Counseling Today, Knowledge Share

Salutogenesis: Using clients’ strengths in the treatment of trauma

By Debra G. Hyatt-Burkhart and Eric W. Owens April 25, 2016

Mark was 16 when he found himself in a youth detention facility again. The reasons for his incarceration aren’t necessarily important; he had committed plenty of crimes in his life. His past actions came as no surprise. His father had been incarcerated for the entirety of Mark’s life. His mother was addicted to methamphetamines and often prostituted herself to pay for her addiction. Mark had been physically, emotionally and sexually abused throughout his life. He had also watched as his cousin was shot and killed.

Branding-Images_SalutogenesisMark had been in and out of the Child Protective Services system since the age of 2 and the criminal justice system since he was 12. Mark was often defiant and oppositional when he was in placement or incarcerated. Yet again, Mark’s counselor was asking him why he kept fighting with staff and losing privileges. In a defiant, yet blunt, sad and hopeless way, Mark responded, “There’s nothing anyone can do to me in here that can hurt any worse than what people have done to me out there. They’ve got nothing on me.”

It’s easy to assume the worst from that statement. We can look at Mark’s history of trauma and conclude that he will likely never break the cycle. It’s also easy to assume that “out there” means society and “in here” means prison.

But what if we reframe Mark’s words? What if we step away from our assumptions about trauma and its effects and instead view Mark’s past as a gift of sorts? If Mark points to his chest when he says “there’s nothing anyone can do to me in here …” does this dramatically change our understanding? “In here” can just as easily mean within Mark as outside of him. After surviving everything that had happened to him out there, Mark could certainly survive in here too. Perhaps Mark could find strength from his past and learn from it.

The concept of posttraumatic growth is an important one. If we assume from what Mark said that his path is predetermined, then we are not very well-equipped to help him foster change. From the counselor’s perspective, if the belief is that Mark continually engages in self-defeating behaviors and doesn’t think things can ever change, all we see is resistance to the counseling process. We don’t see the attempts at self-preservation and the potential that Mark has; we see a defiant, angry, wounded young man who doesn’t want his life to be different. But if we look at Mark’s words and behaviors through a different lens, maybe we can help Mark see himself through that lens as well.

Pathology of the profession

Treating trauma has become an increasingly important aspect of the counseling field. Clinicians can quickly point to the symptomology in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and assign a diagnosis of acute stress disorder, posttraumatic stress disorder (PTSD) or reactive attachment disorder. Ongoing research has helped us to make major strides in explaining how the body reacts to trauma and how brain function changes after the experience of a traumatic event. Gone are the days of referring to someone as “shellshocked.”

Now we also recognize that trauma isn’t necessarily the result of a one-time, catastrophic event. Instead, trauma can be cumulative, and mental health professionals have even established labels such as Type I and Type II trauma to help clarify the distinction between catastrophic and ongoing exposures.

However, in a race to count symptoms and assign diagnoses, we may forget that trauma is best defined by the client’s experience. That is, if the client believes that he or she has experienced a traumatic event, then the reality is that the client has experienced a traumatic event.

A larger question may be, what has all of the attention on trauma done to the counseling profession? Rooted in a wellness model that focuses on holism, the profession of counseling attempts to set itself apart from its counterparts in psychology and psychiatry. The notion of professional counseling was, and hopefully still is, to focus on a client’s strengths as a pathway to mental health. Although understanding symptoms and diagnoses is increasingly important in the world of managed care, a diagnosis born of a set of symptoms does not necessarily drive the most effective treatment strategies.

Yet the focus on client strength has become less important in our daily work. When we conduct an intake for a client who has experienced a trauma, what do we look for? It’s common practice to focus on the client’s symptoms and daily struggles, but not as common to delve into the positives the client brings to therapy. The words we use and the questions we ask send critical messages to our clients, especially those whom we are meeting for the first time.

How many pages of most intake forms are devoted to pathology as opposed to strength? When we do ask about client strengths, too often it is not so that we may later return to those strengths in our work, but rather so that we can demonstrate to someone else that we completed the brief section of the intake form that asks about them.

When a client such as Mark tells us his story, too often we immediately make conclusions about his functioning and prognosis. In an effort to avoid “retraumatizing” a client, we may intentionally sidestep important client data. Does our concern about retraumatization translate to an assumption that the client is fragile and must be handled with sympathy or even pity? It seems counterintuitive to assume that Mark is fragile after everything he has survived.

None of this discussion is to imply that trauma isn’t serious and shouldn’t be treated as such. The experiences that our clients bring to therapy are often horrific, and there is simply no other word to describe them. The wellness perspective of professional counseling is rooted in the notion that we must respect the client’s experience and should meet clients where they are. What we are suggesting here is not a “you’re fine, it’s not a big deal” approach to treating trauma. Quite the contrary, appreciating the traumatic experience of the client and empathizing are characteristics critical to successful outcomes.

However, the very forces that have shifted our professional focus toward pathology and symptomology may very well assist us when it comes to moving back to our profession’s roots. Our goal is to move away from pathology and toward solution-focused, strength-based approaches to the treatment of trauma. These approaches not only benefit our clients by respecting autonomy and resilience, but they also benefit our profession by keeping us true to our historic roots.

Salutogenesis

As we attempt to reconcile the horrors of trauma with a model based in wellness, strength and holism, we are brought to the work of medical sociologist Aaron Antonovsky. Antonovsky defined health as more than a dichotomy of sick versus well. Instead, he argued that physical health exists on a continuum, and that wellness is more than simply the absence of illness or disease.

Antonovsky sought to discover why people who are exposed to the same stressors may have very different outcomes related to physical health. Although stress is ubiquitous, Antonovsky noticed that disease is not, and he sought answers as to why that is. In the process, Antonovsky developed the term salutogenesis, which comes from the Latin salus, meaning health, and the Greek genesis, meaning origin.

If salutogenesis is the origin of health, what does this term mean for professional counselors? Simply put, as counselors, it is important for us to examine what it means to be mentally and emotionally healthy. It means that mental health is not merely the absence of mental illness, as defined by the deficient symptomology described in the DSM-5, or, worse, being defined as subsymptomatic due to having an inadequate number or severity of symptoms. Instead, salutogenesis in counseling suggests that mental health exists on a continuum between asymptomatic and diagnosable mental illness. Salutogenesis suggests that mental health is more than simply lacking a diagnosis. Instead, mental health incorporates a holistic vision of the self. It is, in fact, the essence of the counseling profession.

Furthermore, salutogenesis captures the notion that many people may be exposed to the same stressor yet experience different outcomes. Again, stress is ubiquitous, but mental illness is not. Three passengers may be riding in a car that is involved in a severe accident. All three passengers experience the same accident and may have similar physical injuries yet still experience vastly different psychological results. One passenger may experience acute PTSD, whereas another might simply have a nervous reaction when hearing the squeal of tires. The third may become a race car driver without so much as a second thought concerning the accident.

Salutogenesis examines the factors that individuals possess that help them overcome stressors such as traumatic exposures. Furthermore, salutogenesis examines why one person may define an experience as traumatic while another person does not. In this, Antonovsky’s work intersects with that of Urie Bronfenbrenner, who discussed risk and protective factors. Risk factors are those that may disrupt one’s developmental processes; protective factors are those that mitigate risks.

Bronfenbrenner described human development as a process inexorably tied to the influences of the systems in which a person functions. He described far-reaching influences, such as world politics and societal norms, and influences that are close to home, such as family dynamics and peer relationships. Because every person has a different set of systems, every person experiences the interaction between himself or herself and his or her environment in a different way. It is these differences that create our individual perceptions of events and our unique sets of risk and protective factors. As counselor clinicians, the questions become how we can use these unique experiences and characteristics to promote wellness, and how we can help our clients return to wellness should they experience a traumatic event.

A shift toward strength and growth

Antonovsky examined wellness through the notion of “sense of coherence,” which is a construct that helps us connect mental wellness to systemic influences, risk and protective factors, and individuals’ perceptions. Sense of coherence is really about meaning making. It is about the degree to which people believe they have what it takes to understand the world around them (comprehensibility) and possess the resources and skills to meet the challenges of that world (manageability), and that these challenges are worthy of the efforts to surmount them (meaning). When these three factors align from a position of strength, mental wellness is likely.

Let’s return to our example of the three individuals in the car accident. Each person experienced this event in his or her own way, and each made sense of it in a unique manner. Perhaps the person with acute PTSD was unable to manage the stress presented by his injuries or the emotionality of the accident. Maybe another passenger ruminated on concerns that such an accident could happen again and worried that she wouldn’t be able to handle it happening again.

There are no clear answers, but what is evident is that the passengers who experienced ongoing stress reactions were not able to make sense of the event or find the resources within to meet the significant challenges of the experience. These passengers experienced a diminished sense of coherence. But one of the great things about human beings is that we are continually experiencing growth and change. The circumstance of a lack of diminished sense of coherence isn’t necessarily permanent.

As we look at our work with people who have experienced trauma, like the people in the car accident, we can use a focus on sense of coherence to promote a return to wellness. Helping clients gain an understanding of their experiences and assisting them in finding their inherent strengths shifts our work as counselors into a salutogenic approach. We can validate the trauma while putting the experience in a context that allows clients to see their own potential. We can nudge them toward creating an inner narrative that places them in a position of strength and power over their experience. We can focus on changing the “why me?” to “why not me?” We can help clients look at the protective factors and unique strengths they possess that have helped them survive thus far. Because on whatever level, if they are in your office, they have been surviving. When clients can find those strengths, we can help them move beyond surviving to thriving.

Humans are resilient by nature. When we look at the statistics regarding how many of us will experience a traumatic event, the numbers are pretty grim. Using a broad definition of trauma — one that validates that trauma is in the eye of the beholder — nearly all of us are likely to have some traumatic exposure. Yet those who suffer from acute stress reactions as a result of such exposure are generally believed to be less than 20 percent. In other words, recovery and resilience are normative. In fact, a growing body of work is focused on the experience of growth after and as a result of traumatic experiences.

In their work, Richard Tedeschi and Lawrence Calhoun have been exploring the ways in which people grow from negative experiences. We are all likely familiar with someone who has grown from a negative event. Maybe a loved one survived a potentially terminal illness that created in them a mentality of “life is short; carpe diem!” Perhaps an accident promoted awareness that life is fragile and that the most important things are relationships with loved ones.

Tedeschi and Calhoun identified five domains in which such posttraumatic growth is likely to occur:

1) Changes in the perception of the importance of relationships

2) Increases in spirituality

3) An increased sense of self and personal strength

4) A broadening of the sense of possibilities for one’s life

5) Increased appreciation for life

As we look at meaning making, sense of coherence and systemic interactions, it makes sense that these areas would emerge. If we can approach our clients from a salutogenic perspective, we may even be able to promote such growth.

Putting it into practice

So, what does all of this look like when we are working with clients? Again, this should not be confused with a Pollyanna view that everything is great. It is not a dismissal of the negative symptomology or the suffering that a client may be experiencing. Instead it is the process of leaning in to find the client’s strengths that are present even in the midst of despair.

The thing is, clients may not have the slightest inkling that they have any strength left. They may believe that this experience has taken everything from them. It is our job as counselors to find even the tiniest spark of ability and fan that flame until it burns bright enough for them to see it. We explore from a strength-based approach. We ask strength-based questions such as “What was working before? What is going well? What resources do you have? What if a miracle happened? What gives you meaning?” Clients may not have answers in that moment, but we can help them to find answers.

We personally love the question, “What do you ‘groove’ on?” We ask clients what is present in their lives that makes them smile, gives them a lift and helps them find peace, even if those things come in the smallest of measures. We can use that information to connect clients to other strengths upon which they can build, much like stacking blocks. We can promote a feeling in our clients that they are the experts on themselves, and they can help us to promote their positive change. We can empower our clients to believe that they are capable of coping. We can help them draw on both their inner reserves and the external resources that they might be having difficulty accessing.

We aren’t suggesting that a salutogenic approach is easy, nor is it a panacea for all people in all circumstances. As professionals, we know that we must meet our clients where they are. Validation of a client’s experience and careful interventions are always important. Some clients may have a hard time identifying any strengths. They may be so wounded that it would make such an approach a hard sell. What we must do as clinicians is be patient, empathize and continue to provide strength-focused reframes whenever possible. This dance requires sensitivity on the part of practitioners. With a focus on clients’ current needs and an eye toward positive coping, we can help our clients to move forward in their journeys.

We would be remiss if we didn’t discuss the fact that we share the journeys of our clients in very real ways. Any clinician who has worked with these issues has been warned of the dangers of vicarious trauma — the potential that, as clinicians, we can experience disturbance as a result of just listening to the experiences of our clients. The result of such exposure can be as mild as thinking too much about a client or as severe as full-blown PTSD symptoms.

But there is an upside. If we can be disturbed by our clients’ disturbance, then we can also grow from watching our clients grow. Vicarious posttraumatic growth is a burgeoning area of study that suggests we can experience the same kind of fundamental shifts in positive thinking that our clients may undergo just by watching them do it. What a great side effect of a salutogenic approach to our work.

It seems that every day there are terrible, traumatic things reported in the news. There are mass shootings, natural disasters, horrific accidents and incidents of community violence. It seems that each day creates a new Mark. If we were to focus on the pathology of Mark’s experience and the bad in the world, he — and we — may never choose to venture out again.

Mark didn’t choose that path, however. He eventually chose to be a phoenix. He decided to rise up from the ashes of his own experience. It wasn’t an easy process. A great deal of emotional pain was involved. He had to let go of a significant amount of anger and blame. He had to come to understand that all of his experiences, all of his suffering, all of his trauma, did not define him. Mark came to know that all of those things made him tough. They made him compassionate toward others. They made him a survivor who had the skills to fly as high as he wanted to go. Mark chose flight. Watching him fly was beautiful.

 

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

Debra G. Hyatt-Burkhart is an assistant professor in the counselor education program at Duquesne University in Pittsburgh. With more than 25 years as a practicing clinician, her work focuses on positive approaches to clinical supervision and treating trauma. Contact her at hyattburkhartd@duq.edu.

Eric W. Owens is an assistant professor and graduate program coordinator at West Chester University of Pennsylvania. He has worked in higher education, K-12 and clinical settings for 20 years. His work focuses on strength-based approaches to trauma treatment and crisis intervention. Contact him at eowens@wcupa.edu.

Letters to the editor: ct@counseling.org

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