Tag Archives: EMDR

eye movement desensitization and reprocessing

Tapping into the benefits of EMDR

By Lindsey Phillips September 27, 2021

Andie Bernard, a licensed professional clinical counselor at Rootworks Wellness in Cincinnati, was working with children and families in marginalized communities who had experienced complex trauma, but she didn’t get the sense she was truly helping them get better through the use of play and talk therapies.

“As I was treating these children and their families, I just couldn’t get to the root of what was really needed to make lasting gains. Their bodies were calm with me in session when they could be, but they were activated everywhere else,” she recalls. “I needed something more powerful beyond talk and play. I needed something that could help to reshape their worldview [and] their belief about themselves.”

This led Bernard to eye movement desensitization and reprocessing (EMDR) therapy. After using the therapy, she finally started seeing improvements with these clients.

EMDR was developed in the late 1980s when Francine Shapiro discovered a connection between eye movement and a decrease in the negative emotions associated with her own upsetting memories. More than 30 years after EMDR was first introduced, it has not only proved to be effective but has also been recognized by the World Health Organization, the U.S. Department of Veterans Affairs (VA) and the U.S. Department of Defense as a primary treatment for posttraumatic stress disorder (PTSD).

EMDR pulls directly from many evidence-based therapeutic approaches such as psychoanalysis, cognitive behavior therapy and somatic therapy, notes Bernard, a member of the American Counseling Association. Like psychoanalysis, EMDR therapy explores clients’ past, present and future, but its aim is to help clients realize that what happened to them in the past is not happening now. The cornerstone of EMDR, Bernard explains, is the adaptive information processing model, which asserts that humans will move themselves toward healing once they have all necessary information and can see it adaptively.

Our body’s ability to naturally heal itself from a cut is similar to how we heal emotionally, Bernard points out. “But if we are unconsciously locked in unsafe experiences that still feel true, the body cannot get to that natural healing,” she says. “EMDR moves the past into the now in partnership with the therapist so the client can see what’s in front of them and assess threat from today.”

Bernard, an EMDR-certified therapist and a consultant-in-training with the EMDR International Association (EMDRIA), finds that clients often come to counseling with a myopic view of their problems. EMDR therapy helps them widen that lens and move toward healing.

How EMDR differs from other approaches

The first three phases of EMDR (history and treatment planning, preparation and assessment) are similar to other counseling approaches because they focus on understanding the client’s full history, building a strong therapeutic relationship, creating safety, and cultivating coping skills that are centered on the mind and body. Phase 4, desensitization, is where EMDR shifts toward a neurobiological approach by helping the client change the way the brain and body associate the trauma with its trigger, Bernard explains. Rather than directing the client to simply share their narrative verbally (as might be done with trauma-focused cognitive behavior therapy), an EMDR therapist will have the client focus on a targeted traumatic memory while they undergo bilateral stimulation such as eye movements. This process speeds up the client’s ability to integrate the material into an adaptive neural pathway, she says, and removes the emotional charge and associated behaviors in everyday life.

This hints at one major way that EMDR differs from many traditional counseling approaches: It doesn’t require much talking, at least during the desensitization phase. (See sidebar below for an overview of the eight phases of EMDR therapy.) Addie Brown, a licensed professional counselor (LPC) in Virginia and a licensed marriage and family therapist in California, acknowledges that at first it was challenging for her to resist the urge to reflect and validate her clients’ thoughts and feelings. She had to retrain herself to follow the EMDR protocol and respond only with simple phrases such as “go with that” when a client mentioned a new feeling or memory.

Brown says this aspect of EMDR can be freeing for clients who prefer not to share details about their traumatic experience. “Some clients like the fact that they don’t have to talk a lot, they don’t have to give a lot of details, because there are things that are so shameful for them that they don’t want to talk about. [Talking about those things] can be more traumatizing. They’re still doing the work [with EMDR] … but they’re not having to tell that story over and over again,” notes Brown, an EMDR-certified therapist with a private practice, Harbor Site Counseling, in Woodbridge, Virginia.

Carla Parola, an LPC in private practice at Seven Centers Counseling in Phoenix, once worked with a client who was hesitant to share his history of being sexually abused as a child. She explained to the client that he didn’t need to disclose many details of his abuse while doing EMDR therapy and that he didn’t have to talk about the abuse until he was ready. If he decided to work on a trauma memory, he had to share only the image that represented the worst part of the traumatic experience as well as the emotions, negative cognition and body sensation associated with the image. For example, the client could select the image of “being alone in the closet,” without having to disclose what happened in the closet or the events leading up to it, says Parola, an EMDRIA-approved consultant and humanitarian assistance program facilitator. This explanation eased the client’s concerns, and he agreed to continue with treatment.

EMDR’s use of bilateral stimulation can be powerful, but some clients are naturally verbal and are accustomed to sharing more details than are required when using EMDR therapy. Clinicians in EMDR training often tell Bernard that they struggle to help some clients effectively target and reprocess certain traumatic memories because these clients seem to want only to talk about their feelings and feel supported by the clinician.

But there is room for clients to talk and process when doing EMDR therapy, Bernard says. In her sessions, she stays relationally attuned and listens to the client for the first 10-15 minutes. While connecting with her clients, she looks for themes that relate to their already-targeted negative memories and associated self-beliefs. For example, if a client comes in talking about how she was arguing with her husband because he was busy with work and was distant at home, Bernard may say, “I’m wondering if your feelings with your husband this week relate to not feeling important to your mom when you were growing up. Does that feel like it fits?” If the client agrees, Bernard steers the content back to reprocessing the client’s past targeted memories and belief that she is not important. This allows the client to begin seeing how the self-belief she developed in childhood is shaping her thoughts, feelings and reactions in her current relationships. “This is the power of EMDR. We are not asking clients to cope with their symptoms; we are helping them know how they developed them,” Bernard says.

Unlike other counseling approaches that help clients make a state change (moving from an anxious state to a calm state, for example), EMDR therapy helps clients make trait changes, Bernard says. As she explains, a state change approaches the problem through the brain’s frontal cortex and helps clients learn coping strategies to deal with their symptoms, whereas a trait change involves looking at what is underneath the state by using historical memories, the nervous system and the limbic part of the brain. Integrating new insights and beliefs through bilateral stimulation creates a trait change that helps clients form more adaptive viewpoints and appropriate responses to difficult triggers.

Bernard uses an analogy to highlight the difference between state changes and trait changes. Whereas a state change requires clients to change lanes (moving from an anxious road to a calm road), a trait change requires building a new highway in the brain that reshapes how clients view their world and themselves in it.

“If [clients are] interested only in state change and just want to talk through their symptoms to learn ways to cope … that can be accomplished with phase 2 of EMDR. But if [they] want to clearly believe, see and know that the threat has changed regarding that trigger and make a true trait change,” then that involves the latter phases of the EMDR protocol, she says.

When to use (and not use) EMDR

G. Michael Russo, a visiting assistant professor of counselor education and addiction program coordinator at Boise State University, specializes in integrating neuroscience into counseling practice. He took part in a meta-analysis led by Richard Balkin and A. Stephen Lenz, consisting of research studies from 1987 to 2018, to determine the overall efficacy of EMDR for reducing symptoms of overarousal. They found that EMDR can be an effective treatment for anxiety and trauma, but the results showed varying levels of efficacy — with some reporting high levels of efficacy and others indicating that it may be better to go with a different intervention.

“None of the articles that were included in the study utilized neuroscience measures. So … we are unable to explore claims regarding neurological changes resulting from EMDR,” says Russo, an LPC in Idaho. “Some might even say that neurological changes resulting from the EMDR processes are unfounded. However, what we can say is that there very well could be an alternative explanation for client growth in EMDR sessions that does not relate to the eye movement, tactile or auditory stimulation. It is possible that the relationship itself is the agent of change.” Russo presented the findings from the meta-analysis, which has been accepted for publication in the Journal of Counseling & Development, during ACA’s Virtual Conference Experience this past spring.

The bottom line, Russo says, is that despite the potential effectiveness of EMDR, counselors should remain critical consumers when using it with clients. They should ask themselves: When does EMDR work? When doesn’t it work? Who is represented in the research? Is this the best approach for this client?

According to the VA, other recent meta-analyses suggest that EMDR produces moderate to strong treatment effects for PTSD symptom reduction, depression symptom reduction and loss of PTSD diagnosis.

“EMDR is not exclusive to trauma or PTSD. It can be applied across the board,” Brown asserts. “There’s so many experiences we have that leave an emotional impact on us, and that really is why EMDR can be helpful, because it’s addressing the emotional impacts we’ve experienced.” Those impacts might include trauma as well as grief, job loss, eating disorders or relationship issues. If a client is having a strong emotional response to an event, or if a negative feeling or memory lingers and the clients wonders why they still feel this way, then EMDR can be a good approach to use, she says.

Still, Brown acknowledges that EMDR may not be for everyone, so she assesses when and if she wants to use the therapy with her clients. She also explains the process to clients to determine if they are ready to begin the treatment.

Brown finds three main barriers that might prevent EMDR therapy from working with some clients. First, a client may be too emotionally detached. This often happens when family members or friends encourage a person to seek counseling, but the person doesn’t really believe that they need to be there, she says.

Second, clients may not be ready to completely release their emotions related to an event. Brown advises counselors to use phase 2 of EMDR therapy to explore any potential barriers that would prevent the client from fully processing their feelings.

Third, an internal conflict could hinder the client’s progress. If a client is working on an issue that conflicts with their value system, they may have to work on that conflict in a different way before attempting to use EMDR, Brown says. For example, a client may not want to completely reprocess and heal from their grief because they would feel guilty about “letting go” of their pain.

Brown once worked with a client who sought counseling because she was struggling after the death of her son. When Brown asked about her son, the client started sobbing as if he had died the day before and the loss was still very raw; in fact, it had been 10 years since her son had passed away. After a few sessions of EMDR with Brown, the client had lowered her distress level only modestly, from a 10 (high level of distress) to a 6 (moderate level of distress). Despite still being in a great deal of pain, the client was satisfied with that progress, Brown recalls, because she didn’t want to feel better than that.

Because EMDR therapists are excited about the potential impact this therapy can have, they may be tempted to use it with every client they encounter, Brown says, but that isn’t an ethical practice. She reminds counselors to stay within their scope of competency. Someone recently came to see Brown because they wanted to use EMDR therapy to help them with obsessive-compulsive disorder (OCD). Even though Brown is trained in EMDR and EMDR is a good intervention for treating OCD, she referred the person to another clinician because Brown did not feel competent working with that particular disorder.

“Just because you’re trained in a really great intervention that can be used for so many different issues doesn’t mean that you, as a clinician, have to use it for all of those issues if you don’t have the clinical competency to address those issues,” she says.

Case example with complex trauma

Larisa Lomaeva/Shutterstock.com

Bernard offered to provide a case example (based on a composite of her clients) to illustrate how to apply the EMDR protocol with a client experiencing complex trauma. The client is a woman in her 30s who experienced significant abuse and relational neglect in her family beginning at birth. The client is functional in her everyday life, but she struggles to let go of the shame and feelings of responsibility for what happened to her. “Kids are hardwired to believe that traumatic things that happen to them are their fault, and she was no exception,” Bernard notes. For many years, the client coped with the trauma by dissociating her mind and body from her past experiences. She had gone to counseling on and off throughout her life, but this was largely unsuccessful because she was stuck in the childhood belief loop that her past traumas were her fault.

During phase 1 of EMDR, Bernard gets to know the client and her history. EMDR allows counselors to be creative when taking a full history, she notes. Bernard asks the client to mark on a chronological timeline (from ages 1 to 38) any significant events that have affected her or contributed to her symptoms and how she sees herself today. This includes both positive and negative experiences. Bernard sets a three-minute timer, and the client marks these events in grounded silence.

When the client finishes, Bernard looks for any marks that are more pronounced than the rest — those with a thicker line or a circle around them, for example. She notices one mark is larger, and she asks the client to tell her about that event. The client says, “This is when I met my one and only true friend.” Bernard writes this down at the top of the timeline.

Bernard continues to discuss these experiences with the client, marking positive events on the top and negative events on the bottom of the timeline. Clients are often stuck in seeing only the negative, Bernard explains, so marking the timeline in this way helps show clients the duality of their experiences (i.e., some are hard, while others are good or OK).

Highlighting these positive experiences is also the first step toward building the client’s resources, which occurs during phase 2 of EMDR. This phase is crucial for this client because initial sessions reveal that she has limited resources for assessing her own relational and physical safety, which often leaves her hypervigilant, anxious and overwhelmed in everyday life.

Bernard asks the client how she feels about the memory of making that one true friend. The client replies that she doesn’t have any feelings about it, which becomes a theme indicating to Bernard that the client is experiencing some levels of disassociation.

After three months of working on creating a sense of safety, developing a strong therapeutic alliance and cultivating coping skills, Bernard determines that the client still does not have sufficient resources to target distressing memories in the latter phases of EMDR, so she decides to use EMDR to increase access to stabilizing resources with the client. This allows them to tackle the issue through a strengths-based approach by targeting positive (rather than negative) memories and beliefs.

“EMDR is an artful, flexible and powerful approach to meet any client where they are in their healing journey,” Bernard says. “We can use the bilateral stimulation to reprocess past traumas or to help them see their strengths and resilience in the present, in spite of the trauma. So many clinical choices are possible for EMDR clinicians who understand the robustness of the protocol and can apply it creatively to the therapy.”

Next, Bernard writes down a list of positive things the client is responsible for, such as surviving her past abuse, graduating from college, and being a good teacher and parent. She asks the client, “Are you responsible for all this?” Then she uses bilateral stimulation to grow these positive neural pathways in the client’s brain. This allows the client to focus on the present positive experiences instead of the negative feedback loop that stems from her past abuse.

“While I’m building resources, I’m also teaching past versus present orientation to this client,” Bernard explains, “so, later, when we’re doing the hard traumatic reprocessing, I can say, ‘See those experiences back there? That is over; you made it through.’” This is a powerful aspect of EMDR therapy, she asserts, because it allows the client’s mind and body to begin to know that the past traumas are over and they are safe.

A few months later, the client is ready to target the traumatic memories, including the thoughts, sensations and self-beliefs developed from those experiences. The self-beliefs formed by her early trauma are such foundational elements of her present self-concept that she and Bernard must target them one at a time. After working on reprocessing the memory to understand it (using bilateral stimulation), they integrate the new insight into the body to create new meaning. This process is repeated for every traumatic memory target, which ultimately allows the client to revise the thought that she is responsible for what happened to her as a child.

After reprocessing the traumatic memories for several months, the client no longer feels responsible for the past abuse that happened to her. The client now sees her abusers as a row of dominoes and realizes that she no longer belongs in the same line with them.

“This shift could not have been achieved without the use of EMDR’s full protocol of using bilateral stimulation in conjunction with holding the traumatic memories, images and bodily sensations; processing the emotions; and redefining what the experience has come to mean to [the client] from a vantage point of safety and recognition that it is in the past,” Bernard notes.

Now, the client possesses a healthier sense of self and stronger boundaries, works in a career she loves, and feels safe in her own mind and body again.

Be fluid, not rigid

As an EMDR coach, Bernard has seen several competent therapists doubt themselves when undergoing EMDR training, which involves five intense days of learning new terms and concepts. She recently wrote a blog post, “Five things every newly trained EMDR therapist wished they knew,” to address these issues. In it, she reminds practitioners that they don’t have to be competent when starting out. Instead, she recommends that they remain curious and practice with other EMDR-trained therapists in consultation to grow their confidence.

“EMDR is a protocol and a process to learn, but it’s an art when delivered,” Bernard says. If counselors are too rigid or more cognitive-oriented, then they may struggle with EMDR, she notes, and they may not be able to create a sense of coregulation with the client.

“The protocol feels linear, but it’s not always the case,” Bernard emphasizes. Counselors should move through the EMDR phases as needed in attunement with their clients. If they try to stay too on script or are overly focused on what phase they are in, then the approach will feel rigid and affect the energy in the room, she points out. In addition, they may not be attuned to what the client just said or what the client needs.

Most counselors are well-intentioned and want to get it “right,” Bernard acknowledges, which is why having colleagues and consultants to support them while learning and remind them to trust their clinical instinct is so important. She always advises her trainees to practice EMDR with fluidity rather than rigidity.

Counselors can be faithful “and have efficacy to the treatment model while also being creative and flexible,” she says. “In the beginning as a new EMDR therapist, is it going to go slower? Yes. Is it going to be more impactful and profound and life-changing for you and the client than many other clinical approaches? Yes.”

Don’t rush the process

People often assume that phase 4 — the desensitization or bilateral stimulation component — is EMDR, but that is wrong, Bernard says. If counselors jump too quickly to desensitization, then clients can get overactivated. “When we take people to intense feeling states without paying close attention to their window of tolerance, they can’t stay present in their body, and if they can’t stay in their body, we’re not healing them. We’re retriggering them,” she explains.

She advises counselors to slow down and not to overlook or rush phase 2. This phase helps prepare clients to handle the intense emotions that may come up during latter phases of EMDR by using containment skills such as a mind-body shift, deep breathing, safety cueing, mindfulness and grounding.

“When working with clients with complex trauma or highly activated ones with anxiety, depression or dissociation, you’re going to spend important time creating safety, strengthening the therapeutic alliance and building regulation skills to use to bring them affectively down when in later reprocessing phases of EMDR,” Bernard says.

She assesses a client’s sense of safety the moment they walk into her office, asking them what makes them feel safe about the room. If a client responds by saying, “I know where the front door is,” then she knows their sense of safety is low and that she will need to strengthen it to prepare them for EMDR. If, on the other hand, the client responds, “I like the colors in your office and your plants,” then she knows the client possesses a higher degree of safety to leverage during the reprocessing phases.

Parola has found some clients are hesitant to proceed with EMDR therapy because they worry the dual-attention stimuli (or bilateral stimulation) involves hypnosis or that they will not be in control of their emotions or body. So, she introduces them to the concept of dual-attention stimuli by doing a slower and shorter version of it when they are establishing the client’s safe place in phase 2. The client picks a place that makes them feel safe. Then she tells them to think about an image that represents this place and asks, “What emotions are you feeling? What sensations are you having?” If the client is having a positive reaction, she incorporates short, slow dual-attention stimuli to reinforce this resource. This helps the client prepare to use a faster and longer version of dual-attention stimuli later when they are reprocessing memories that are more traumatic, she says.

Brown notes that some clients say they are ready to begin processing their traumatic memories but then hit an emotional wall during the latter phases. For example, someone who was constantly told by their parents as a child not to cry may protect themselves by learning how to stop themselves from crying. If they don’t address this barrier before moving to the desensitization phase, then this protective strategy may prevent them from fully feeling that emotion during treatment, Brown explains. For that reason, she started incorporating the internal family systems model (which views the mind as made up of subpersonalities or “parts,” each with its own unique viewpoint) during phase 2 of EMDR to ensure that, together, they explore all parts of the client and address any barriers that could interfere with healing.

“Phase 2 is life-changing but is often overlooked by many EMDR therapists,” Bernard stresses. “If we have limited time with a client for reasons outside of our control and are only able to help them develop accessible feelings of safety and much-needed cognitive and somatic regulation resources, we have still changed their lives in powerful ways, even without the trauma reprocessing.”

Adapting to the client’s needs

EMDR therapy continues to evolve and now has specialized approaches that address the needs of certain populations or mental health issues. For example, the desensitizing triggers and urge reprocessing (DeTUR) protocol was developed by AJ Popky to treat addiction; this approach helps clients target their desire to use drugs or alcohol while also addressing underlying traumas.

Parola, who is EMDR sand tray certified, sometimes incorporates sand tray techniques throughout the eight phases of EMDR therapy. For example, she may have a child use the figurines in the sand tray to represent a safe place while she engages the child in bilateral stimulation by slowly moving a paintbrush back and forth across the child’s hand.

Counselors can also make modifications to the eight-phase protocol. Bernard’s case example illustrates one adaption of tailoring the protocol toward installing resourcing and adaptive self-beliefs, rather than processing trauma, because the client’s internal resources were so low initially.

Bilateral stimulation is another way counselors can adjust the protocol to fit clients’ individual needs. Eye movements are the most commonly used and well-researched form of bilateral stimulation, but clinicians can also use tapping, tactile stimulation or auditory tones. Bernard finds using tappers for bilateral stimulation helpful for people with attention-deficit/hyperactivity disorder or who are highly distractable because it allows them to close their eyes and tune in to their body. For clients who dissociate or those who have difficulty managing their emotions, she often uses a light bar (a bar containing LED lights that move back and forth) or finger movements because the proximity allows her to notice changes in clients’ eyes as they track the movement.

Brown discovered that several of her clients didn’t want to use the light bar for bilateral stimulation and didn’t want her sitting in front of them during the reprocessing phases. So, she adjusted to better meet their needs. She often sits off to the side where she can still observe them from a safe distance, and she allows clients to use different types of bilateral stimulation. Most of her clients prefer holding pulsers that vibrate, but she has one client who chooses to simply tap on the side of their leg.

Research continues to shed new light on ways EMDR can be used to help clients who are struggling with trauma and other mental health issues. Two recent articles in EMDRIA’s Go With That magazine discuss how EMDR can be used to address racialized trauma and addiction.

Bernard notes there is promising research highlighting that just taxing working memory (and not necessarily with bilateral stimulation) shows signs of decreasing the emotional charge around traumatic memories.

Bernard appreciates that Shapiro’s theory has given her an eight-phase protocol that allows her to be with her clients in extraordinarily profound ways: “Any therapy that sees the person as a whole — brain, body and mind — that asserts it’s not about what’s wrong with you but what happened to you, that teaches what happened to you then is over and we’re here now, and that says the information your body is sending to you is an important part of your own healing … is a gift to the therapeutic community at large.”

1) History and treatment planning (discuss the client’s history, develop a treatment plan, assess the client’s internal and external resources)

2) Preparation (build a therapeutic alliance, explain EMDR, set expectations, build the client’s coping strategies)

3) Assessment (identify the event to reprocess, establish a baseline with the Subjective Units of Distress (SUD) and Validity of Cognition measures)

4) Desensitization (use bilateral stimulation while the client thinks about the traumatic event with the goal of reducing the client’s SUD to zero)

5) Installation (strengthen a positive belief that the client wants to associate with the target experience until it feels completely true)

6) Body scan (ask the client to think about the target event and positive belief while scanning the body from head to toe, process any lingering disturbances with bilateral stimulation)

7) Closure (help the client return to a calm state)

8) Reevaluation (discuss recently processed memories at the beginning of a new session to ensure the client’s distress is still low and positive cognition is strong, determine future targets and directions for continued treatment)

(Information adapted from EMDRIA)

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Lindsey Phillips is the senior editor for Counseling Today. Contact her at lphillips@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.

There’s nothing small about trauma

By Bethany Bray June 24, 2021

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
being identified.

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.”

fran_kie/Shutterstock.com

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.”

Digging deeper

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.”

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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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Action steps to learn more

Read Introduction to Crisis and Trauma Counseling, edited by Thelma Duffey and Shane Haberstroh, available at counseling.org/store.
Search for articles with the tag “trauma” at CT Online (ct.counseling.org).
Browse ACA’s continuing education offerings by topic.

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Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@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 high cost of human-made disasters

By Lindsey Phillips March 1, 2018

The stories of the aftereffects of human-made disaster have become all too familiar: a refugee forced to make a dangerous journey to find a new home; the soldier deployed thousands of miles from home for months at a time; the person who finds his or her world turned upside down when a shooter enters the room and begins firing. It’s not surprising, then, that according to a report by the American Psychological Association, in 2017, 60 percent of Americans felt stressed about terrorism and 55 percent felt stressed about gun violence.

In addition, refugees fleeing war-torn countries have created an international crisis, and, among other things, they aren’t getting the mental health care they need. The International Medical Corps found that 54 percent of Syrian refugees and internally displaced populations in Syria, Lebanon, Turkey and Jordan suffered from severe emotional disorders, including depression and anxiety.

The increase in human-made disasters raises a question for counselors and others: Does the type of disaster — natural, human-made or technical — affect the severity of the trauma or the counseling approaches used to treat it? Devika Dibya Choudhuri, an associate professor at Eastern Michigan University, says sufficient research indicates that when human agency is involved, the disaster has a more traumatizing effect. Although natural disasters are traumatizing, there is often a huge response of communities taking care of one another, which tends to be a restorative factor, she explains.

“With human-made disasters … the aftermath is also conflicted,” says Choudhuri, a licensed professional counselor and American Counseling Association member who presented at the ACA 2017 Conference & Expo in San Francisco on group interventions in the aftermath of violence, terrorism and dislocation. “Most [refugees’] … traumatizing stories are not just [about] the original trauma. … The journey after is so profoundly traumatizing as well because not only are they ungrounded from the loss of home, but then all of these additional wounds are made. There is no safety anywhere, as opposed to that sense [after a natural disaster that] people are coming forward to help.”

Rebuilding trust, regaining control

Choudhuri, who worked with Cambodian and Bosnian refugees in the 1990s and has worked with Iraqi and Karen refugees since the 2000s, points out that survivors of human-made disasters are fighting on two fronts: struggling to survive in their environment and engaging in an inner conflict where the original strategies for survival during the trauma are no longer helpful. Thus, when it comes to trauma and human-made disasters, counselors should focus on restoring a client’s sense of control, not safety, she advises.

Hannah Acquaye, an assistant professor of counseling at Western Seminary in Portland, Oregon, works with refugees from war-torn countries such as Afghanistan and Iraq and parts of Africa. She finds that for refugees from countries where neighbors are fighting neighbors, the trauma is unique in terms of feeling a sense of betrayal. If the person holding the gun and causing the devastation is someone they know and used to play with growing up, then the trauma becomes especially troubling, she says. “It affects the way they trust people … and makes it harder to build a community back,” explains Acquaye, an ACA member whose research focuses on refugee trauma and growth.

Thus, rapport and trust are crucial for survivors of a human-made disaster. According to Mark Stebnicki, professor and coordinator of the military and trauma counseling certificate program in the Department of Addictions and Rehabilitation Studies at East Carolina University (ECU), empathy and listening are critical elements of establishing rapport and gaining the trust of these clients.

Establishing a therapeutic alliance can be problematic, however. Counselors often learn to build a therapeutic alliance by offering warmth and connection and by encouraging clients to tell their stories, Choudhuri points out. But for individuals who have experienced a “traumatizing offense through human agency … the betrayal and abandonment and loss of trust during the process gets triggered by the very warmth of the connection,” she explains. Counselors will often experience that after making a connection and getting the client to open up, the client never shows up again or ends up in the hospital, Choudhuri says.

Before uncovering the trauma, counselors must help rebuild and ground clients so that they will have resources to address the trauma, Choudhuri argues. “Rather than creating a therapeutic alliance, it’s about rebuilding the kinds of ways in which people can take care of themselves so that they don’t require the therapist to do that,” she explains. In fact, she advises that counselors should work with survivors of human-made disasters as if they will have only one session together. The first few sessions should focus on techniques that will help clients function in case they don’t return, she says.

One way counselors can help clients become autonomous is by providing them with tools to regulate their emotions. Somatic and emotion regulation techniques allow survivors of human-made disasters to notice their triggers on a sensorial basis and use their brain to counter this negative trigger, says Choudhuri, a certified eye movement desensitization and reprocessing (EMDR) therapist. In a sense, their brain becomes an ally, rather than an obstacle or hindrance, in their recovery.

One of Choudhuri’s clients suffered trauma after being held captive and tortured for several days. Smelling the cologne worn by one of his captors would trigger the client. After identifying this sensorial trigger, Choudhuri set out to counter it. She discovered that the client found lavender essential oil calming, so she directed him to take in the lavender scent anytime that he encountered the smell of cologne. The process works on two levels, Choudhuri notes, because “it’s addressing the sensorial piece, but it’s also giving control back [to the client].”

Choudhuri also finds that traumatic resilience is important when working with survivors of human-made disasters. Many resourcing and grounding techniques that counselors use can also make clients more resilient in the face of ongoing trauma, she notes. For example, Choudhuri finds the container technique helpful for her clients: She tells clients to think of a container with a secure lid (e.g., a jar, a jewelry box) and then to use that container to mentally store the parts of the trauma that get in their way and prevent them from moving forward.

Group work is another resource that can help survivors of human-made disasters rebuild a sense of trust. At the same time, Choudhuri says, “group work is really challenging, particularly for [people] who have had human-made disasters, because other human beings are a source of threat [to them].”

In fact, Choudhuri is careful to avoid touching clients who have been hurt by other human beings. Instead, she teaches clients how to give themselves a comforting touch. For example, she uses the butterfly hug method (clients cross their hands over their chest and alternately tap their hands to a heartbeat cadence) while she facilitates thoughts of being safe and loved. This technique works well with children and is one that clients can do themselves when they are upset, she adds.

Rather than asking individuals to share their trauma in groups, Choudhuri suggests having them process it in a way that allows group members to provide comfort to each other, thereby helping restore a sense of control, trust and efficacy. For example, counselors could have individuals teach each other how to engage in deep breathing. “It allows for people to feel empowered to … not just be on the receiving end but also on the giving end,” Choudhuri explains, “and then they’re giving something that they themselves are learning, which helps them learn it better.”

From Stebnicki’s perspective, groups not only allow counselors to identify people who need more individualized treatment but also provide a safe space to verbalize and normalize survivors’ feelings (e.g., anxiety, depression, grief, sleeplessness) about an event and prepare them for the forthcoming weeks. “If you get [clients] to open up and share feelings [in a group], then the group itself is your own best source of support because they can normalize what that scary event was like,” he says.

Bridging cultural differences

Stebnicki acknowledges that working with people who are culturally different from the counselor can be challenging. Clients who are refugees, immigrants and asylum seekers may pose an even greater challenge because American counselors are often far removed culturally from individuals from war-torn countries such as Syria and Afghanistan, he adds. But successful treatment relies on understanding clients’ cultures and how they heal, he asserts.

In some cultures, counseling as generally practiced in the Western Hemisphere doesn’t exist, so counselors shouldn’t force clients to share their stories, Acquaye says. Instead, counselors should focus on providing a safe, supportive environment and inform clients that they are in the moment with them, she advises.

Stebnicki, a member of both ACA and one of its divisions, the Military and Government Counseling Association, says that he distinguishes between civilian and military responses to human-made disasters. “Military is a culture unto itself,” he says. “Military personnel experience person-made disasters differently in that instead of detaching, isolating, running and going into shock like civilians do, they adapt and survive, and they aggress … [not] stress.” Unlike civilians, who typically respond to a shooting by running away, military personnel are generally running toward the gunfire, he points out.

At the same time, civilians and military personnel experience similar physiological, psychological and emotional responses to human-made disasters. However, military personnel also experience ongoing trauma stressors (such as multiple deployments) and generally do not undergo the full range of posttraumatic stress disorder (PTSD) symptoms until after their deployment or military service ends, Stebnicki says. Thus, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders “measures PTSD, but mainly in civilian life because it doesn’t take into account this … repeated exposure to trauma which military [personnel] are exposed to,” he argues.

In addition, military personnel often cannot easily take advantage of mental health services in the same way that most civilians can because of the stigma that military culture places on it, Stebnicki says. Using these services can sometimes put their security clearances at risk, cause them to get demoted or have others in the military lose faith in them and their ability to lead, he explains.

Despite these difference, many counselors try to treat military personnel as civilians and do not recognize the distinctions between civilian and military mental health, Stebnicki says. To help address this issue, he developed the certificate in clinical military counseling at ECU. The course trains professional counselors on some of the unique cultural differences in diagnosis, treatment and services for members of the military.

Making meaning of human-made disasters

In the face of a human-made disaster or a large-scale political event, people often feel helpless, like a small cog caught in a big wheel, Choudhuri says. In such cases, the counselor’s aim is not to help clients find an answer to existential/spiritual questions of why the disaster happened but to help them figure out a meaning to these events that they can live with, she says.

Meaning making should also involve some degree of personal growth, Stebnicki notes. He says that counselors can determine whether clients have experienced posttraumatic growth by their actions: Are they taking their medications? Are they going to counseling? Have they reconnected socially? If the answer is no, then there is no growth, he says.

The counselor’s job, Stebnicki contends, is to provide tools and resources to help clients take responsibility for finding meaning and growing from the trauma. However, he points out, growth is painful, so counselors must prepare clients to take small steps toward identifying ways of feeling safe and ultimately finding meaning.

Acquaye actively celebrates her clients’ small victories because she believes it encourages them. She had one client who was a refugee who was depressed because she didn’t know how to communicate in her new culture. Acquaye asked her to try to leave her apartment each day and walk around for five minutes. When her client was successful, Acquaye jumped up and down in front of the woman to celebrate her progress. Taking this small step forward helped her client begin to sleep regularly again, Acquaye says.

Choudhuri looks for ways to address clients’ despair without trying to change their beliefs about what happened. She finds EMDR helpful because it allows people to process internally without having to give the counselor details about their trauma. At the same time, clients are able to arrive at a meaningful narrative about their experience. “It may not be my answer, but it’s their answer,” Choudhuri adds.

Choudhuri provides an example of a Syrian refugee who participated in EMDR therapy that involved drawing and processing his trauma. At the end of the session, he said that regardless of the terrible things that had happened to him, he realized that every night has a morning. “It wasn’t that he got an answer or that he had a solution,” Choudhuri says, “but he got what he needed — hope.”

For many clients, spirituality plays a large role in meaning making. If the client’s and counselor’s spirituality differ, then the counselor should find common ground to discuss spirituality, Acquaye advises. The majority of her clients are Muslim and Acquaye is Christian, so in session, they discuss the general concept of God and who is in control of everything. “We can’t explain why people do what they do, but we can hold on to somebody who is greater than people and know that some good may come out of that,” she explains.

Self-care and counselor fatigue

Clients’ stories of trauma, suffering and loss can take a toll on counselors, resulting in counselor burnout, compassion fatigue or empathy fatigue. The cumulative effect of seeing multiple survivors of human-made disasters and other traumas can start to deteriorate counselors’ spirit to do well and damage their own wellness, Stebnicki notes. For that reason, counselor self-care must become a priority when working with survivors of human-made disasters.

Stebnicki differentiates between empathy fatigue, a term he coined, and other fatigue syndromes such as burnout and compassion fatigue. He explains that empathy fatigue results from a state of physical, emotional, mental, spiritual and occupational exhaustion that occurs as the counselor’s own wounds are continually revisited through a cumulation of different clients’ stories of illness, trauma, grief and loss.

The major difference between these types of fatigue syndromes is that empathy fatigue has an added spiritual component, Stebnicki notes. Horrific experiences such as genocide and torture go beyond the range of ordinary human experience and affect the mind, body and spirit, he explains. Thus, it is crucial that counselors are properly trained to be empathetic and compassionate, he says. In addition, because people experience and define spirituality in their own individual ways, counselors must understand their clients’ views of spirituality to assist them in cultivating hope and psychosocial adjustment to their trauma.

Acquaye acknowledges that she didn’t initially realize how much the stories of her refugee clients would affect her. If counselors are struggling with counselor fatigue, they need to seek help to avoid harming their clients, she advises. “It’s not about me. … If I claim I’m an advocate for my refugee clients, then I should get over myself and ask for help, so I’ll become a better person for them,” she says.

Choudhuri says counselors must also guard against making another common mistake. Because refugees often have little meaningful support, they are incredibly grateful when they do receive it, and there can be a danger in that for counselors. “If [counselors] work long enough with [refugees], it gets really easy to feel like a savior,” Choudhuri admits.

“One of the things that trips [counselors] up is this belief of indispensability — that there is nobody else, so I have to keep doing it even if I don’t want to,” Choudhuri adds.

She also finds that working with clients who have survived a human-made disaster can bring out something of a competitive nature in counselors: They assume (often incorrectly) that if the client can deal with the trauma, then they can too because they are the counselor.

Among the possible signs of counselor fatigue syndromes that Stebnicki notes are having diminished concentration, feeling irritable with clients, feeling negative or pessimistic, and having difficulty being objective or compassionate. “We’re good as counselors at giving advice to others and helping facilitate self-care strategies, but we don’t do it ourselves. We need to take our own best advice and get help,” he advises.

Stebnicki has found peer support helpful when dealing with fatigue syndromes. He and other colleagues meet once or twice a month to vent and share their stories. In fact, he notes that it is common to have ongoing peer support on-site for counselors and first responders at large-scale human-caused disasters. These support groups allow counselors to discuss what they saw, how it affected them, how they are responding and how they are going to overcome it, he says.

Acquaye is thankful for her supervisors and own personal counselor who help her guard against burnout. “I have to remind myself all the time that I’m not God … so I can’t carry my client because sometimes the stories are so heavy that you can’t sleep at night,” she says. She realizes that carrying the burden of her clients’ stories will serve only to make her negative and ineffective as a counselor.

Many counselors are drawn to working with refugees because they want to help, but before jumping in, Acquaye says, counselors should understand what their strengths and limitations are. “Ask yourself [if] you have enough strength for the kind of stories they will throw at you. [If not], it doesn’t mean you are not good enough. It just means that that is not your area,” she says. “When it comes to refugee work … you are going to go through the trauma yourself, so you have to ask yourself, ‘Do [I] have what it takes to go through that?’”

Lessons learned

How can counselors prepare to handle the specific needs of survivors of human-made disasters? “Training to be trauma informed becomes key. … There shouldn’t be counselors coming out of counseling programs who don’t have a basic understanding of trauma,” Choudhuri asserts. Yet, she finds that counselors often report not knowing how to deal with trauma and disaster mental health.

Choudhuri thinks that one area of disaster mental health where training needs to improve is clinical competency. Often, counselor educators aren’t practitioners, which can be problematic because they don’t see the chronic nature of clients’ issues and thus don’t prepare adequately, she contends. She argues that counselor educators should stay clinically active — perhaps even working with survivors of human-made disasters — to keep their finger on the pulse of what is happening.

Of course, Acquaye admits that counselors are never likely to have all of the training they need to handle disaster mental health straight out of school. Many of the skills must be learned on the ground. She recounts a time when despite her training on refugee trauma and posttraumatic growth, a client’s story scared her to the point that she was shaking. She had to remind herself that even though she had no idea how to treat the client’s many issues on the spot, she needed to start by listening to the client and then figuring it out as she went along by researching and assessing the client’s needs.

What people consider to be trauma or traumatizing changes over time, Choudhuri notes, so the symptoms that veterans displayed after the Vietnam War are not the same ones that soldiers returning from Afghanistan and Iraq have displayed. Today, counselors also have to take into account the fact that there is more aggression digitally, and digital aggression distances people from the trauma, she adds. For example, drone warfare has changed the rules of war, allowing people to kill from a distance. This makes killing more impersonal and affects the mental health of drone pilots differently.

“As conflict becomes handled differently, [so does] the kinds of betrayals and ways in which people can be hurt electronically. … [People’s] sense of danger and risk become different than if somebody broke into [their] house. They’re related, but they’re different,” she says.

One mistake that counselors often make when working with clients is expecting a more intense early disclosure of the traumatic incident, Stebnicki says. Stebnicki worked as a member of the crisis response team for the Westside Middle School shootings in Jonesboro, Arkansas, in 1998. In the aftermath, he witnessed a counselor go up to a student, take him by the shoulder and almost shake him to force disclosure of what the student had just experienced. Counselors must remember that everyone heals at his or her own rate, so survivors of human-made disasters may not want to discuss their experiences immediately after the event, he says.

Stebnicki has also found that people’s experiences vary based on their proximity to the disaster’s epicenter. “We all differ in stress and trauma in terms of the pattern, the frequency, the exposure, the magnitude/intensity. So, in other words, we all turn our stress response on differently,” he says.

In working with refugees, Choudhuri has learned that counselors can’t assume to know the trauma. One of her clients had been married off by her parents while in the refugee camp to a man who raped her. Was the worst part of her experience being in the refugee camp, losing her home or being raped? Choudhuri discovered that for the client, it was that her parents didn’t love her enough to have chosen a better husband for her.

“It wasn’t the violence that drove her from her home, it wasn’t the destruction of her life as a schoolgirl, and it wasn’t even the brutality of her experience in the marriage,” Choudhuri says. “It was the sense of being betrayed by her parents.” Thus, counselors should remember that the focus of the work is not about the trauma but about the client, she adds.

Choudhuri has also observed that although disaster mental health professionals have developed ways to work with people immediately after a disaster, they often fail to implement this guidance back home. She argues that counselors don’t respond to the ongoing, everyday disasters happening in their backyards — the microaggressions and microassaults that wear people down as they try to overcome obstacles of systemic racism, chronic poverty, violence and substance abuse — in the same manner as they respond to large-scale events.

“If we can point to the singular event, we can be horrified by it and [respond] with compassion and helping, but when we live in it, we numb ourselves … to it because we feel helpless,” Choudhuri says.

“It’s difficult because we all want a place of safety … so it’s easier to go away somewhere and work on [disaster mental health] and then come back [home] and be safe,” she points out.

Counselors need to resist the urge to let trauma and disaster response fade into the background because of the discomfort these events can generate, Choudhuri argues. Instead, they must keep disaster mental health in the foreground and help rebuild communities and individuals affected by disasters, including those less obvious disasters happening in counselors’ backyards.

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Lindsey Phillips is a freelance writer and UX content strategist living in Northern Virginia. She has a decade of experience writing on topics such as health, social justice and technology. Contact her at lindseynphillips@gmail.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.

EMDR for the co-occurring population

By Jeanne L. Meyer May 29, 2014

In my work with clients with co-occurring mental health and substance use disorders, it became clear to me early on that most have experienced trauma in their lives — trauma that they must resolve to achieve and maintain a healthy recovery.

These traumas are sometimes categorized as little “t” or big “T” traumas. Big “T” traumas include childhood sexual, physical or emotional abuse, natural disasters, war experiences, severe car accidents and rape. Little “t” traumas can be just as damaging, especially because they tend to occur over time and build on each other. This complicates the overall effects of the trauma as well as the trauma treatment. Some examples of little “t” traumas include ongoing emotional abuse or neglect, experiences of shame, being humiliated and being bullied. Incidents involving racism, sexism or homophobia could be classified as either big “T” or little “t” traumas depending on the severity. These traumas might involve one or two distinct incidents, or be more complex, ongoing experiences. The result is a primary belief that the world is not safe. In some cases, individuals who are traumatized learn to expect pain, dishonesty and betrayal from the people they love the most.

In the case of clients with addiction, even if they have not experienced trauma prior to the onset of their disease, they most likely have experienced violence, rage, betrayal, abuse (sexual, physical or emotional), incarceration, homelessness or a whole host of other negative experiences while using alcohol or other drugs.

There are two clinically appropriate strategies for treating posttraumatic stress disorder (PTSD) with people in substance abuse recovery. One strategy is to address the trauma or abuse immediately as the client enters the beginning stages of recovery. The other is to wait until the client’s ability to achieve and maintain abstinence has stabilized.

How do we know which strategy will be successful? Ultimately, the client is the one who knows. If the ability to maintain abstinence from alcohol or other drugs is precarious or impaired due to memories, suicidal ideation or self-harm, it is essential to treat the cause of these symptoms from the beginning. For these clients, recovery will likely remain elusive until their trauma is addressed. If the client is relatively stable, however, waiting until the later stages of recovery is indicated. Clients who are pressured into addressing their trauma issues before they are ready are likely to relapse into active addiction.

According to recent brain research described in Uri Bergmann’s 2012 book Neurobiological Foundations for EMDR Practice, when someone experiences an event or multiple events that cause intense fear, it can change the neural pathways, or maps, in the brain. Whenever something is experienced as a reminder of the trauma, clients can relive that trauma, making them afraid of certain places, tones of voice, objects or even other people with certain body types. Smells can also trigger intense anxiety and fear. The repetitive experience of anxiety and fear can result in panic attacks, health problems, chronic pain, sleeping difficulties and eating difficulties. The individual eventually becomes self-centered, focusing so much on self-protection that there is little objectivity or ability to have empathy for others. This makes every relationship unstable.

The good news is that several proven therapeutic techniques, including eye movement desensitization and reprocessing (EMDR), can alleviate symptoms stemming from past traumas. EMDR uses the mechanism by which information from frightening and horrifying events is processed into memory and stored in the brain. By manipulating the brain’s intrinsic information processing scheme, a practitioner can help clients release themselves from the intense hold those memories have on them. EMDR combines sensory bilateral stimulation (visual, auditory or physical sensations) with emotional memory and the underlying belief system to lessen the intensity of the experience. It does not erase the memory, but it can reduce or alleviate many of the associated symptoms.

The mystery of EMDR

It is not known precisely how EMDR works, but various research studies have verified its effectiveness in the treatment of trauma. Twenty-four randomized controlled (and 12 nonrandomized) studies have been conducted on EMDR. Most of these studies address simple rather than complex trauma. For a list of these studies, visit the EMDR Institute website at emdr.com and click on the “Research Overview” link under the General Information tab.

In developing EMDR, Francine Shapiro postulated that PTSD is caused by a disruption in the adaptive information processing system. Because the fear and helplessness experienced by clients stays attached to the memory of the traumatic event, it creates havoc in their lives. It is as if the trauma is continuing to happen to them. Because it is still occurring neurologically, it cannot be processed as a memory.

EMDR changes the configuration of the neural connections or map of that event, detaching the dysfunctional physiological and emotional components so that it becomes a more manageable memory. This helps the client “let go” of the past because the neurons are literally letting go of some connections and replacing them with new ones.

In my experience, EMDR is the fastest, most effective and least intrusive way to help clients release trauma, regardless of whether it stems from childhood abuse, sexual abuse or assault, accidents, disasters or combat, and regardless of whether it is the result of a single event or multiple experiences. I have also seen EMDR reduce or eliminate chronic pain, headaches, fibromyalgia and cravings for alcohol and other drugs. One of the best things about EMDR is that it doesn’t require clients to retell their horror stories. In my view, when people don’t have words to describe what they are experiencing, don’t remember the original incident, have somaticized their pain or are too emotionally raw to put the experience into words, it is essential to offer treatment that does not require verbalization.

[Click on the image to see the chart in full size]

The eight phases

To practice EMDR, a clinician must have a master’s degree, counseling experience and the proper EMDR training. Although the process may seem simple to an outside observer, it requires both an understanding of how the brain and emotions work with trauma and a specific protocol. As shown in the table below, there are eight phases of treatment.

We’ll use “Carrie” to highlight how each phase of the EMDR treatment protocol might be carried out with a client.

History taking and treatment planning (Phase 1): This is used in most counseling therapies. The therapist and client review biopsychosocial history and trauma history, assess client resources and strengths and determine the frequency and level of any dissociation symptoms. The therapist will suggest different targets and strength-building skills depending on the overall emotional stability of the individual.

“Carrie” comes to the clinic requesting help with night terrors and anxiety. While obtaining her background history, it becomes clear she has survived many traumatic events, has few financial or social resources and is currently separated from her abusive husband. She smokes cigarettes, uses marijuana, uses some mindfulness tools and practices breathing techniques to manage her distress and anxiety. The therapist determines it is essential to improve her emotion regulation and distress tolerance skills, along with targeting various symptoms such as her recurring nightmare.

Preparation (Phase 2): The therapist explains the adaptive information processing system and how trauma disrupts it. The mechanics of treatment are reviewed. Emphasis is placed on clients nonjudgmentally observing their reactions and awareness, and communicating those observations to the therapist. Rapport is established. Relaxation and self-soothing techniques are taught and practiced.

In Carrie’s case, she is able to best understand the adaptive information processing system with the help of a simple illustration the therapist draws to engage her in the therapeutic relationship. The therapist says, “I will show you exactly what the technique looks like. We can use eye movements, sounds using headphones, or I can tap the back of your hands. Which feels most comfortable to you?” When Carrie chooses eye movements, they arrange the chairs so Carrie and the therapist are facing each other. The therapist holds a pen in front of Carrie and asks, “Is that comfortable? Do I need to change the distance or the pen I’m using? What I will do is wave my pen back and forth, and you follow it with just your eyes.” The therapist does this, and Carrie follows the pen easily.

Assessment (Phase 3): The client and the therapist determine exactly what the target is, including any images, physical sensations or memories that are associated with the emotionally loaded material. They rate the intensity of the feelings that are attached using the Subjective Units of Distress Scale (SUDS). An “irrational belief” (as defined by Albert Ellis) is identified by the client as the negative cognition. The client chooses a more reasonable belief to use as the positive cognition and rates the perceived validity of this statement.

In Carrie’s case, she remembers parts of her dream: She is in a dangerous situation with people looking for her; she crawls through a hole in a wall to discover she is in a bunker with gunfire all around her. She rates the fear she feels as she recalls the nightmare at a SUDS score of 9. She identifies her belief when these feelings come up as, “I am never safe.” The therapist asks her what she would rather believe.

Carrie responds, “That I am safe, I guess.”

“Are you safe?” the therapist asks.

“No, not always,” Carrie says.

“But sometimes you are safe.”

“Yes, sometimes I am safe.”

The positive cognition becomes “I can be safe.”

The therapist asks, “How true does that statement feel right now?”

Carrie rates it on a Validity of Cognition (VOC) scale as a 1, indicating it feels “like a lie.”

Desensitization (Phase 4): The cognition, the emotion and body awareness are combined with bilateral stimulation. The therapist changes the bilateral stimulation speed with eye movement, tapping and sounds throughout and between sets. A set is composed of a series of bilateral stimulations. For example, moving the eyes back and forth 10 times would represent a set. The therapist varies the length of a set depending on the intensity of the material the client is experiencing. In between sets, the therapist determines that the process should continue by asking the client if he or she is noticing any changes. This pattern continues until the client reports no change between sets and the SUDS score has been reduced to a 0 or 1.

For example, the therapist tells Carrie, “Bring up that memory, crawling through the hole and being in the bunker. Remember the sounds and smells. Notice how your body feels. Allow the thought, ‘I am never safe,’ to float in your mind. Do not try to direct your thoughts. Let your mind wander. Wherever it goes is where it’s supposed to go.”

Carrie watches the therapist move the pen back and forth, causing her eyes to move from left to right rhythmically. After a set of 10 eye movements, the therapist stops and says, “Take a deep breath. Tell me what you are noticing right now.”

The therapist makes a note of Carrie’s response and starts another series of bilateral stimulations. The process continues until Carrie reports several times that she feels “nothing.” When recalling her nightmare, her SUDS score is 0.

Installation (Phase 5): The positive cognition is strengthened for the client. The bilateral stimulation is used as the client thinks of the positive cognition. The sets are shorter and slower to allow the positive experience to establish itself. The VOC is measured again until a score of 6 or 7 (“completely true”) results.
Body scan (Phase 6): The therapist asks the client to pay attention to the way her body feels from head to toe (or vice versa) and report it.

Carrie notices some trembling in her hands. The therapist uses more sets of eye movements until the trembling ceases.

Closure (Phase 7): The therapist ensures clients are safe to leave the session and navigate their way to their next destination. They are guided through self-calming rituals. The therapist explains that the client may feel spacey or very tired for anywhere from one hour up to a few days. Clients are given an assignment to journal their experiences, emotions, thoughts and dreams until the next session.
Reassessment (Phase 8): This phase occurs at the beginning of the following session. The targeted material is recalled and the client’s SUDS score is determined. The VOC of the positive cognition is also reevaluated. Any residual processing that occurred between sessions is discussed. If there is a change in either the SUDS or VOC score, it indicates there are more aspects of the target to process.

At Carrie’s next session, she reports the nightmare has not returned. When she remembers it, her SUDS score is 1. The positive cognition, “I can be safe,” is rated at a VOC of 7 (“completely true”).

Conclusion

When I work with a client, I keep meticulous notes about the intensity of the individual’s negative emotions and the perceived validity of the positive cognitions before and after a treatment. I keep this record partly so that I can review it with the client in the future. Many times, the client possesses no memory of having the original problems and emotions. The client still remembers the traumatic incident and has feelings about it, but the incident does not haunt the client any longer.

My experience of utilizing EMDR with clients has been no less than amazing. I continue to be surprised at its effectiveness addressing a number of concerns. It works relatively quickly, and its results are maintained. After the initial setup, it relies on clients’ own processing and therefore validates their experience completely. With EMDR, there is also a shorter period of intense unpleasant emotion that clients experience than with other talk or exposure therapies. It engages the parasympathetic nervous system, leading to relaxation or drowsiness when the process is complete.

Whether EMDR is used at the beginning of addiction recovery or after a period of abstinence, clients are able to manage their recovery more easily and more successfully when PTSD symptoms are alleviated.

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Jeanne L. Meyer, a licensed mental health counselor, licensed professional counselor and master addictions counselor, is a co-occurring therapist with Choices Counseling in Vancouver, Washington. She is also a member of the American Counseling Association Trauma Interest Network. Contact her at jmeyer@ChoicesCounseling.org.

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