In 1995, the Centers for Disease Control and Prevention and Kaiser Permanente began what would become a landmark study on the health effects of adverse childhood experiences. Over the course of two years, researchers collected detailed medical information from 17,000 patients at Kaiser’s Health Appraisal Clinic in San Diego. In addition to personal and family medical history, participants were asked about childhood experiences of abuse, neglect and family dysfunction, such as emotional and physical neglect, sexual and physical abuse, exposure to violence in the household and household members who had substance abuse problems or had been in prison.
Researchers found that the presence of these negative experiences in childhood was predictive of lifelong problems with health and well-being. The more negative experiences a participant had, the more likely — and numerous — these problems became. Another disquieting finding was that adverse childhood experiences were incredibly common. Almost two-thirds of participants had endured at least one adverse childhood experience, and more than 1 in 5 respondents had endured three or more such experiences.
In the decades that followed, this discovery of the prevalence and devastating effects of trauma spurred the development of practices such as trauma-informed counseling, which stresses the importance of recognizing and treating trauma and, most importantly, preventing additional trauma.
Drawing on basic counseling skills
According to the U.S. Substance Abuse and Mental Health Services Administration, programs, organizations or systems that are trauma informed:
- Realize the widespread impact of trauma and understand potential paths for recovery
- Recognize the signs and symptoms of trauma in clients, families, staff members and others involved with the system
- Respond by fully integrating knowledge about trauma into policies, procedures and practices
- Seek to actively resist retraumatization
In many ways, trauma-informed care involves using skills that every counselor should already possess. “Remain empathic, open, nonjudgmental and steady. Steadiness is particularly important,” says American Counseling Association member Cynthia Miller, a licensed professional counselor (LPC) in Charlottesville, Virginia, whose practice specializes in trauma. “You don’t want to overreact to things a client tells you. But you don’t want to underreact either. Screen for trauma at intake. Don’t just ask a client if they’ve ever been abused or neglected. Many clients won’t define themselves as victims of abuse or neglect, and if you ask it that way, you’ll miss it. Ask behaviorally instead.”
Miller suggests using questions such as, “Has anyone ever hit, punched, slapped or kicked you? Has anyone ever put you down, called you names or made you feel worthless? Has anyone ever touched you without your permission? Have you ever witnessed a violent or upsetting event that really troubled you?”
“If a client responds with a ‘yes’ to any of those questions, ask them if they’d like to share more about it now,” Miller continues. “Help them feel in control of what they disclose and when and how much. Don’t make the mistake of thinking you need all the details and then push to get them. You can retraumatize someone that way. Instead, ask them how they think the experience impacted them and if they think it is related in any way to their current struggles.
“At the opposite end, if they respond to everything with ‘no,’ don’t assume a trauma never happened. It may very well be that they’re just not telling you about it right now because they don’t yet feel comfortable. Stay open to the possibility and rescreen as appropriate.”
When specific questions about trauma don’t elicit answers, ACA member Rebecca Pender Baum, a licensed professional clinical counselor in Kentucky who has worked with survivors of sexual assault and interpersonal violence, often asks clients if there is anything they haven’t already told her that they think she needs to know. She has found that this approach often helps clients express concerns that they have been holding back.
Jane Webber, an ACA member and LPC in New Jersey who has written extensively about trauma and disaster, often mixes less threatening questions in with questions related to trauma. For example, in the midst of gathering basic background on family history, she will ask clients about events such as accidents or a history of falling. She then works up to questions about physical and sexual abuse. Webber emphasizes the importance of counselors using the same calm, steady tone of voice for all questions to prevent distressing the client.
Webber also finds it useful to tell her clients, particularly those on the younger end of the spectrum, that they can answer her questions via text during the session. She says that sometimes clients are more open to texting about things that they might struggle to express verbally.
Webber urges counselors to be intuitive with clients and look for signs of unexpressed trauma such as sweaty palms, restless movement in sessions and failure to make eye contact.
Miller says that she stays alert “for what I think of as disordered self-soothing,” which may include “substance use, self-injury or aggression. Individually, any one of them can be a clinical indicator. As a triad, they’re almost certainly covering up an untreated trauma.”
A different focus
At first, it may seem strange to treat every client as if he or she is a trauma survivor. However, clinicians who use trauma-informed counseling say that the practice is also about changing the overall focus of counseling by moving away from the “problem” approach. That approach demands, “What’s wrong with you? What did you do wrong? What’s making you act that way?” says Webber, a lecturer in the counselor education department at Kean University’s East Campus in Hillside, New Jersey. “[Trauma-informed counseling] is a paradigm shift from what is wrong with the client to what happened to the client.”
Julaine Field, an ACA member and LPC from Colorado Springs who works with traumatized children, agrees with Webber. Field explains that rather than focusing on changing a client’s thoughts or behaviors, trauma-informed care seeks to understand how people react and adapt to experiences.
A trauma-informed counselor helps clients understand where their behavior is coming from by explaining trauma’s effects on the brain and emotional regulation, says Field, a counseling professor and coordinator of the clinical mental health track in the Department of Counseling and Human Services at the University of Colorado Colorado Springs. “[Counselors] can also help [clients] understand the real importance of basic self-care, deep breathing, good eating, exercise and that a focus on wellness on a daily basis is the best way to fight the trauma impact and arousal,” says Field, who has also counseled veterans and survivors of interpersonal violence.
A recurrent — and perhaps predominant — theme when talking about trauma-informed counseling is safety. Making the client feel safe and welcome is paramount, say trauma experts. That sense of safety starts with the environment. Counselors should make sure their offices appear warm and inviting, considering everything from comfortable seating to appropriate lighting (neither too harsh nor too dim), says Pender Baum, an assistant professor of counselor education and practicum internship coordinator at Murray State University in Kentucky.
Clients should also feel that they have some control over the counseling process. “Even if you don’t know if a client has been through trauma, you can do things as a clinician that communicate to clients that they are safe and in control of what happens in the consulting room,” says Miller, an assistant professor of counseling at South University in Richmond, Virginia, who has also worked with incarcerated women.
“Let them determine where they want to sit. Ask if they are comfortable. Give them permission to decline to answer any question they are uncomfortable with and to take breaks at any time during the intake if they start to feel uncomfortable,” she suggests. “Pay attention to body language, tone of voice and other cues of emotional distress, and respond to them. Be willing to pause during a session and encourage clients to take a breath, ground themselves or stretch.”
Both Miller and Webber stress that uncovering trauma is not an automatic green light for counselors and clients to start dissecting the past.
“Establishing safety is the most important and, often, the longest stage of treatment,” Miller says. “Don’t jump immediately into reprocessing, and don’t assume that everyone needs to reprocess. And remember that if you take away someone’s primary coping skill — however maladaptive it may be — you’re leaving them with nothing to soothe themselves when their emotions run high unless you teach them more productive skills.”
Webber spends substantial time helping clients build coping skills. She says that deep breathing is the fastest, easiest and most effective way to regulate emotion, but she cautions that there is no one-size-fits-all approach to this technique. Some people like to use counting — breathing in for three or four beats, holding the breath for another three or four beats, and then slowly breathing out, perhaps for six to eight beats.
However, some clients find it stressful to focus on counting, Webber says. In those cases, the counselor and client should just focus on breathing in and breathing out. She directs clients to inhale slowly and to exhale twice as slowly, noting that the slow exhale is what calms the nervous system and helps decrease a person’s level of physical agitation.
Another factor in breathing “style” is environment. Some people need to look at something specific such as a wall to focus on their deep breathing, whereas others prefer to close their eyes, Webber says. Counselors and clients should experiment with what works best. It can also be difficult to visualize what breathing from the diaphragm means, so counselors should practice their breathing in front of a mirror so they can better demonstrate it to clients, Webber advises. Because it is hard for people to learn when they feel overwhelmed, she also emphasizes the importance of teaching deep breathing and other grounding techniques to clients when they are calm.
Another grounding technique that Webber uses is anchoring in a safe place. Before asking a client to visualize a safe place, however, she says it is important for the counselor to know whether the client has experienced sexual or physical trauma. In those cases, “safety” for the client might mean hiding behind a locked door, which doesn’t provide a healthy, calm image.
“They may not have a happy place,” Webber says. “We might have to create a brand-new place [to visualize], such as a place with no people.” Counselors can help clients visualize their safe places by asking what environments are most comfortable for them.
Webber also uses tapping as a grounding technique. Tapping is a form of bilateral stimulation that helps clients desensitize feelings of trauma and stress. Webber leads clients through deep breathing and asks them to imagine something that is agitating but not overwhelmingly traumatic. Then, she instructs them to use their hands to tap their shoulders repeatedly, alternating between left and right. After about 40 taps, she asks clients to stop and smile.
Clients can also use tapping in public if they are feeling agitated or overwhelmed. Simple and inconspicuous techniques include tapping a foot on the ground three times, lifting a heel in and out of a shoe, or simply looking left and then right repeatedly, Webber says.
Even in the midst of teaching clients coping skills and grounding techniques, their safety is never far from Webber’s mind. To avoid retraumatizing clients, she monitors their level of distress in each session, giving them a scale on which 1 represents complete calm and 10 represents overwhelming agitation. Webber begins and ends sessions with the scale. She also pauses and does a quick check within the session if the client shows signs of agitation or arousal. If the client’s distress level is too high, Webber stops and does some grounding and deep breathing with the client.
All of the professionals interviewed for this article stressed the importance of counselors receiving supervision or working in tandem with a trauma specialist if needed. “When you start to feel in over your head, you’re probably in over your head,” Miller says. “That’s a good time to get supervision or to consult with someone who has more training and experience than you.”
However, there are basic principles of trauma-informed counseling that all counselors should know, Field says. These include:
- Psychological first aid
- Mindfulness techniques
- Breathing techniques
- Grounding strategies
- Relaxation methods
“Psychoeducation about the brain and the impact of trauma on the brain is something that all practitioners can do,” adds Field, noting that simply normalizing the effects of trauma can be enormously helpful for many clients.
Helping the helper
Another tenet of trauma-informed counseling is self-care. Immersing themselves in others’ problems and pain can take a toll on counselors, and counselors who regularly engage in trauma work face an increased risk of vicarious or secondary traumatization. According to the second edition of the APA Dictionary of Psychology, burnout can be “particularly acute in therapists or counselors doing trauma work, who feel overwhelmed by the cumulative secondary trauma of witnessing the effects.”
To continue to treat clients affected by trauma with compassion, counselors must extend some of that same consideration toward themselves. A practice of good self-care can help trauma-informed counselors to safeguard their own mental and physical health.
That is a lesson Jessica Smith, an LPC with a private practice in the Denver area, learned early in her career. “My work used to define me,” says Smith, an ACA member who specializes in addictions and trauma. “If I did a pie chart of where I found meaning in my life, three-quarters of it would have been my work as a counselor when I first started out on this professional journey, but through my burnout and recovery, I’ve learned that I am so much more than this work. I care about my clients deeply, but I also love and care about myself deeply too.
“I used to view self-care as a burden — just one more thing to do. But now I see it as an opportunity to show up more fully in my life and the lives of those around me, including my clients.”
Smith now makes self-care a regular part of her day. “I start my day with meditation, journaling and movement in the form of walking, yoga or another form of exercise. I infuse self-care throughout my day through meals, writing, music, mantras, and connections and conversations with other colleagues. I have a mantra that I say before each session, which is, ‘Help me to be a conduit or reed to transmit … messages to this person in a way that they are able to receive them. Help me to remember that I cannot fix, change or save this person and that I am only one small part of their healing journey on this earth. Give me love, give me hope and give me light.’”
The creative interventions that Smith does with clients — including movement, art, visualizations, writing and breathwork — also serve as a kind of pressure valve, she says. “I’m constantly checking in with my body during sessions, especially when I’m working with [clients who have experienced] trauma, to notice, breathe into and release any areas of tightness and tension.” Smith finds that her body reflects the tension in clients’ bodies. “[I] check in with them about their sensations, then disclose mine as well in order to help model healthy body awareness and connection.”
At the end of the day, Smith clears the office by burning sage and consciously making a decision to let go of any residual trauma or distress. When she gets home, she physically “shakes off” the day before going into the house.
“I end each day with a meditation and gratitude practice where I write down three things I am thankful for that day,” Smith says. “I stretch and do heart-opening yoga poses, then go to sleep.”
Counselors need to have self-care strategies that allow them to gain distance from their work and give them the ability to check out mentally and physically from the responsibilities of being a counselor, Pender Baum says. She has learned to literally put self-care on her calendar.
“I live by my calendar, so if it is on there, it becomes just like another required staff meeting or counseling session,” she says. “It’s not negotiable. Admittedly, I can still struggle with this one at times, [but] it’s important not to let work get in the way of your me time. Get that self-care in whenever you can. It might be closing the door for five minutes and doing some deep breathing or taking a walk around the building. Something to break up the day and get you away from your office.”
It’s also important to engage in activities that don’t have a timeline or deadline and, most importantly, that are fun, Pender Baum says. “I like to kayak, watch movies with my husband [and] read to my daughter. Others might like going for a run, reading their own book [or] soaking in a bubble bath.”
Another self-care strategy that Pender Baum emphasizes for counselors is to avoid isolation. “Developing connections sometimes can involve seeking out professional development opportunities. This helps to keep you connected to the profession, learn new skills and be around other professional counselors without hearing the traumatizing stories from clients.
“For example, just this summer, my mother — a fellow counselor educator and counselor — and I attended a training on finding meaning with mandalas. We not only learned a fantastic clinical skill, but it was very therapeutic [for us] at the same time.”
Pender Baum also stresses the importance of peer support and supervision. “It’s … important to debrief after particularly difficult cases,” she says. “Have that peer support group, supervisor [or] consultant on hand that you can engage with. Have a mentor or be a mentor to someone.”
Smith participates in two therapist support groups that meet once a month. “Since I’m in private practice, isolation can be a risk, so I do these groups as well as go to lunch or coffee with at least one friend or colleague in the field each week,” she says. “I take time off each month and no longer feel guilty about doing so as I did early on in my career. I try to do a training or workshop quarterly for self-care, connection and to nurture my inner student.”
Pender Baum says counselors need to know themselves. “Give yourself permission to experience the emotions, but also set clear boundaries,” she says. “Know your limits, avoid overtime, commit to a schedule, and recognize and change negative coping skills.”
All counselors should also be aware of the signs and symptoms of vicarious trauma, Pender Baum stresses.
“Vicarious trauma can change one’s spirituality, and this can impact the way we see the world and how we make sense out of it,” she says. “Some counselors experience difficulty talking about their feelings, anger or irritation, an increased startle response and difficulty sleeping. Others might experience over- or undereating, an ever-present worry that they are not doing enough for their clients [or] possibly even dreaming about clients’ traumatic experiences. Still others might feel trapped in their jobs, lose interest in things they typically enjoy and even [experience] a loss of satisfaction and accomplishment. Some experience intrusive thoughts related to client stories and feeling hopeless.” These are all signs that counselors need to step back and focus on self-care, she says.
Other symptoms include:
- Chronic lateness or absence from work
- Low motivation and an increase in errors at work
- Avoidance of responsibilities
- Conflict at work and in personal relationships
- Low self-image
Pender Baum also urges practitioners to listen to their peers, family members, friends and loved ones if they say they are noticing a change in them. Counselors may be unaware that they are showing signs of burnout, and feedback from others can be helpful in preventing a crash from overwork and stress.
To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association:
Counseling Today (ct.counseling.org)
- “Coming to grips with childhood adversity” by Oliver J. Morgan
- “The toll of childhood trauma” by Laurie Meyers
- “Traumatology: A widespread and growing need” by Bethany Bray
- “The transformative power of trauma” by Jonathan Rollins
- “A counselor’s journey back from burnout” by Jessica Smith
- “Stumbling blocks to counselor self-care” by Laurie Meyers
- Terrorism, Trauma and Tragedies: A Counselor’s Guide to Preparing and Responding, third edition, edited by Jane Webber & J. Barry Mascari (fourth edition being published in 2018)
- “ABCs of trauma” with A. Stephen Lenz
- “Children and trauma” with Kimberly N. Frazier
- “Counseling students who have experienced trauma: Practical recommendations at the elementary, secondary and college levels” with Richard Joseph Behun
- “Traumatic stress and marginalized groups” with Cirecie A. West-Olatunji
ACA interest networks
- Traumatology Interest Network (counseling.org/aca-community/aca-groups/interest-networks)
Laurie Meyers is the senior writer for Counseling Today. Contact her at email@example.com.
Letters to the editor: firstname.lastname@example.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.