullying are at a disadvantage in this power differential for various reasons, which include:
- Being perceived as different or weak and defenseless
- Experiencing depression, anxiety or low self-esteem
- Being less popular
- Being perceived as annoying or attention seeking
Bullies, on the other hand, are generally students who are easily angered or frustrated, have family issues or are overly concerned with popularity.
For the targets of bullying, the gap between them and their tormentors must seem huge, but Moore notes that the bully and the bullied usually have similar backgrounds. For instance, children who come from abusive or violent backgrounds, grow up in neglectful environments in which there is little parental involvement or are caught in the middle of a high-conflict divorce face a higher likelihood of being bullied and bullying others, she says.
Bullying has serious and long-lasting effects on both the bully and the bullied, Moore points out. These effects include anxiety, low self-esteem, depression, suicidality, fear, mistrust, truancy, academic decline and nonsuicidal self-injury. In addition, the bully and the bullied are not the only ones affected. Bystanders, teachers, parents and siblings also suffer the consequences, directly or indirectly, she says.
Counselors face myriad challenges with both populations when working to address the issue, Moore says. Research has found that those who bully:
- Often minimize or deny their aggressive acts and behaviors
- Can be reluctant or resistant to disclose sensitive issues such as family violence or emotional problems that may be at the root of the bullying
- Are sometimes repeating behavior that is intergenerational
- Are often handled punitively and therefore may be distrustful of counselors
Similarly, research has found that those who are targets of bullying:
- Often won’t tell anyone they are being bullied
- May present in counseling with other issues such as depression, anxiety or school avoidance that may complicate or obscure the bullying issue
- May have difficulty verbalizing their feelings
- May not want to disclose bullying because they are ashamed and humiliated
- May not disclose family problems that are at the root of or complicating the bullying
In her private practice, Moore has worked extensively with adolescents who bully or who have been bullied. She recently took on a school counseling position that allows her to address bullying with prekindergarten-age children through eighth-graders, both from a group and individual perspective. She notes that early education and intervention are the most effective means of preventing bullying.
Moore was hired specifically to address bullying at a private school that was having serious problems. Her goal was to help prevent bullying through identifying the sources of the problem, providing education and implementing active classroom strategies.
Moore presents weekly classroom sessions in which she combines educational sessions and activities in the form of games. She says the students enjoy the activities because they’re fun and provide a break from classroom work. The games also give Moore an opportunity to observe the classroom and identify the children who act out. She will often follow up by providing individual therapy to the most disruptive children.
Her activities focus on neutralizing bullying by increasing self-esteem and developing anger management skills. The self-esteem building activities include things such as a written quiz with 10 questions: 1) What’s good about you? 2) What’s good about you? 3) What’s good about you? And so on, with the same question repeated 10 times.
“It makes them laugh,” Moore says. “Kids often get stuck and can’t think about what’s good, so we’ll talk about how it’s hard to say good things about yourself because people will think you’re bragging, but it’s really important.”
In another game, Moore hands out Riesens caramels when students tell her the reasons or “Riesens” they like themselves.
During her presentation at the ACA Conference, Moore handed out balloons to audience members to demonstrate another activity she conducts for anger management. She asks the students to blow into the balloons to represent how stressful their day has been. The balloons end up being anywhere from just a tiny bit full to completely blown up.
“We talk about how amazing it is [to see] how quickly the balloons can fill up,” Moore says. She then goes on to talk with the students about how to moderate anger.
Another activity, “Bullying Bingo,” has helped students learn about the different types of bullying. Moore has also led students in activities to strengthen their sense of collaboration, such as by working together to build a peanut butter sandwich without looking at one another.
The activities seem to be having an effect. In the two years since Moore started working at the school, it has witnessed a huge decline in incidents of bullying.
Moore credits the creative approach for the results. She believes it works because the approach is nonthreatening, allows kids to express things they have trouble verbalizing and helps to build their confidence. On top of that, the activities are fun.
Moore encourages counselors to explore the creative approach when addressing issues of bullying. She also urges counselors who want to learn more to join the Association for Creativity in Counseling, a division of ACA for which Moore currently serves as secretary.
“Be open to new approaches,” she concludes.
Laurie Meyers is the senior writer for Counseling Today. Contact her at firstname.lastname@example.org.
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