When talking about trauma, Hillary Cook, a licensed clinical professional counselor (LCPC) with a solo private practice in Boise, Idaho, has a saying that she often imparts to clients: It’s as possible to drown in a puddle as in the depths of the ocean.
Trauma is often lumped — some would even say oversimplified — into “big T” or “little t” categories. Big T trauma encompasses what many people think of when they hear the word trauma: large-scale, life-shattering events such as living through a war or natural disaster. Little t trauma includes more common events such as pet loss, work stress, parenting struggles or racial microaggressions, which on the surface may seem smaller. However, trauma is a complex issue, and all traumatic events — no matter how big or how small they may appear to others on the “outside” — have the potential to negatively affect clients’ mental health.
Cook, like many counselors who specialize in trauma, has seen clients who minimized their little t, everyday traumatic experiences or failed to even recognize them as traumatic. Even when clients seek counseling because they recognize that something is causing them distress and disrupting their life, they sometimes are unable to pinpoint or verbalize why, she says. Others may harbor feelings of shame or insecurity about how they feel. Cook has often heard clients, unsure of whether their experience warrants counseling, preface their stories by saying, “I don’t want to waste your time.”
Cook, a member of the American Counseling Association, has also worked with clients who dismissed their traumatic experiences by stating, “I didn’t go to war,” “It wasn’t violent” or “I don’t know why this is bothering me.” She explains to these clients that the sticking point is not the traumatic incident itself but rather how it is stored in their brain. Counseling won’t take that traumatic memory away, but it can change how it is stored, enabling the client to carry it in a less painful way, Cook explains.
Providing psychoeducation is a critical first step when working with clients who have experienced little t traumas, says Debbie Millman, a licensed professional counselor and director of a trauma therapy practice in Madison, Wisconsin. It is helpful to explain to clients the depth and breadth of trauma, which can range from something catastrophic or systemic, she says, to “someone who didn’t get picked for the kickball team [in childhood] and it cut deep, and they still dwell on it today.”
“I see trauma as anything that affects how you see yourself or feel now. No matter how big or small it seems, it’s worth revisiting that [in counseling],” notes Millman, an ACA member.
She helps clients understand the importance of recognizing and addressing trauma — even everyday ones — with the following illustration: Trauma is like pushing a ball under the surface of the water in a swimming pool. You don’t know where it’s going to resurface, but it always will. The same rule applies to trauma: You can’t keep it buried; it will always resurface. The key is to process it.
Jessica Tyler, a professional counselor licensed in Alabama and Georgia, considers trauma to be “any experience that shifts your perspective on self, others or the world.” For one person, that experience might be tied to surviving a horrific car accident. For another person, it might trace back to feeling humiliated when they were called on by their first-grade teacher to read something aloud in class. The important point to communicate is that all of these experiences are valid, she says.
“I am very adamant [with] my clients that it serves no one to compare suffering,” Tyler says. “Suffering is suffering is suffering is suffering, and if we stop comparing the validity of our suffering, we can get to work on how these experiences can expand us as individuals versus define us and our worth.”
What lies beneath
Everyday trauma can dovetail with grief and loss, attachment issues, racial or cultural issues, panic attacks, self-esteem struggles, depression, suicidal ideation, eating disorders and many other challenges that clients present in counseling. For clinical practitioners, the key is not to take those presenting concerns at face value because unprocessed trauma may be a contributing factor or even the root cause, says Susan Gabel, an LCPC at a trauma-focused group practice in the Chicago suburbs.
If a client comes into counseling with symptoms of social anxiety, for example, clinicians should not limit their counseling work to addressing those symptoms or viewing the client simply as socially anxious, because then they may miss some of the larger reasons behind those symptoms, Gabel explains.
“There can also be things that they won’t identify as trauma, such as a parent who was invalidating,” she continues. “It’s not a big T trauma, but if you add that up over and over and over again, they internalize it, and it becomes a powerful negative cognition of how they view themselves and expect people to respond.”
Low self-esteem, conflict avoidance and people-pleasing behaviors can be common among clients who have experienced trauma, Gabel notes. Because of this, practitioners must be mindful that clients may exhibit people-pleasing behaviors in therapy toward a counselor. This behavior can show up in a number of ways, she says, including when clients are not completely honest in sessions because they want to agree with their counselor, avoid conflict, or tell the counselor what they think the counselor wants to hear. These clients may also apologize frequently during sessions.
Gabel points out that this fear of conflict can stem from clients having people in their life who had a pattern of responding negatively to their needs or feelings. Thus, they may reflexively expect that response from others, including their counselor.
“For a lot of people, [trauma] tends to lean into larger issues, including their views of themselves, views of others and fear responses,” says Gabel, an ACA member who holds two trauma certifications. “Difficulty with assertiveness can [indicate] a pattern of having relationships where their needs were not met, or they needed to appease or do what the other person needed.”
Tyler, an assistant clinical professor and coordinator of the clinical mental health counseling program at Auburn University, notes that a client’s self-talk can also yield clues that the person experienced trauma in their past. Drawing from the work of North Carolina licensed clinical mental health counselor Candice Creasman, Tyler urges practitioners to listen closely for a client’s “wounded inner child,” which Creasman defines as the voice of their unhealed hurts. Exploring how this voice influences a client’s beliefs and decision-making can reveal the lived experience that generated the client’s problematic thoughts, Tyler explains.
“In my experience, this typically appears as the inner critic that we, as counselors, hear in a client’s hostile and harsh self-talk narrative,” says Tyler, an ACA member who counsels adult clients at a private practice in Columbus, Georgia. “In clients, this can also appear as anger, frustration, [or] controlling or needy behavior in therapy. The wounded inner child tests their therapist’s [ability] to show up with care, acceptance and compassion despite [the client’s] behaviors. This inner child is often the impulsive and risky part of a client that ‘acts out’ despite the potential for adverse consequences.”
Gabel often hears clients use language about feeling worthless, being “never enough” or assuming they are a bad person. Counselors can learn more about a client’s history, she says, by challenging those negative beliefs in counseling and asking when and where the client first heard those statements.
Gabel and Cook also note that somatic complaints can indicate that unrecognized trauma lies beneath a client’s presenting concern. Cook finds this especially true for symptoms that clients have explored with a medical specialist — such as hives with an allergist — without any cause
Both physical responses and unresponsiveness can be connected to unprocessed trauma. Carrying any kind of tension in the body, including headaches, stomach troubles or sensations such as feeling a tightness in the chest, can be signs of untreated trauma, Gabel says. At the same time, past trauma can cause a client to talk about an experience that would typically elicit an emotional response in a disconnected or unemotional manner, she says.
If left unprocessed, little t trauma can become problematic in myriad ways, Tyler says, and treating it requires counselors to go beyond symptom management with clients. For example, a client’s self-protective behaviors could manifest as codependency and people-pleasing in romantic relationships to validate their security and worth as a person. This can make the client vulnerable to partners who are controlling, manipulative and even abusive, Tyler explains.
“Focusing on behavior modifications and symptom management may bring short-term relief for a specific life situation. However, I find that clients often have difficulty applying these coping skills to new challenges that emerge in their lives,” Tyler says. “I have found more success in therapy when I can identify the cognitive key, or core beliefs that filter how a client sees and reacts to the world, others and themselves. This cognitive key may serve as a survival measure at first — [for example] avoidance, mistrust, perfectionism — but over time can create barriers to the client living a thriving life. … If a cognitive key can be discovered in therapy, the client learns how to adjust that ‘filter’ and see the world, others and themselves in the most flexible, rational way.”
Tyler illustrates this process through an example of a client who experiences panic attacks whenever she is away from her small child. The client may find relief after a few sessions if the practitioner focuses on breathing exercises, medication management and mindfulness with the individual. This may look successful on the surface, Tyler notes, but the root cause of the client’s distress remains unaddressed.
Instead, Tyler says, she would take a deeper look at the underlying issues by using Socratic questioning. This process helps the client “discover a long-held core belief that ‘I only feel safe when I am in charge,’ [which] can give us important data to work with to help address the client’s filter that goes beyond mothering and extends to other parts of her life,” Tyler says. “Here, I find the most potent change in clients.”
Handle with care
Regardless of whether a client has experienced big T or little t trauma, the brain is interpreting what happened as harmful to the client in some way, Cook explains. What matters is not how “bad” the event was but how maladaptively it was stored in the brain.
“The type of trauma, or how bad it was, doesn’t change the approach [in counseling]. What the client needs will change the approach,” Cook says.
She advises considering whether the client has adopted healthy or maladaptive coping mechanisms or if the client has a strong social support system. If not, the counselor should focus on those aspects before diving into deeper work to help the client process the underlying trauma, she says.
The clinical practitioners interviewed for this article use a variety of techniques, including brainspotting, eye movement desensitization and reprocessing (EMDR), hypnosis, internal family systems (IFS) therapy and cognitive behavior therapy (CBT), to help clients who have experienced trauma. These practitioners stressed, however, that counselors should focus on self-regulation and social connection with clients and establish coping mechanisms before deploying techniques to process clients’ trauma. This is especially true with clients who have experienced everyday trauma and do not recognize the effect it is having on their presenting concern.
As a licensed mental health counselor who specializes in trauma work, Christine Smith has an extensive toolbox of coping mechanisms to equip clients with depending on their needs. Coping mechanisms not only help clients with emotional regulation but also instill containment skills they can use to manage their feelings and carry on with everyday life after heavy counseling sessions that deal with raw or troubling memories, she explains.
“People tend not to use their coping skills until their hair is on fire,” Smith says jokingly. She works with clients to instead ensure that coping skills become part of their everyday life, sometimes even assigning them as homework in between sessions.
She encourages clients to keep a list of coping mechanisms they find helpful on a piece of brightly colored paper in a visible spot in their home, such as the refrigerator door or bathroom mirror. She also recommends that they move this list around periodically, so they don’t begin tuning it out.
“Coping mechanisms themselves are trauma work in a way. I tell clients, ‘We’re going to do safety, safety, safety until you are rolling your eyes, and then we’re going to do it some more.’ If you don’t have a good foundation [before doing deeper trauma work], you’re building a house of cards,” says Smith, an ACA member with a solo private practice in Saratoga Springs, New York. “The best coping mechanisms are the ones that are so integrated in a client’s life that they don’t think of it as coping.”
Smith says this early work helps forge a therapeutic bond with clients and offers the practitioner a chance to ask questions that plant seeds about a possible connection between a past experience and the discomfort that caused the client to seek counseling. Questions such as “When was the first time you felt like that?” can help both the counselor and the client begin to make connections, she adds.
Gabel agrees that coping skills should be tailored to a client’s individual needs. Deep breathing or mindfulness may be helpful for some clients, whereas others may need to work on skills that they haven’t fully developed, such as interpersonal communication or problem-solving skills, because of their trauma history.
When starting trauma work, Cook often uses EMDR and hypnosis for immediate relief of nightmares, flashbacks and intrusive thoughts to help clients find stability. Only afterward do they unpack trauma and other related issues such as grief.
Millman begins trauma work by talking through clients’ life timelines, making note of events that shaped them and have stuck with them. She also devotes significant time to doing case conceptualizations and asking clients about their strengths, personality and likes/dislikes. This helps her with gaining a holistic understanding of the client and forging a therapeutic bond, she says.
Similarly, Cook recommends asking questions that help to paint a picture of a client’s framework, including their social supports and how they deal with intense feelings. Knowing more about a client’s background might also inform counselors about cultural and racial issues that can dovetail with everyday trauma that is systemic in nature.
Millman notes that it can be helpful to encourage clients who have experienced trauma to maintain “emotional margins” around each session. This means not rushing to a counseling session from work or after picking their children up from school. Instead, she encourages clients to engage in calming rituals, such as having a cup of tea or doing some deep breathing exercises, before and after sessions.
Millman, a doctoral student in the counselor education and supervision program at Liberty University, also advises counselors to keep trauma clients in mind when outfitting their office spaces. She emphasizes the importance of being intentional about what counselors expose their clients to. For example, having fashion or health magazines in the waiting room could potentially be triggering for clients whose trauma histories or related behaviors are connected to body image or disordered eating. Instead, Millman suggests striving to create an atmosphere that is warm and calming.
“All counselors have to be prepared to come across trauma; it’s at the root of so many mental health concerns and disorders,” Millman says. “Everyone needs to have some trauma-informed care training [and] be aware of what triggers clients and what phrases or buzzwords you might be using that could be problematic for someone. Especially in regard to race, be aware of the words you’re using. Getting culturally competent, trauma-informed care is really connected to [addressing] the daily trauma that people are facing right now.”
In counseling sessions, a client’s past trauma will “come up when it needs to come up,” Millman says. For some individuals, that will happen right away, and it will come out “like a volcanic eruption.” For other clients, it may be a year into therapy before they’re ready to talk about it. But when they do, Millman says, she “can almost feel the relief in the counseling room,” especially for clients who associate feelings of shame with their trauma. “It’s like a weight has lifted, disempowering that hold it has over [them] now that someone else knows about it and can carry it with [them],” she says.
In trauma work, Smith adds, it’s not uncommon for clients to broach a traumatic subject by saying, “I’ve never told anyone this but … ” When that happens, Smith tells the client she is honored that they trusted her with this information.
“I try not to ever forget how much courage it takes to walk into a therapist’s office,” Smith says. “I try and be really encouraging, positive and respectful of that and recognize the wins that they have that other people aren’t going to recognize.”
Smith finds that work that focuses on emotional regulation can be especially helpful for this client population. In some cases, this involves simply talking through and processing interactions and events clients have experienced since their last counseling session. It can be helpful to “move at a glacial pace,” slowly unpacking an incident the client found distressing down to the minutiae, Smith says. This allows the client to identify the exact moment they started to feel triggered and lost the use of their self-regulation skills. Then, the counselor and client can talk about what the client could do differently the next time this type of scenario arises.
EMDR can be particularly helpful to work through troubling scenarios and feelings with clients who may not recognize a past experience, such as little t trauma, as the root of their discomfort, Cook says. However, these clients will be able to name the challenge that caused them to seek counseling, such as relationship trouble, work stress or panic attacks. EMDR allows the practitioner to target and heal clients’ distressing feelings and triggers without having to relive the trauma that lies underneath, she explains. The beautiful thing about EMDR, Cook says, is that it allows the practitioner to target a distressing pattern that the client is experiencing, which, in turn, targets anything else that is in that neural pathway, including related trauma.
During EMDR, the client engages in bilateral stimulation, such as rhythmic tapping, while talking through a scenario with the practitioner. The process rewires the client’s brain and creates a new neural pathway, revising the pattern into one that is free of distress, Cook says.
EMDR allows clients to “see themselves in a scenario in a different way and imagine how they want to feel … without having to go through it” and relive the trauma, she explains.
This was the case for an adult client whose presenting concerns involved relationship issues and anxiety related to dating. Cook was able to use the client’s specific anxieties surrounding first dates as a target in EMDR. Cook guided the client to talk about the details of how they felt during their worst dating experiences.
“All of a sudden, it went much [further] back, and we realized there were some parenting issues [involving verbal abuse] from many years ago in childhood,” Cook recalls. “It was really hard for them to hear at first. There was a lot of denial, [saying] ‘that’s not trauma.’ But then I used an illustration: If you could imagine a small child that’s not you and this was happening to them, how would you feel? Then it sunk in, and they realized how awful it was.”
Cook continued to use EMDR, as well as CBT, to focus on the client’s self-worth and to build healthy boundaries. This therapeutic approach built up the client’s coping skills so that on dates, they were able to focus more on the other person and be less “in their head,” Cook says. When the client worried less about what the other person was thinking about them, they were able to instead focus on finding connection.
EMDR, along with a combination of other therapies, was also helpful for a past client of Tyler’s whose presenting concerns were low self-esteem and anxiety. As they began to unpack things in counseling, the client also disclosed a history of self-harming behaviors and chronic suicidal ideation.
“She was successful in her career yet presented with chronic and relentless self-talk that was significantly cruel and self-blaming. Everything was her fault and everything terrible that had ever happened to her resulted from her failures; she was convinced that she was unlovable and worthless,” recalls Tyler, who co-presented the session “Trauma-Informed Care: Working With Trauma-Related and Survivor Guilt” at ACA’s Virtual Conference Experience in April.
In counseling, Tyler gently probed with questions to identify where and how this client learned such hypercritical self-talk. The client reported that it was simply “something she had always done,” Tyler says.
Tyler gently challenged this thought with psychoeducation that infants are not born with self-hatred; it is something they learn from their environment. Through that lens, she explained to the client how life experiences may reinforce negative beliefs and feelings of rejection. Over time, the client was able to reprocess several early childhood and adolescent experiences that she had previously believed were “not traumatic enough” to cause her mental health to dip to its current state, Tyler recalls.
“However, in examining these experiences through the lens of how young, vulnerable and impressionable she was as a child, it made sense how one thing spiraled into another, which then turned into years of confirmation bias,” Tyler says. “Using a careful combination of EMDR, CBT and IFS, she communicated with her younger self and realized that, in reality, being worthy was her birthright and that she was allowed to make mistakes and learn from them just like everyone else. Moreover, every time she damaged herself emotionally or physically, she betrayed that younger version of herself that was not adequately protected from the harm and toxicity of others.”
This change occurred gradually over one year of counseling. Eventually, the client’s self-harm and suicidal ideation ebbed, Tyler says, and she adopted a lens of “gratitude for the younger versions of herself who endured — and her present adult self who now had the control and power to make choices to nurture and soothe her along the journey of life’s challenges.”
Not so little
Gabel thinks it is more helpful to view client trauma on a spectrum rather than sorting experiences into either “big T” or “little t” boxes. She urges counselors to keep an open mind, regardless of how severe a client’s experience may — or may not — seem.
“Little t traumas can add up and hold a lot of power. Complex, relational trauma can be little t’s that add up and become overwhelming,” Gabel says. “A lot of times [counselors] are trying to make logical sense of it — if this [experience] is affecting [the client], it must be connected to a past event (e.g., peer conflict as an adult and past bullying as a child) — when in reality, that’s not how our brain wiring works. It doesn’t always make logical sense.”
Smith also encourages counselors to keep an open mind about what qualifies as traumatic. Something that on the surface appears to be a smaller trauma, such as the death of a pet, can be a huge loss to someone who didn’t have healthy attachments growing up, she notes.
“It’s not up to me to decide what’s a small t trauma versus a large T trauma. Something that’s small might be linked to something that’s not so small,” Smith says. “What I’m looking at is someone who has experienced some kind of disruption or loss that they’re having trouble getting over. You and I could have the exact same experience, and you might come out unscathed, and I might really suffer, and we don’t always know why that is. … Just keep yourself open and curious [in counseling sessions]. My clients are my greatest teachers, and if I listen very carefully, they know exactly what they need to heal.”
Referring and co-treating
The nonprofit organization Mental Health America offers an online mental health screening each year on its website. In 2020, nearly 2.5 million people took the screening, and past trauma was second only to loneliness as the most reported cause of mental distress.
This data illustrates what many counselors see in their daily work: Trauma is ubiquitous and can have a profound effect on mental health. With that in mind, clinical practitioners must be mindful of when a client’s trauma goes beyond their expertise. The counselors interviewed for this article stressed that trauma is a complex issue and clinicians who do not specialize in this realm need to be ready to seek additional training or supervision, consult with colleagues or refer clients for specialized trauma work.
Seeking outside help is especially important when a client is no longer making progress with their counselor, says Hillary Cook, a licensed clinical professional counselor in Boise, Idaho.
A strong, trusting therapeutic relationship is crucial in trauma work, Cook notes, and a referral doesn’t necessarily mean this bond is broken. Clients can continue to work with their original counselor while being co-treated by a specialist. In this scenario, the client would need to grant permission for the two clinicians to consult with each other.
“We can’t be all things to all people,” agrees Christine Smith, a licensed mental health counselor who specializes in trauma work at her private practice in Saratoga Springs, New York. “If a counselor doesn’t have specialized training in dealing with some of the more complex trauma issues, don’t be afraid to refer out.”
Consult Standard A.11. of the 2014 ACA Code of Ethics at counseling.org/ethics for more on the ethical guidelines surrounding the referral process.
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Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at email@example.com.
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.