Monthly Archives: February 2019

The messy reality of perfectionism

By Lindsey Phillips February 26, 2019

Philip Gnilka, an associate professor of counseling and the coordinator of the counselor education doctoral program at Virginia Commonwealth University (VCU), has heard of severe cases of perfectionism at college counseling centers in which a student refuses to submit any work out of fear of being evaluated. As long as the student does not turn in work, his or her sense of self remains intact, he explains.

This raises a question: Is perfectionism a bad thing? Within the mental health professions, healthy debate is taking place on this very topic. Some therapists view all forms of perfectionism — whether self-oriented, others-oriented or socially prescribed — as negative, whereas others believe there is an adaptive component to perfectionism.

Gnilka, a licensed professional counselor (LPC) and the director of the Personality, Stress and Coping Lab at VCU, is in the latter camp. He notes that, historically, perfectionism has been considered a negative quality, so the goal was to reduce clients’ perfectionistic tendencies to make them “better.” However, he says, this black-and-white thinking — a quality of perfectionism itself — does not fully capture perfectionism.

Instead, Gnilka, a member of the American Counseling Association, argues that perfectionism is a multidimensional construct that consists of perfectionistic strivings (i.e., Do you hold high personal expectations for yourself and others?) and perfectionistic concerns, or one’s internal critic, (i.e., If you don’t meet these standards, how self-critical are you?). He says these two dimensions can help counselors determine who they are working with: an individual with adaptive, or healthy, perfectionism (someone with high standards but low self-criticism) or an individual with maladaptive, or unhealthy, perfectionism (someone with high standards and high self-criticism).

In his research, Gnilka has found that one’s perfectionistic concerns, not one’s strivings, are what correlate with negative mental health aspects. “What’s really correlating with depression, stress and negative life satisfaction is this self-critical perfectionism dimension. It’s not holding high standards itself per se,” he explains.

In fact, Gnilka argues that lowering clients’ perfectionist standards or instructing them to do things less perfectly is the wrong approach. Anecdotally, he’s found suggesting that clients lower their standards is a nonstarter and often doesn’t work. Instead, Gnilka advises counselors to focus their interventions on the self-critical voice. “Focusing on that internal critic … is where you’re going to get your most malleability because that’s the one [dimension] that’s connected with all the [negative aspects of mental health],” he says.

Healthy striving

Beth Fier, the clinical director of SEED Services: Partners for Counseling and Wellness in New Jersey, finds perfectionism to be problematic. “It’s rigid and it’s interfering in some way, and it’s pretty unforgiving in terms of its high standards so that it actually is creating difficulty either for [people] and their experience of themselves or maybe in their relationship to others or how they’re interacting in the world.” However, she also acknowledges that many people want to be high achieving.

Because perfectionism can be limiting with its focus on being “perfect,” Fier, an LPC and an ACA member, likes the concept of excellentism. As an excellentist, people still want to do their best, but the term allows them to think more flexibly about how to do that, she explains. The focus is more on the process, which allows people to appreciate and enjoy the effort, the learning curve and their growth along the way. Perfectionism becomes problematic when people focus solely on the outcomes — on if they meet a certain goal, Fier adds.

Emily Kircher-Morris, the clinical director and counselor at Unlimited Potential Counseling and Education Center in Missouri, offers a similar perspective. Rather than using the term adaptive perfectionism, she prefers the phrase striving for excellence. Perfectionism, she explains, often implies there is no room for error, which becomes self-defeating. “All of these [perfectionistic] characteristics can be strengths,” she notes. “It’s when they go too far that they start causing disruptions to our lives.”

Despite their differences in terminology or mindset about perfectionism, Gnilka, Fier and Kircher-Morris all agree on the importance of healthy strivings and the need to intervene on the critical voice.

Kircher-Morris does this in part by having clients create realistic reframes, which is a way of changing a negative thought into something more optimistic. Counselors can draw thought bubbles and ask clients to fill in one of the bubbles with the negative thought and the other bubble with a realistic reframe. For example, the negative thought “I got an answer wrong when the teacher called on me. Now everyone thinks I’m dumb” could be rewritten as “I am allowed to make mistakes just like everyone else.” This exercise helps clients figure out a way forward without ignoring the uncomfortable emotions, Kircher-Morris adds.

However, too much reframing may cause clients to feel like counselors are imposing a “right” way to think about the situation, says Kircher-Morris, an LPC and a member of ACA. She finds that using dialectical thinking to look at and validate both sides is empowering for clients. For example, one technique she finds helpful is moving clients from either/or statements to both/and statements such as “I’m doing the best I can and I know I can also do better” and “This is going to be really hard and I know I can get through this situation.” By shifting their thinking, clients realize that two opposite statements can both be true; they are not necessarily exclusive to each other, she explains.

Much of Fier’s work involves softening the critical voice. She often poses the following scenario to her clients to illustrate the potential danger of this voice: “Imagine you are put in charge of selecting a child’s kindergarten teacher. Would you want a teacher who is strict and will tell the children they are horrible as a means of motivating them to learn and grow? Would you want a teacher who lets children do whatever they want and not worry about the quality of their work? Or would you want a teacher who has high expectations but works with and supports children to help them figure out opportunities for growth and learning?”

Although the answer seems obvious in that context, it is often difficult for people to apply that same balance of high expectations and support to themselves, Fier says.

Valuing progress, not outcomes

It is common for people who possess perfectionistic tendencies to assume they can achieve something quickly and easily, Fier points out. That’s why breaking down activities into smaller step-by-step pieces that clients can build on is important, she says. This process provides opportunities for positive reinforcement; allows clients flexibility in achieving their overarching aim; and allows clients to focus on what they have accomplished rather than on the ultimate outcome, she explains. 

Fier, the past president of the New Jersey Association for Multicultural Counseling, redirects clients from working toward goals to working toward values and aims, which allows them greater flexibility in how they address the situation. This includes asking clients the reasons they set a particular goal and why that goal matters. Shifting the focus to values and aims helps clients feel good about what they accomplish rather than beating themselves up for what they fall short of achieving, she adds.

Fier recently worked with a client who had a goal of balancing care for her mental and physical self. The client focused on outcome-based goals of diet, exercise and weight loss. By focusing on the outcome, she would berate herself whenever she didn’t make it to the gym. Fier helped the client broaden her perspective on how to achieve her aim or value of having a healthy lifestyle, which can include exercising, eating well, getting adequate sleep and pursuing good mental health.

“Some days that might be going to the gym. Some days that might be taking a quick walk outside because [she has] all of these other competing priorities,” Fier says. “It’s that intention and motivation that keeps [the client] focused on the care piece as opposed to the ‘I didn’t make it’ piece — ‘I screwed up and did it again.’”

Kircher-Morris also warns counselors to watch out for “goal vaulting.” This is when people set a goal and, as they close in on reaching that goal, they instead raise the bar. In the process, she explains, they forget about all the steps they completed to get to that point, which makes them feel like they aren’t making progress or haven’t accomplished anything.

One technique Kircher-Morris uses to address this counterproductive thinking is to have clients write down the steps they have accomplished to reach a certain goal on a graphic organizer, such as a visual symbol of stairsteps or a ladder reaching an end goal.

Kircher-Morris worked with a gymnast who was frustrated because she couldn’t seem to master a back handspring. Kircher-Morris helped the client break down all the skills she had accomplished in pursuit of that goal, such as learning how to do a cartwheel and roundoff. “You have to recognize those successes along the way because, otherwise, you’ll always feel like you’re falling short,” Kircher-Morris says. “A lot of times it’s easier to work backward — starting with the end goal but then thinking back to what were all of the things you had to do to get to that point. That, sometimes, is a little bit easier to conceptualize.”

Understriving

Most people equate perfectionism with overstriving and overachieving. But this isn’t always the case. Perfectionism manifests in different ways, Kircher-Morris points out.

“When clients come in … I hear anxiety, I hear stress [and] I hear being overwhelmed,” she says. “When we get into what is causing that level of distress, I find that it’s often coming from a place of perfectionism, whether that’s manifesting as procrastination or risk avoidance or just really trying to control situations.”

Avoidance, Gnilka says, “seems to be a big coping difference between adaptive perfectionists and maladaptive perfectionists. They use the same amount of task-based coping and emotion-based coping, but the avoidance-based coping seems to be very, very high for maladaptive perfectionists compared to an adaptive one.” Thus, counselors might ask clients why they are avoiding certain things and what they are afraid of, he says.

Kircher-Morris agrees that counselors should help clients understand what they are avoiding. People often assume that avoidance is based on a fear of failure, but what they don’t realize is that avoidance can also result from a fear of success, she argues. For example, imagine a student who avoids going to medical school based on a fear of doing well at school only to discover that he or she hates being a doctor and is unhappy.

“They fear the success that then might lead to something negative in the future,” Kircher-Morris explains. “It’s not something you would typically think of when you’re thinking of perfectionism, but it can have a negative outcome in the future and lead to procrastination or avoidance of decision-making.”

The challenges children and parents face

Socially prescribed perfectionism extends beyond the microcosm of the nuclear family, Kircher-Morris says. Thanks in part to the influence of social media, children and parents alike often start to think that others have a “perfect” life and then feel the pressure to measure up to that impossible standard.

Kircher-Morris recalls a client who chose a college degree program based on the respect he thought it would garner from others rather than based on his own interests. The client had struggled in high school, so he wanted to prove to others that he was capable.

To offset these societal pressures, counselors can help clients become aware of their own personal goals and ways to measure success for themselves, Kircher-Morris suggests. This might include guiding clients to figure out what is at the root of their motivation to get into a particular school or to achieve a certain ACT score, she says.

Kircher-Morris has also noticed a connection between perfectionism and people who are gifted or of high ability. “Part of the reason why you see [perfectionism] so commonly with people who are gifted and … with talented athletes is because things come so naturally to them, so then they don’t know how to handle it when something is difficult,” she says. People who are gifted are often told that they are smart, so they internalize this quality as a part of their identity, she continues. Then, when they face something difficult or challenging, they don’t know how to handle it because it doesn’t fit with who they think they are.

Kircher-Morris builds on these clients’ strengths by using analogies about times in the past when they got through something difficult or handled a situation differently. Then she points out how they could apply those same skills to their current situation. Counselors might also encourage clients to find their own comparisons, which facilitates independence, she adds.

Many parents also feel the pressure to be perfect. Seeing other people’s children getting accepted to elite schools or competitive athletic teams (things that often get trumpeted on social media posts) can cause parents to worry about not being good enough, Kircher-Morris points out. “When they see their child fail, it feels like a reflection on them,” she says. Or there’s the “fear that if [they] don’t handle this correctly, it’s going to change the trajectory of [their] child’s life.”

Counselors can help parents reframe this negative line of thinking. One method is to have them consider how allowing children to make mistakes is actually a sign of good parenting because it helps children learn, grow and become independent, Kircher-Morris says. “You don’t have to be the parent who always has all of the answers and who always manages your emotions,” she reminds parents. “It’s OK to show that vulnerability and process through that.” In fact, she often advises parents to be vulnerable within the parent-child relationship. Rather than hide their vulnerability, parents can talk through their feelings and model how to handle the stress.

For example, if a parent is anxious about a phone call or a meeting, the parent can share that feeling with the child and show the child how he or she would handle the situation. “You’re teaching the kids that it’s OK not to be perfect,” Kircher-Morris says. “It’s OK to have worries and stresses, but also you can still work through them.”

Kircher-Morris also finds that parents sometimes unintentionally facilitate perfectionism in their children. For instance, when a child brings home a school assignment, parents might focus on the errors and have the child correct them. Parents might also offer praise whenever the child scores 100 percent but question the child otherwise (e.g., “What happened? Why wasn’t this a better grade?”).

Another common example is when a parent unloads the dishwasher after the child loads it because it was not done to the parent’s standards, Kircher-Morris says. This behavior undermines the child’s level of independence and feeling of self-efficacy, she explains. In constantly critiquing and correcting their children in such ways, parents are teaching them that there is no room for error and that they aren’t “good enough” unless perfection is attained, she says.

Instead, counselors can help parents learn to focus on the process, not the outcome, Kircher-Morris advises. For instance, rather than fixating on individual test grades, parents can ask, “What did you learn on this paper? What did you get out of the assignment? What was the area of struggle?”

In an episode last year on Kircher-Morris’ Mind Matters podcast (mindmatterspodcast.com), Lisa Van Gemert, an expert on perfectionism and gifted individuals, discussed how teachers and schools also inadvertently engage in behaviors that increase perfectionism in students. She cited two examples of ways the educational system isn’t set up to recognize effort, persistence and diligence. First, teachers often give out stickers to reward “perfect” work. Second, having a perfect attendance award causes some children to come to school even when they are sick just to get the award. These types of rewards set up an unreasonable standard, Gemert said

“When we focus on the outcomes — the grades — then that’s going to lead to that perfectionism,” Kircher-Morris says. “When we focus on the process and the learning, then we’re going to move away from that and really focus on that striving for excellence.”

Imperfect experiments

To ease clients’ expectations of doing things perfectly, Fier often uses the word experiment: “We’re going to experiment this week with trying this [practice] and see how it goes. … This is simply a process that we’re going to test out and troubleshoot and come back to.”

The emphasis on experimenting is also a way of modeling flexibility, Fier stresses. “It doesn’t have to be all or nothing, I succeeded or I failed,” she says. “You’ve succeeded in the process of attempting.”

Rather than asking clients who expect to do mindfulness or meditation practices “perfectly” to engage in that practice every day, Fier may ask them to experiment with practicing their soothing rhythm breathing (slowing the exhale and inhale down to a rhythmical rate) twice during the week for 30 seconds. Then, the next week she may ask them to engage in this practice for five minutes every day or every other day. Again, counselors should emphasize that they are experimenting and exploring what works for the client, she says.

Kircher-Morris also finds it helpful to frame counseling activities as experiments. She often instructs her younger clients to be “scientists” with her. She tells them that together, they will come up with a hypothesis and test it out.

She has a middle school client who was deliberately not submitting work unless it was “perfect” (i.e., a completed assignment that lived up to her standards). In this situation, Kircher-Morris and the client crafted the following hypothesis: “If I turn in a math assignment and I have missed two problems, nothing will happen.” To test this hypothesis, the client intentionally missed two problems on an assignment that wasn’t worth a lot of points. In doing this, the client realized that the world didn’t fall apart when she got an 80 (instead of a 100) on this one assignment because it didn’t affect her overall A in the class. Kircher-Morris adds that this technique is similar to prescribing the symptom or systematic desensitization (a method that gradually exposes a person to an anxiety-producing stimulus and substitutes a relaxation response for the anxious one).

As scientists, clients also collect data. Kircher-Morris asks clients to document every time that they procrastinate on an assignment, think they are going to mess up or believe they have to do something perfectly. They can track these data with a phone app, in a notebook they carry with them or on an index card placed on the corner of their desk, she says.

Counselors should avoid framing this activity so that it unintentionally becomes a reward system for clients — an assignment they can “win” or “lose,” she warns. Instead, the point of the experiment is to have clients gain awareness, establish a baseline and test whether their beliefs associated with perfectionism are based on emotions or facts, she explains.

The shame of ‘falling short’

Fier doesn’t think she has ever worked with a client with perfectionistic tendencies who wasn’t also experiencing a sense of shame. She finds that perfectionism, depression and anxiety often cluster together, and the underlying thread is “this proneness toward self-conscious emotions, particularly shame, and that tendency to then get caught in a feedback loop in the brain that leads us down this road of self-criticism.”

Because clients who have perfectionistic tendencies often mask their struggles, building rapport and a trusting and open relationship with them as counselors is crucial, Kircher-Morris emphasizes. “They know that they’re in distress. They know that they’re struggling, but they don’t want it to be perceived that they can’t handle it on their own,” she says.

Perfectionism reinforces the idea that we are not enough to reach the standards we set for ourselves — the ones that are unrelenting and too high to be achieved, Fier says. “We start to have this sense of self that is based on this global sense of failure,” she explains. “It’s not that my behavior failed or that one part of me hasn’t been able to accomplish something. It’s that I’m the failure.”

In addition, shame makes people feel like they don’t belong, so they want to hide or disappear, Fier adds. In fact, some clients experience such a sense of unworthiness — to the point of self-loathing — that they often don’t feel they deserve compassion, she says. Thus, she finds compassion-focused therapy beneficial. Some compassion-focused techniques that help to regulate the body include soothing rhythm breathing, body posture changes (e.g., making the back and shoulders upright and solid and raising one’s chin to help the body feel confident) and soothing touch (e.g., placing hands on one’s heart).

Fier will also have clients imagine a compassionate image such as a color that has a quality of warmth and caring. She has clients explore their various emotional selves, such as their anxious self or their angry self, and think about how these emotions feel and sound when they speak to the client and to each other (e.g., “What does the angry self say to the anxious self?”).

Fier acknowledges that these practices and techniques do not get rid of the self-critical thoughts or difficult emotions entirely. However, over time, clients learn to pull up a compassionate self to sit alongside the difficulty, she says. “The compassionate self is the hub of the wheel that holds all these other parts of [the individual together],” she adds.

Kircher-Morris also identifies another point of emphasis. “One of the main components of perfectionism is a discomfort with vulnerability,” she says. “So, when [counselors] can facilitate that and give permission for that vulnerability, that’s where the change happens.” She recommends that counselors look for opportunities to use appropriate self-disclosures with these clients. She believes this gives clients permission to be vulnerable and reduces the power differential between client and counselor.

Being vulnerable and compassionate takes strength, Fier points out. She helps clients redefine strength — which in the United States is often viewed in terms of competition and domination — to realize that it is about being open to care and vulnerability.

Fier has also learned an important lesson: When working with clients, she doesn’t begin discussing compassion as something warm and caring. When counselors begin a session discussing compassion as a caring aspect, some clients think this emotion is too scary or difficult for them to relate to, she explains.

Instead, Fier begins by talking about accessing courage and eventually transitions into the courage it takes to be open, vulnerable and compassionate. She finds that some clients have experiences of feeling courageous or strong, but they have a difficult time connecting to experiences in which they have offered themselves any sort of care or comfort. “So, if [counselors] can start with where the client is and build up that courage, [they] can use that to help access the vulnerability and begin to redefine the strength aspects of being vulnerable,” she says.

Living with imperfection

For some counselors, perfectionism hits close to home. Counseling is a profession in which people often feel like they need to get it “perfect,” Fier says.

Kircher-Morris suggests that counselors follow the advice they often give to clients: Make the best decision based on the information you have at the time. “Our clients give us what they can, and it’s our job to connect with them and facilitate that and help them put those pieces together,” she says. “But we’re also working with what we have at the time, whether that’s our training and our professional development … [or the client] relationship and what we know about that particular client.”

Kircher-Morris says she often looks back at herself from five years ago and sees a counselor who thought she had everything figured out and knew what she was doing. Now, she says, she
realizes she was just doing what was best in the moment.

Counselors have to remember that they will not always get it “right,” and they have to learn to tolerate imperfection, Fier says. Every morning, Fier glances at the misaligned shower shelf in her bathroom, which serves as a gentle reminder that it’s OK to live with imperfection. Counselors can guide clients to find similar reminders to help them feel less threatened by imperfection, she suggests.

Perfectionism always goes back to one central issue — the self-critical voice, Gnilka asserts. “The idea that human beings are going to be able to walk around in life and not have any self-critical talk is just not possible. It’s not that healthy perfectionists are just walking around with no self-critical piece to them. It’s just that they’re walking around with no more, or maybe slightly less, than the average person of the population,” he says. “What [counselors] are trying to do is alleviate [the critical voice] so it’s not so critically depressing and keeping people from enjoying life.”

At the end of the podcast episode on perfectionism, Kircher-Morris acknowledges that if we don’t allow ourselves to admit we have flaws, then we are setting ourselves up for disappointment. “Perfectionism is the refusal to show any vulnerability,” she says. “It’s vulnerability that allows us to be authentic, who we really are, and establish those strong relationships with those around us. Giving ourselves permission to make mistakes allows us to be perfectly imperfect.”

 

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Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist living in Northern Virginia. Contact her at consulting@lindseynphillips.com or through her website at lindseynphillips.com.

 

Letters to the editor: ct@counseling.org

 

 

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

Voice of Experience: Facing death

By Gregory K. Moffatt February 25, 2019

As soon as the sheet of metal roofing hit the back of my leg, I knew I was in trouble. Working on my timber farm, I was repairing a roof when the piece of metal slipped and slashed across my calf. I looked down, knowing what I would see.

My left leg was severed nearly in half and blood was gushing from the wound. I sat down, stripped off my sweatshirt and wrapped the fragments of my leg as tightly as I could. Even though this took only a matter of seconds, the ground beneath me was already a pool of red.

I dug my cellphone from my pocket and called 911, explaining the situation and giving my location, which was far from any main road. The operator said someone was on the way and hung up. After that, the wind through the trees and my breathing were the only sounds I could hear.

I knew it would be a while before anyone could find me so far from anywhere. Watching the flow of red soaking through my makeshift tourniquet, I wondered if I was bleeding to death and tightened it even harder.

For those first few minutes, I questioned whether I would survive. “Maybe this is it,” I thought. But it wasn’t like you might think. I was surprised at how calm and at peace I was.

At first, I thought, “I have so much I still want to do.” But, immediately, I realized a day would never pass when I didn’t think that way. Almost with a shrug, I started thinking that everyone has to die sometime, and even though I hadn’t planned on it being that day, I supposed it was as good as any other. Huh … the end. Strangely peaceful.

Sitting there for almost an hour on the cold, muddy ground, gray skies above me and misty rain beginning to fall, I was at peace. I called my wife to say goodbye, but there was no answer. So, cold as it might seem, a voice message had to do.

My life didn’t flash before my eyes and I didn’t feel any remorse, other than knowing that my family would be devastated. Despite the intense pain, I was totally lucid — no shock or dizziness. I monitored my breathing, sensed my blood pressure, checked my toes for movement and sensation, and listened to the wind, wondering if help would arrive before I expired.

As counselors, we often are faced with helping people manage life’s problems in the context of their weak and crumbling self-perceptions. One’s sense of self — or internal well-being, you might say — is the bedrock (or sand) on which the weight of life’s difficulties rest. That day, I came face to face with who I am at my core.

I love the outdoors, and if that had been my last day, it would have been OK. I would have died in a place that I love knowing I had done all I could to save myself.

The point of this story isn’t to milk readers’ emotions or to create cheap melodrama. The point is that I’m grateful to have another chance at life, but I’m equally gratified not to have found myself facing death with sadness and regrets. I’ve lived a good life, and despite my failings and imperfections, I know my existence has made a difference in people’s lives.

My work has influenced thousands of students, thousands of readers and hundreds of audiences, clients and clinicians. I think that, overall, I have left the world a better place than when I arrived in it, and maybe that is what it is all about. I’m OK with who I have become and how I have spent my days. Maybe that is as good as it gets.

I’m not sure exactly how I arrived at this place in life but, frankly, I think a lifetime of mistakes and struggles have helped me to develop resilience and comfort in my own skin. Isn’t it peculiar that the things we wish to avoid — pain, loss, difficulty — are the very things that help foster strength? This very painful event will itself make me a stronger and better person.

Obviously, I didn’t bleed to death. Beyond that, I didn’t lose my leg. Long months of recovery are still ahead of me, but I’m grateful that walking again is in my future.

Knowing our defects and failings as counselors, many of us struggle to live with ourselves, just like our clients do. I suppose what I’m hoping is that you too can find a place where you are OK with the end, no matter how many years away that might be. That strength is the firm foundation we need to manage the curveballs that life throws at us, thus making us better helpers for our clients.

I was tested by facing death, and it has shown me that I can live with myself. No “what ifs” or “if onlys.” Of all my accomplishments in life, that kind of peace may be the most significant.

 

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Gregory K. Moffatt is a veteran counselor of more than 30 years. His monthly Voice of Experience column for CT Online seeks to share theory, ethics and practice lessons learned from his diverse career, as well as inspiration for today’s counseling professionals, whether they are just starting out or have been practicing for many years. His experience includes three decades of work with children, trauma and abuse, as well as a variety of other experiences, including work with schools, businesses and law enforcement. Contact him at Greg.Moffatt@point.edu.

 

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

Touched by trauma

By Laurie Meyers February 22, 2019

Licensed professional counselor (LPC) Ryan T. Day often refers to himself as a trauma survivor turned trauma therapist. When he was 11, Day was molested several times by a family friend. He had also already endured serious bullying brought on by a temporary childhood speech impediment. Day eventually began to act out and get into trouble at school. At age 13, as punishment for this misbehavior, he was severely beaten by his father, a preacher in a Pentecostal African-American church who interpreted the saying “spare the rod, spoil the child” literally.

Once he was molested, Day says he began to feel that something was wrong — he was constantly angry and often used his fists to express that anger. Day knew he wasn’t feeling “normal,” but it didn’t occur to him that what he was feeling was tied to the molestation. He says there was simply no awareness of any kind about trauma in his community, which he describes as a rough area of Richmond, Virginia, where residents learned to ignore the sounds of gun shots and to turn away from domestic violence.

“I never knew that violence was an issue,” Day says. To him, it was just a normal part of life. Nor did Day know what sexual abuse was. Although he took a sex education class in high school, he says that sexual violence was never mentioned.

Day was also an athlete in high school, but instead of changing clothes in front of other students, he would retreat to a bathroom stall. “I felt uncomfortable around males. I didn’t trust men,” he says, adding that his feelings were not about homophobia but simply about not feeling safe. “Locker room shenanigans triggered me and made me want to fight or freak out.”

Still grappling with emotional and personal barriers as a young adult, Day earned his bachelor’s degree in information technology and then decided to become a counselor. He says his counseling program didn’t emphasize self-assessment, however, so it wasn’t until he confronted a crisis during his internship that Day finally made the trauma connection.

During this time, Day had become suicidal, in part because he realized he was married to someone he didn’t love. Day says he hadn’t learned how to establish personal connections growing up, so, as he puts it, “I married the first person to show me some affection and love.” The religious tradition in which Day was raised didn’t consider divorce an option. In addition, Day and his wife were expecting a child, so he didn’t see a way to escape the stress of his marriage.

Fortunately, one of Day’s supervisors realized that he was experiencing a crisis and referred Day to a therapist. Day was in therapy for five months before he started talking about his childhood. The therapist helped Day see how his traumatic childhood experiences had shaped him and, in some cases, held him back.

After Day earned his counselor licensure, his first few clients were adolescents who had experienced multiple traumas and were living in violent neighborhoods. Their experiences paralleled Day’s own, and he realized that his personal history with trauma gave him extra insight. And that was it — Day decided to become a trauma specialist, and he’s never looked back, including presenting an education session on complex trauma at the ACA 2018 Conference & Expo in Atlanta.

Like Day, many clients don’t initially present to counseling for trauma but rather for help handling other issues. “You have an individual coming in for treatment, coming in for depression, etc., but the further you get into [the person’s] history, there’s so much more story,” Day says, adding that it’s like unpeeling the layers of a client’s life.

Day doesn’t screen for trauma during a client’s first session — he prefers to reserve that for beginning to build the therapeutic relationship. But he does complete a screening within the first few visits, often using the Life Events Checklist from the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

Day says he also probes for trauma as he listens to clients’ stories, asking questions such as “Have you had trouble sleeping?”; “Are you having any relationship issues?”; “Have you ever been in a serious romantic relationship?”

Why the questions about relationships? Day explains that difficulty forming and maintaining personal relationships is a hallmark symptom of complex trauma, which is different from — and not as familiar to most people as — posttraumatic stress disorder (PTSD).

Complex trauma vs. PTSD

PTSD is typically considered to be the result of a single traumatic event that occurs at any point over the life span, whereas complex trauma is the result of repetitive trauma that begins early in life and endures for a prolonged period of time, explains Cynthia Miller, an LPC in Charlottesville, Virginia, whose practice specializes in trauma. Complex trauma might result from numerous occurrences of the same kind of trauma — such as ongoing physical or sexual abuse — but it can also develop from the accumulation of different kinds of trauma.

“It’s the difference between taking a single blow versus absorbing multiple blows over the course of years,” says Miller, an American Counseling Association member. “The accumulation of those blows causes a different kind of damage than what is caused by a single blow. The damage doesn’t impact just one system but multiple systems. With a single blow, I may have swelling and bruising and scarring, but that will be confined to one area. With multiple blows over time, I will have bruising and swelling in multiple places at different times and scar tissue all over.”

People with complex trauma or PTSD may experience some of the same symptoms, such as hyperarousal, disturbances in cognition, intrusive memories and avoidance of triggers, but there are critical differences between the two types of trauma. For instance, people with complex trauma have much more trouble with interpersonal relationships and their overall self-concept, Miller says. “In addition to all the usual PTSD symptoms, they will struggle with their sense of identity, with building stable relationships and with making meaning of the world and their lives,” she explains.

Miller says it is vital that counselors understand and recognize the differences between PTSD and complex trauma because misdiagnoses are common. Complex trauma is often mistaken for borderline or other personality disorders or, in some cases, diagnosed as PTSD with co-occurring mental health issues such as depression, anxiety and somatic disorders.

“People can end up with a bunch of different diagnoses which don’t really encapsulate and accurately formulate the total problem. The trauma gets lost in the various diagnoses,” Miller says.

In addition, the treatment approach for complex trauma is not the same as that for PTSD. “Treatment differs mostly in the sequence of interventions one might use, along with the length of treatment,” Miller explains. “Gold-standard interventions for PTSD typically involve the exposure and reprocessing therapies like EMDR [eye movement desensitization and reprocessing], prolonged exposure therapy, etc. Those treatments can be effective, but they can also destabilize clients, at least in the short term, and clinicians need to be really careful to ensure that clients have strong and varied coping skills in place before doing exposures.”

Although prolonged exposure therapy and EMDR are popular therapeutic methods that can be very effective, Miller believes clinicians should be more flexible in their approaches to treating trauma. “It’s great to be trained in EMDR or prolonged exposure therapy, but those approaches don’t work for every client,” she stresses. “Some clients are just dubious of them, others don’t want to do the exposure, and others just aren’t comfortable with it. [Also,] people don’t necessarily need to process the trauma in order to get better. I’ve had clients come into my practice who have stopped seeing other therapists because the therapist was too wedded to a particular approach and, when the client expressed discomfort with it, the therapist either couldn’t or wouldn’t adapt. You have to be able to tailor treatment to the client, not tailor the client to the treatment.”

Miller routinely uses cognitive behavior therapy (CBT) and psychoeducation to help clients understand what is going on with them, how trauma has impacted their life and what can be done about it. “This, in and of itself, is really helpful for clients,” she says. “They often believe that they are deficient in some way and have caused all their problems. Once I explain what [complex trauma] is and how it affects people, they really start to understand themselves better and feel less shame.”

Miller recommends workbooks such as Life After Trauma: A Workbook for Healing by Dena Rosenbloom, Mary Beth Williams and Barbara E. Watkins and Seeking Safety: A Treatment Manual for PTSD and Substance Abuse by Lisa M. Najavits. The workbooks “have great psychoeducational handouts and readings for clients that provide education on how trauma affects the body and the brain,” she says. “I typically use the first few sessions of therapy to go over the handouts and help clients notice ways in which what is described applies to them and does not apply to them.”

Regardless of the methods clinicians choose, the initial stage of any therapeutic intervention for complex trauma should focus solely on client safety, helping them remain in the present and build their coping skills, Miller says. She adds that this is usually the longest phase of treatment.

To help clients learn how to stop symptoms such as flashbacks and dissociation, Miller teaches grounding skills. “Groundings skills involve different ways of trying to get the brain’s attention, helping it focus on what is literally happening in the moment instead of focusing on a memory from the past or checking out entirely,” she explains. “Grounding skills can involve techniques that use the five senses or techniques that attempt to engage the cognitive portion of the brain.”

Exercises that involve the senses include tasks such as asking clients to feel their feet on the ground, inhaling a relaxing scent such as lavender or running cold water over their hands. “We [also] might teach them how to describe everything they are seeing around them in detail, as if they were trying to paint the picture of a room with their words,” Miller continues. “One of my favorite grounding skills for using in emergencies is holding an ice cube in the palm of your hand or against your cheek. The sensation of cold, and then nonharmful pain, tends to get the brain’s attention fairly quickly and help someone reorient.

“Cognitive grounding skills can include things like reciting the ABCs backward, or naming every state in alphabetical order or [naming] every make of a car that one can remember. These skills try to engage the frontal cortex, which tends to go offline when someone is having flashbacks or dissociating.”

Miller also helps clients reframe their cognitions, making them aware that their past is not continually playing itself out in their present. “We help them notice how today is just today,” she says. “For example, clients often have difficulty with the anniversaries of traumas that have happened to them. They get anticipatory anxiety and, as the date approaches, they will fall apart. We work in therapy to help them notice ways in which the upcoming date is different from the date of their trauma. The year is different, their age is different, the people around them are different, their life circumstance is different, etc. It’s helping them be fully in their present and in the reality of that instead of in their past.”

Counselors also need to be mindful of the accumulative physical toll of long-term trauma, Miller adds. Research has shown that experiencing trauma — especially when it is prolonged and repetitive — rewires the nervous system in ways that cause hyperarousal and persistent anxiety. This continuous stress causes the body to release cortisol, which can cause chronic inflammation. Over time, the inflammation leads to negative health effects. To help counteract this cascade of neurological and physical damage, practitioners can teach clients skills for calming their nervous systems, Miller says. Again, counselors should tailor the treatment to the individual client. Some clients may find yoga or meditation helpful, whereas others might benefit more from neurofeedback.

Triggers and trauma responses

Debbie Sturm, an LPC in Virginia and South Carolina, has extensive experience working with trauma survivors. Currently an associate professor and director of counseling programs at James Madison University in Harrisonburg, Virginia, at one point Sturm counseled clients through the state of South Carolina’s crime victims support service, which allows people who have experienced a crime to receive 20 state-funded counseling sessions.

Sturm’s clients had experienced a range of terrifying incidents. Among others, she worked with a bouncer who had been shot at work, a woman who had been stabbed and left for dead by someone trying to steal the cash from her paycheck, people who had witnessed a homicide and a client who had been held captive by an abusive family member. Some of her clients also lived in violent neighborhoods or had histories of adverse childhood experiences. “[All] of my clients, however, were just regular people going about their daily lives [who had] experienced something awful,” says Sturm, a member of ACA.

Most of the people Sturm counseled didn’t necessarily meet all the criteria for PTSD, but they all presented with numerous trauma symptoms. The core issue for these clients was that the distress of what had happened, combined with how unfamiliar, uncomfortable and often frightening these new symptoms were for them, caused them significant difficulties. Typical symptoms included anxiety, fear, hypervigilance, sleep and eating disturbances, a compromised sense of safety and, sometimes, anger, resentment, blame or self-blame, shame and helplessness.

“For those who experienced violence, the shock of the violence and the damage to [their] personal sense of safety, control or power could be profound,” Sturm says. However, the intensity of the trauma response did not necessarily line up in the expected way, Sturm continues.

Many people assume that the most “serious” or violent events are more traumatic than a less dramatic experience, but that is often not the case, she says. A person’s trauma response is always unique to the individual and the circumstances surrounding his or her traumatic experience. “It’s really important for the clinician to hold that belief and really honor whatever response each individual is having,” Sturm emphasizes.

The treatment path that Sturm followed with each client revolved around how that person was experiencing his or her symptoms. Sturm says that identifying clients’ triggers played an important role in their recovery. She did that in part by asking: “When do you feel like things are at their worst? What is happening around you? What do you do for comfort or reassurance? As you feel that sense of fear or hypervigilance welling up, how can you start to recognize it sooner and listen to what it’s telling you?”

“Helping people really recognize when their [sense of] fear and lack of safety is starting to elevate can also help them get out of a situation or connect to something or someone safe sooner,” she explains.

Interestingly, the triggers were not always tied directly to the client’s trauma. For example, one client who had been sexually assaulted at work would “lose time” whenever she saw a white truck. The vehicles had no connection to her assault, but for whatever reason, they triggered her, Sturm recounts. But for other clients, the triggers were connected to their previous traumas.

The search for what triggered trauma symptoms provided some therapeutic benefit in and of itself, Sturm says. The clients’ “discoveries” also allowed Sturm to suggest strategies for responding to their fears. For example, the client who feared white trucks connected a sense of safety to her mother, so Sturm suggested that when she was driving and spotted a white truck, that she pull over and call her mom.

Employing such strategies helped Sturm’s clients increase their sense of efficacy, power and control because they were no longer passive captives to their symptoms. Instead, they were armed with strategies that brought comfort and helped dispel their fear.

A person’s traumatic response is typically adaptive and can even be protective, Sturm says. “For example, consider hypervigilance. If something horrible has happened and your sense of safety is shattered, the most adaptive and protective thing you could do psychologically is to be on alert. After all, the world is now proven to be quite unsafe. So, be alert!”

At the same time, the state of alertness involved in hypervigilance is very uncomfortable, can be frightening and takes a toll on trauma survivors psychologically, neurologically and biologically, Sturm says.

Traumatic environments

In some cases, a certain place is the trigger for the person’s trauma response because it isn’t safe and will never become safe, Sturm says. Part of trauma therapy might involve talking with clients about the possibility of removing themselves from that environment. Unfortunately, leaving isn’t always an option.

ACA member Leah Polk, a licensed master social worker with Change Incorporated in St. Louis, asserts that trauma can never be treated separately from the environment in which it occurred. While some survivors of traumatic events go on to reestablish safety in their lives, others must continue living in places that are directly linked to their traumas or in environments that are violent or dangerous, such as unsafe neighborhoods, war zones or violent homes. Ultimately, practitioners must accept that they cannot prevent clients from experiencing or reexperiencing traumatic events, stresses Polk, whose specialties include helping clients recover from trauma.

However, to help clients cope, counselors can support the survival skills that these clients have while distinguishing the times and places in which those skills are useful or necessary, Polk explains. “For example, perhaps it’s crucial to be vigilant while walking home alone at night from the bus stop, but that same vigilance is not required at one’s place of work or a doctor’s office,” she explains.

Practitioners can also provide clients a safe place to express the emotions tied to the burden of living in an unsafe environment, Polk says. Clients can express the sadness and frustration of not having their needs met, the pain and anger caused by social and economic oppression, and the fear that comes from living in an unpredictable and chaotic environment.

Polk says counselors can become a safety resource for clients wrestling with trauma by modeling a consistent and predictable relationship within a contained environment. “Often … clients’ trauma is founded by a violation of trust, confidence or safety from what should have been a trusted figure in their lives,” she explains. “Without establishing an explicit alliance within the [therapeutic] relationship, much of this work is nearly impossible.”

Polk also works with clients to identify other sources of support in their lives, such as caring relationships or enjoyable hobbies and interests. To help regulate emotional arousal, she teaches clients relaxation techniques such as brief meditation, deep breathing, body scanning (to identify where in their bodies they might be holding tension) and progressive muscle relaxation.

Miller has also worked with clients who could not escape traumatic environments. “I would have loved to send my clients in prison to entirely different communities and home environments when they finished their sentences,” acknowledges Miller, who has previously worked with female inmates at correctional facilities. “It would have helped a lot, but it’s just not possible. So, what do you do when [clients] have to go back to the same environment?

“It’s not a great solution, but I think part of what you can do is help clients learn how to take control of what they can in an environment that feels uncontrollable. You can help them learn to set better boundaries around how they will allow themselves to be treated. You can teach them skills for asking for help when they need it. You can link them with supportive resources. You can also help them focus on their strengths and resiliencies and learn how to calm their system when there’s chaos all around them. Any little bit of control someone can feel is better than feeling no control at all.”

For many clients who have been through complex trauma, especially those who have been physically or sexually abused, the idea that they can have any say over how people treat them is a new concept, Miller says. “They are very used to being controlled by others and being told who they can and can’t talk to, what they can say and what they can’t, where they can go and where they can’t, even down to what they can eat or wear. They are also told that they must do whatever people want them to do. So, helping them set boundaries begins with helping them see themselves as people who have rights and who don’t have to tolerate any and everything.”

When counseling these clients, Miller says, “we work on building self-esteem and teaching assertiveness skills. Just helping them learn how to say ‘no’ can take time. We practice it in session through role-plays. We also focus on helping them learn ways to keep themselves safe when saying no to someone who might not take kindly to it. This can include having them take a personal safety class or a self-defense class that is geared specifically toward [assault] survivors. It can also include talking through how to determine how much risk is involved in a given situation.”

Body guards

When it comes to cases involving sexual trauma, the person’s own body can feel like the “unsafe environment.” Therefore, feeling safe in one’s own body constitutes the core of work with these survivors, says Laura Morse, an LPC and a sex and relationship therapist in Lancaster, Pennsylvania, who specializes in helping clients recover from trauma.

Morse starts by providing psychoeducation about the fight-or-flight response to trauma. This step helps normalize the symptoms that her clients are experiencing. Morse also teaches clients how to self-soothe and ground themselves. She pairs mindfulness and deep-breathing techniques with tapping, using either EMDR or self-tapping. During the tapping work, Morse has clients practice deep breathing accompanied by a calming scent, which gives them a method to ground themselves and self-soothe wherever they are.

Polk notes that clients with a history of complex trauma may never have possessed a sense of confidence or autonomy about their bodies. She uses mindfulness-based stress reduction exercises to help clients integrate the mind and body. This might include a guided meditation in which the client’s anchor of awareness is an upward scanning of the body, from toes to head. During the exercise, the client may notice that certain areas within the body elicit specific emotions or sensations.

“Once the client is discovering feeling in these areas, the client may offer compassionate thoughts or phrases to the impacted areas,” Polk says. “The client may also be encouraged to continue compassionate exercises such as offering gratitude for the ways in which their body has helped them survive trauma.”

Clients can also explore nonsexual touch, such as different temperatures (a cold compress versus a warm bath) or textures (a soft brush versus a silk ribbon) and journal about their experiences, says Polk, who is also seeking certification as a sex therapist.

“If the client wants to move toward reclaiming their sexuality, it may be important to discuss their sexual self-perception and relationship with themselves,” she says. “Are they able to achieve pleasure through masturbation? If not, what seems to get in the way? If certain touches are uncomfortable or triggering, the client’s sense of choice must be paramount — they can choose to try something different or set a limit around specific experiences.

“For example, while caressing and external stimulation may be pleasurable, penetration leaves the client feeling overwhelmed and tearful. Therefore, the counselor would encourage the client to observe their thoughts and feelings about their self-exploratory experience and determine what feels right for them in that moment. The sense of agency that comes with integrating the mind and body, along with rediscovering self-pleasure, can be a life-changing concept for survivors of chronic sexual trauma. Therefore, the counselor must give plenty of patience and space for these experiences.”

Sexual assault survivors also frequently experience problems with sexual intimacy. Says Morse, “I use the dual-control model for sexual intimacy to empower survivors to understand the ‘brakes’ that are keeping them safe [but] may be preventing them from enjoying experiences that they used to in the past. And then we begin to learn ‘accelerators’ of what is helpful.”

Brakes are sexual-inhibition factors such as a history of trauma, body image issues, relationship conflict, unwanted pregnancy, depression, anxiety or, as Morse puts it, “everything you see, hear, touch, taste, smell or imagine that could be a threat.”

Accelerators are sexual-excitation factors such as a partner’s smell or appearance, a sense of novelty, new love or “everything you see, hear, touch [or] smell that is a turn-on,” Morse says.

Morse also helps clients who are in relationships to create sexual scripts with their partners. “When creating a sexual script with a couple, I will do the exercise both with the couple [and] individually,” she says. “I ask the couple, with their permission, if we can create a line-by-line script of the actions that lead to intimacy. This may start with affection at breakfast or date night, well before intimacy in the bedroom begins.”

Creating the script encourages couples to reflect on their usual sexual patterns and, in individual sessions, allows each partner to express any barriers they may be experiencing or areas where novelty or changes could be incorporated.

Polk believes that when clients who have experienced sexual trauma say they are ready to reengage in partnered sex or physical intimacy, it is important for the counselor to assess how they came to that conclusion. “While being supportive of their desires, the counselor may want to ask if this interest arose from their partner, from their own interests or collaboratively. The client’s sexual self-efficacy, or ability to reliably communicate and have sexual needs met, is of paramount interest when approaching this topic.”

Sexual assault survivors who are already in a sexual relationship may also find that trauma symptoms create barriers to intimacy. Clients may experience psychological symptoms such as depression, PTSD, traumatic reenactment and anxiety. Decreased libido or arousal and painful sex are also common, as are sexual avoidance and conflict in the relationship.

To combat these negative impacts, Polk helps clients create a sexual consent model. “The sexual consent model is used to negotiate sexual boundaries and mutual agreements between partners,” she explains. “This is more than a ‘yes’ or ‘no’; [it] is explicit and entails ongoing dialogue between partners. Research currently tells us that men are more likely to see consent as a one-time event, so gender scripts must be considered when approaching this model.”

Polk provides examples of possible script dialogue:

  • “I know I said oral sex was OK last week, but right now, I am uncomfortable.”
  • “If we try this position, it doesn’t mean that you have to always do this.”
  • “After sex, can you make time to cuddle so that I am not left alone?”
  • “While having sex, I noticed that you got unusually quiet. Is everything OK?”

Morse recommends sensate therapy to her clients. She describes sensate therapy as a series of sex therapy exercises that allow for sensual touch to be achieved without anxiety. “Typically,
this will start with just having a couple carve out time twice a week where intimacy is not centered around the genitals and penetrative sex,” she says. “Masters and Johnson initially developed a series of exercises which are now commonly adapted based on a couple’s specific needs.”

Morse recommends the book Sensate Focus in Sex Therapy by Linda Weiner and Constance Avery-Clark for counselors who want to learn more.

Trauma education

Day believes there are still too many people walking around with trauma who have no idea that they can be helped. He says counselors need to be proactive in educating the public about trauma because many of the people who could benefit will never show up in their offices. Day also stresses the need for trauma education in schools but says that because school counselors have so much on their plates, clinical counselors need to step in and be willing to give their time.

“Counselors don’t always have to sit behind the desk,” he states. “Go to places where people are uncomfortable about having these conversations, such as schools, community centers, churches.”

One of the things that Day loves most about being a trauma counselor is getting the word out. He gives presentations, participates on panels and has even talked about trauma on the radio.

“Individuals have to have that conversation,” he says.

 

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Additional resources

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

Counseling Today (ct.counseling.org)

  • “Moving through trauma” by Jessica Smith
  • “The Counseling Connoisseur: The contour of hope in trauma” by Cheryl Fisher
  • “Informed by trauma” by Laurie Meyers
  • “Salutogenesis: Using clients’ strengths in the treatment of trauma” by Debra G. Hyatt Burkhart and Eric W. Owens
  • “Coming to grips with childhood adversity” by Oliver J. Morgan
  • “The toll of childhood trauma” by Laurie Meyers
  • “Traumatology: A widespread and growing need” compiled by Bethany Bray
  • “All trauma is not the same” by Tara S. Jungersen, Stephanie Dailey, Julie Uhernik and Carol M. Smith
  • “The high cost of human-made disasters” by Lindsey Phillips
  • “Lending a helping hand in disaster’s wake” by Laurie Meyers

Books and DVDs (counseling.org/publications/bookstore)

  • Disaster Mental Health Counseling: A Guide to Preparing and Responding, fourth edition, edited by Jane Webber and J. Barry Mascari
  • Youth at Risk, sixth edition, edited by David Capuzzi and Douglas R. Gross
  • Crisis Stabilization for Children: Disaster Mental Health, DVD, presented by Jennifer Baggerly

Webinars (aca.digitellinc.com/aca/pages/events)

  • “Traumatic Stress and Marginalized Groups” with Cirecie A. West-Olatunji (CPA24341)
  • “Counseling Students Who Have Experienced Trauma: Practical Recommendations at the Elementary, Secondary and College Levels” with Richard Joseph Behun, Julie A. Cerrito and Eric W. Owens (CPA24339)
  • “Counseling Refugees: Addressing Trauma, Stress and Resilience” with Rachael D. Goodman (CPA24337)
  • “Dissociation and Trauma Spectrum” with Mike Dubi (CPA24333)
  • “Children and Trauma” with Kimberly N. Frazier (CPA24331)
  • “ABCs of Trauma” with A. Stephen Lenz

Podcasts (aca.digitellinc.com/aca/store/5#cat14)

  • “Treating Domestic Violence” with Tali Sadan (ACA282)
  • “Counseling African-American Males: Post Ferguson” with Rufus Tony Spann (ACA285)
  • “Harm to Others” with Brian VanBrunt (ACA248)
  • “Child Sexual Abuse Survivors, Their Families and Caregivers” with Kimberly Frazier (ACA200)

ACA Mental Health Resources (counseling.org/knowledge-center/mental-health-resources)

  • Gun Violence
  • Trauma and Disaster

ACA Interest Networks (counseling.org/aca-community/aca-connect/interest-networks)

  • Traumatology Interest Network

 

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

 

Letters to the editorct@counseling.org

 

 

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

The gifts of volunteering as a disaster mental health counselor

By Suzanne A. Whitehead February 19, 2019

I was presenting at the Western Association for Counselor Education and Supervision Conference in Santa Rosa, California, on the evening of Nov. 8, 2018, when the urgent call came. The American Red Cross was frantically looking for certified disaster mental health counselors to help with what appeared that it might become a large disaster due to the wildfires that had sprung up near the areas of Chico and Paradise, California. (This would later be named the Camp Fire.) I responded that I could be there on Nov. 11 to help out as much as possible. I had been watching the news reports while at the conference, and I could tell the situation was growing dire.

As I left the conference, being held about an hour west of the fires, that Saturday evening, the acrid smoke filled the air and pellets of ash hit the roof and sides of my car as I made my way south. I live in the Central Valley of California, about 2.5 hours south of the fires and Santa Rosa. All the way home, the smoke lingered in the air like a very dense fog, yet I knew it was far worse.

I raced back to Sacramento (1.5 hours north) the next morning to go to the American Red Cross headquarters to get my assignment. The fires had been raging and spreading for more than 3 days at that point. The skies above were thick with smoke, and I wondered what I might be getting myself into.

A decimated landscape along Highway 33 in Ojai, California after recent wildfires.

As I approached the Red Cross headquarters, I encountered a scene of organized chaos. I had an appointment with our area chief, but finding her took some time. When we finally met, she ushered me into a side office and gave me an assignment to one of the nine shelters opened in the fire areas. She also gave me several breathing masks, some bottled water and a “Go with God” message. There was no time for idle chatter.

I swallowed hard and drove the extra hour north. As I progressed, I couldn’t help noticing that fewer and fewer cars were headed toward the wildfire areas; many, many more were leaving. I had volunteered with the Red Cross along the Gulf Coast for two weeks in 2005 after Hurricane Katrina. After that experience, I also served as a disaster mental health volunteer in the wake of several local disasters on the East Coast, where I lived at the time. So, I already knew what to expect when it came to “shelter life,” but at the same time, I also was aware that each disaster — and each set of life circumstances — is unique. I braced myself for the possibilities, knowing I had to be strong.

 

In the shelter

As I approached the shelter, I again encountered organized chaos. The air was sooty and couldn’t be escaped, either in your car or in the buildings. I was stationed at an old fairground that had been turned into a makeshift shelter. A large building housed a common area, a kitchen and a gymnasium that had been turned into the sleeping quarters. There were two sets of bathrooms, but they featured cold water only – and no shower facilities. For showers, the Red Cross had placed trailers outside that contained three showers on each side for the “residents” to use. There were also dozens of people staying in their cars, in tents, in campers and in recreational vehicles, all surrounding the main shelter. These were the survivors who had escaped with their animals but were not allowed to bring them into the shelter.

As I entered the main hall, crowds were everywhere, lining up to get food, clothing, toiletries, diapers, wipes, supplies and water. I could hear the sense of panic and distress in the voices around me, and the looks on the survivors’ faces told of their immense grief and shock. I made my way over to where the two other disaster mental health counselors were located, inside the gym turned sleeping quarters. They filled me in on some of their areas of concern — and the individuals whom they were concerned about. Every cot was filled, with the distance between each being about 2 feet. My disaster mental health colleagues thought we had in excess of 125 survivors inside. They estimated at least another 75 or so people outside. I knew that we had our hands full because the need was tremendous.

By Nov. 11, the disaster had grown to a Level 5, one of the highest levels the Red Cross declares. It would later grow to a Level 7, the highest level possible, based on loss of life, the number of people affected, duration and overall cost. I started mingling throughout the crowd and saw a tremendous outpouring of distress. Many survivors were simply “walking wounded,” too much in shock to say much and still just trying to absorb all that had happened to them. Many asked me to help them find their loved ones; others cried over the fear that they had lost their precious pets.

I quickly found the list of referrals and resources to hand these survivors, but many didn’t even have a phone or the numbers of loved ones to call. The fires had spread like no one could remember, raging at their backs as they tried to flee. They had time to gather little beyond the clothes they wore. They shared stories of racing through the burning brush with the flames licking their cars as they fled.

Others spoke of quickly abandoning their vehicles when they got stuck in a standstill traffic jam on the few small roads that led to their once beautiful towns. They left their cars with few or no belongings, running along streets, paths and through the forests to escape on foot. When they spoke, their eyes lit up with fear, as if reliving the nightmare.

 

Personal encounters

You do a lot of psychological first aid as a disaster mental health volunteer in the first few days after a disaster. You mentally sort out those who seem to be coping, albeit shakily perhaps; those who don’t talk at all, keeping it bottled inside; and those who are clearly in great distress. You look for support systems of any kind and try to surround them with those who still have some “reserves” to give.

I encountered people from every walk of life during those first few days in the shelter, including those who were desperately poor to begin with. The stories of rescues and heroism made my heart skip, reveling at the strength of the human spirit. There were so many older adults, with walkers and wheelchairs, frightened and seemingly all alone. They struggled to remember phone numbers, addresses and the medications they needed — all common artifacts of trauma and disaster situations. We were eternally blessed at our shelter with several wonderful nurses on staff and a physician. They were a godsend, especially when the norovirus invaded the shelter a few days later. It wasn’t the best time to try to quarantine vast amounts of people, and yet there we were.

For many, the shelter offered a brief respite as they gathered their senses and financial resources, decided which relative or friend to travel to, and filled their gas tanks or purchased their plane tickets. The main hall meeting room was filled to capacity at meal times. The food was prepared at a central location in town and transported to all the shelters via the huge Red Cross emergency response vehicles.

People of all walks of life slowly began to reach out to one another; donations of food, clothing and supplies poured in; and no one was turned away. Friendships began to emerge by the fifth day, and a few smiles began to peer through the depression. The wildfires were still raging, and everyone instantly stopped what they were doing when the fire marshals came in each day to give their updates and reports. You still couldn’t go outside safely without a breathing mask on, and by this point, the acrid smoke and soot were in our hair, clothing and lungs.

And so it went. The days went by with little word about the survivors’ homes. There was one small television in the gym/living quarters, and the “residents” huddled there whenever a news report came on. I began making mental notes of the individuals I was most worried about: the young man who was clearly going through withdrawal of some kind; the older adult women with walkers and canes who were frightened easily and tired quickly; the caring gentleman who reached out to others but quickly escalated to outbursts of anger when he felt distrust; the man recovering from a recent stroke and estranged from his family, wishing now that it wasn’t so.

There were stories of heartache, pain, remorse, forgiveness, bravery, heroism and hope. All the while, I knew that this could happen to any one of us, in a heartbeat. When these people had awoken that fateful morning, they had no warning of the impending doom, no way to prepare and just barely enough time to get out of harm’s way. The fragileness of humanity struck me as I tried my best to help those in dire need. Given the same circumstances, I wondered how I would react.

 

What’s left behind

By the following weekend, Nov. 17, the only residents left in the shelter were the truly needy. These were the poor souls who had lost everything in the fires — they had no resources, no home owners insurance, nowhere to go, no one to go to. A feeling of great malaise and sadness had come over the group, and we did our best to try to restore hope.

It was a normal process and cycle, one I had witnessed after Hurricane Katrina so many years prior, and I was mentally prepared for it. However, these are human lives you are working with, and to say it doesn’t pull at your very soul would be a lie. People wanted and deserved answers, yet few were forthcoming because it was deemed unsafe to return to what remained of their homes.

The fires were mostly contained by this point; the grizzly, heart-wrenching job of finding the missing was well underway. The numbers feared missing had gone from an early count of 20 or so to well over 800, and then back down to less than 100 eventually. The residents cried at every news update and mourned the loss of their dear pets much more than the loss of belongings. Repeating their stories of survival to all who would listen was therapeutic and helped to alleviate some of the general malaise. It was a necessary element for returning to any sense of “normalcy.”

Nov. 18 arrived, and I had to return home, 2.5 hours south. I am a counselor educator, and my university had been closed for several days due to the horrid air conditions; we would remain closed until after Thanksgiving. Yet, there these people remained, trapped in a place they could not leave.

I felt great sadness as I left the shelter that evening to return to my home. I was reminded again and again of how very fortunate I am in life, and I felt blessed that I could be there to give solace to a few dear souls. I was not able to get the smell of smoke out of my hair and clothes for days — and out of my car for weeks — yet I was the supremely fortunate one.

It is so very true that disasters bring out the very best and the very worst in people. I chose to focus on the very best, and I witnessed it over and over. Just as when I deployed with Hurricane Katrina, I learned so very much about myself on this assignment. As a disaster mental health volunteer, you dig deep into your soul and discover what is truly important in this life. Just as with my Katrina experience, I received so many thank-you’s and bless-you’s this time that I was humbled to my core. The survivors told me I had given them so very much, but especially a sense that someone deeply cared about their plight. I am truly the lucky one, however, because giving our time and talents is such a precious gift to share.

The crisis of the wildfires in Northern California has now left the airwaves, but it still looms large. The American Red Cross continues to request assistance there; the need will go on for months, if not years, as the towns of Chico and Paradise try to rebuild.

If I can do anything now, it is to encourage professional counselors to volunteer with the American Red Cross. The trainings are easy, and most can be completed at your own time and pace. The need is tremendous because there is no shortage of disasters in our world. To volunteer, you need to be a clinical mental health counselor or a certified/credentialed/licensed school counselor. It just may be the most precious gift of your lifetime to give, and I can’t encourage you enough.

 

 

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Suzanne A. Whitehead is the program coordinator and an assistant professor of counselor education at California State University, Stanislaus. She is a licensed mental health counselor, national certified counselor and licensed addiction counselor. She has volunteered with the American Red Cross since 2005. Contact her at swhitehead1@csustan.edu.

 

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ACA Disaster Mental Health webpage: counseling.org/knowledge-center/trauma-disaster

 

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

Study: Genetic wiring as a ‘morning person’ associated with better mental health

By Bethany Bray February 11, 2019

Are you a morning person or a night owl?
Most people consider themselves to be one or the other, with a natural inclination for productivity either in the morning or after sunset.

Not only are these tendencies wired into our genes, but they have a correlation to mental well-being, according to a study published Jan. 29 in the journal Nature. A cohort of researchers found that the genetic tendency toward being a morning person is “positively correlated with well-being” and less associated with depression and schizophrenia.

“There are clear epidemiological associations reported in the literature between mental health traits and chronotype [a person’s ‘circadian preference,’ or tendency toward rising early or staying up late], with mental health disorders typically being overrepresented in evening types. … We show that being a morning person is causally associated with better mental health but does not affect body mass index (BMI) or risk of Type 2 diabetes,” the researchers wrote.

A person’s tendency toward what the researchers refer to as “morningness” is wired into the genes that regulate our circadian rhythm. In addition to sleep patterns, the body’s circadian rhythm affects hormone levels, body temperature and other processes.

Using data from more than 85,000 people, the researchers found that the sleep timing of those in the top 5 percent of morning persons was an average of 25 minutes earlier than those with the fewest genetic tendencies toward morningness.

The study also highlights the connection, reported by previous research, between schizophrenia and circadian dysregulation and misalignment, as well as the increased frequency of obesity, Type 2 diabetes and depression in people who are night owls.

“One possibility which future studies should investigate is whether circadian misalignment, rather than chronotype itself, is more strongly associated with disease outcomes,” wrote the researchers. “For example, are individuals who are genetically evening people but have to wake early because of work commitments particularly susceptible to obesity and diabetes?”

 

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Read the full study in the journal Nature: nature.com/articles/s41467-018-08259-7

 

From the Australian Broadcasting Corporation: “Early birds have a lower risk of mental illness than night owls, genes show

 

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Related reading from Counseling Today:

 

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