Tag Archives: eye movement desensitization and reprocessing

Talking about #MeToo

By Laurie Meyers August 31, 2018

In 2006, activist Tarana Burke founded the “me too” movement — a grassroots campaign to help survivors of sexual violence, particularly young women of color from low-wealth communities. Over time, the movement with a simple message — you are not alone — built a community of survivors from all walks of life.

In fall 2017, in the wake of allegations of sexual assault and harassment by film producer and entertainment mogul Harvey Weinstein and other powerful men, “me too” went viral — and global — with a single hashtag. Social media feeds were suddenly flooded with #MeToo, sometimes accompanied by personal stories or alternately issued as a statement in itself.

In the year that has followed this mass call for awareness, stories of sexual harassment and assault have continued to come to light. The discussions about how to achieve safety and equality show no signs of flagging. Some of these conversations are happening in counseling practices as counselors help clients process their own #MeToo stories.

For licensed professional counselor (LPC) Sarah Kate Valatka, a private practitioner in Blacksburg, Virginia, the most striking element of #MeToo has been the sense of community — albeit an unchosen one — the movement has created for survivors. That feeling of community not only helps clients feel less isolated but also engenders hope as they see other survivors navigating their own trauma, says Valatka, an American Counseling Association member whose practice specialties include addressing gender-based violence.

Other counselors say the movement is encouraging women who previously chose to remain silent about their experiences to seek help. “I absolutely believe this has empowered more women to come forward,” says Brooke Bagley, an LPC at the Sexual Assault Center of East Tennessee in Knoxville. “I have heard the narrative repeatedly — that many have been scared, isolated or unsure of the legitimacy of their own traumas, and this movement has given these individuals a voice.”

Indeed, Bagley says although the practice where she works has not seen a substantial increase in new clients, a number of people who had not previously thought of themselves as survivors have come in looking for help to process their experiences.

Charity Hagains, a licensed professional counselor supervisor who specializes in sexual trauma, says she and other counselors at the Noyau Wellness Center in Dallas have seen many new clients seeking help not for assault but for experiences they are just now realizing had crossed the line into sexual harassment. Hagains says she has commonly heard statements from clients such as, “It never occurred to me that this [behavior] wasn’t OK. Every boss I have ever had commented on my body.”

Hagains says the #MeToo movement has also caused many adult women to reconsider their younger experiences. Typical incidents these women have shared in session with Hagains include being pressured to show their bodies in a chatroom when they were preteens or being coerced into having sex as teenagers. At the time, they didn’t consider it coercion because they thought they were old enough to consent or had been drinking and thus excused the other person’s actions.

“It always made me feel awful,” clients have told Hagains. “I was ashamed, but I didn’t realize that it was something that other people would see as not my fault.”

Conversations such as these — both inside and outside of counselors’ offices — are long overdue, asserts Laura Morse, an LPC who specializes in relationship and sexual issues, including assault and trauma. Telling these stories has served to highlight how often sexual assault occurs, but clients are grappling with what comes next, she says.

“So much of the counseling journey with sexual assault survivors is figuring out the ‘and’ after identifying with #MeToo,” says Morse, a private practitioner in Lancaster, Pennsylvania. “Empowering individuals after assault to write their narrative, decide their legal choices and how or if they want to share their story, that’s the part of the conversation that #MeToo leaves us grappling with as a community.”

Moving on from #MeToo

The journey to healing from sexual trauma often begins with defining what has happened to the client, Bagley says. Using psychoeducation, she talks to clients about what constitutes sexual assault or harassment. She also explains common reactions and responses to sexual trauma. Once clients have a better understanding of what they have experienced, Bagley says she can delve into how their trauma is manifesting and work toward the management of symptoms.

Shame and guilt often accompany sexual assault and can be difficult to move past, says Trish McCoy Kessler, an LPC and owner of Empower Counseling, a practice in Lynchburg, Virginia, that focuses on the needs of women and girls. She starts by normalizing what clients are feeling and emphasizing that the sexual violence or harassment they have experienced is not their fault.

Kessler, a member of ACA, uses cognitive behavior therapy to help clients note when they experience a negative emotion and identify the thoughts that are evoking that feeling. She then challenges those thoughts, asking clients to consider whether any evidence exists to support their negative self-talk. Simply instilling hope in clients that their feelings of shame and guilt will lessen over time can help reduce their anxiety and stress, Kessler adds.

Kessler also focuses on coping skills with clients, she says, because many people who have experienced trauma use maladaptive coping skills such as substance abuse and emotional eating. Kessler teaches clients to instead use positive skills such as meditation, reaching out to friends (to avoid isolation), listening to music and writing or journaling. She has found it especially helpful to suggest that clients (and particularly teen clients) keep a list of effective coping skills on their phones to refer to when they are feeling overwhelmed. Kessler also emphasizes the importance of self-care, including getting adequate sleep, getting the proper nutrition and engaging in regular exercise.

Hagains notes that many of her clients lack compassion for themselves. She encourages them to identify as survivors rather than victims and attempts to teach self-compassion by holding a mirror up to the compassion that her clients show to others. For example, Hagains asks clients to consider what they would say to a friend going through the same experiences. “It’s usually not something like, ‘You’re awful,’” she notes wryly. “If you would give your friend a hug, give yourself a hug,” she urges.

Hagains also asks clients to identify the shame statements that they tell themselves. Then she helps them create positive, affirming messages to replace the negative self-talk.

Over time, Bagley has created a five-phase model that she uses for clients who have experienced sexual trauma. In the first phase, she assesses and identifies the client’s level of trauma through a symptom-based checklist. She then explores the emotional, cognitive, physiological and behavioral responses the client is experiencing.

Phase 2 focuses on building rapport and establishing the therapeutic relationship. Because clients who have experienced trauma are very vulnerable, it is imperative to provide a nurturing and safe environment, Bagley emphasizes. Once she has established a bond with the client and a sense of safety, Bagley focuses on the person’s present strengths and explores how the client can use those strengths to cope with the trauma.

Bagley begins cognitive-based interventions in Phase 3. Together, she and the client identify thought distortions attached to the trauma and start practicing ways of reframing negative beliefs.

In the fourth phase, Bagley focuses on identifying specific emotions. She teaches clients to practice mindfulness by noting where on their bodies they feel certain emotions and what is happening around them when they experience these feelings. Bagley says this helps clients identify triggers and also aids in bridging the mind-body disconnect that can occur with recent sexual trauma.

In the fifth and final phase, clients build a narrative surrounding their trauma. “At this stage in the therapeutic process, clients should be displaying more stability and management of symptoms,” Bagley says. “This is often apparent through changes in the language clients use to describe their trauma experience, as well as a shift in self-view.”

At this point, Bagley has clients retell their trauma to desensitize their trauma response and to empower them to feel more in control of their story.

It takes a village

Morse often works with other professionals, including law enforcement, to help survivors of sexual violence. She tells clients there are different paths they can take as part of their treatment and asks them what makes sense or seems helpful to them. Some clients are empowered by learning about their legal rights, and the possibility of pursuing justice gives them a sense of agency. For other survivors, gaining strategies to manage anxiety is critical to their daily functioning, Morse says.

When clients choose to seek justice through the legal system, Morse offers to go to the police station with them and sit in on a meeting with detectives. Beforehand, she prepares clients by explaining that they will be asked numerous questions about what happened to them. She also educates them about how lengthy the legal process can be and the emotional toll it may take.

Many of Morse’s clients have experienced harassment at work, and in these cases, they often choose to file a complaint through their employer’s human resources department. To prepare these clients, Morse goes through their employee handbook so they fully understand the company’s harassment policies.

Morse also strives to help survivors of sexual violence feel safe again, which often requires connecting them with outside resources. She frequently recommends self-defense classes, noting that in many cities, there are now free classes offered for survivors of assault. In some cases, reestablishing a client’s sense of safety may require a change in phone number or residence.

For those who struggle with overwhelming anxiety, Morse is a big proponent of eye movement desensitization and reprocessing (EMDR), and she refers these clients to a certified EMDR practitioner. If anxiety and depression are impeding her clients’ daily functioning, she has them meet with a psychiatrist to explore the need for short-term medication management of symptoms.

Morse says group therapy can also be a crucial therapeutic tool because it provides a way for survivors to share their stories with others who have experienced sexual trauma. Many community agencies and YWCAs offer free groups, she notes.

Morse also emphasizes the power of just being there for clients. “Many survivors of assault reflect that the most helpful part of the therapeutic process is simply having someone to listen and believe them on their journey,” she says. “Oftentimes, we’ll spend several sessions talking through the details and allowing a woman to rewrite her narrative as an assault survivor.”

When #MeToo is painful

Although counselors generally say that the #MeToo movement is socially necessary and can be personally empowering, they also note that for some survivors, the constant reminders of sexual trauma can have an unintended adverse effect.

“The movement can often feel like a double-edged sword in terms of awareness for survivors,” Bagley says. Although many survivors are grateful that the truth of the widespread nature of sexual violence is being made evident, the sheer volume of stories can be overwhelming. “It floods social media, news outlets [and] radio programs, leaving little escape for survivors,” Bagley explains. “Additionally, the backlash and negative media response to the movement has … a triggering and negative impact.”

Valatka agrees. “You [a survivor] may be on social media, and it’s just a normal day. Then someone shares, and it’s bringing it into your day — bringing it to survivors when they weren’t planning for it.”

Shaina Ali, an LPC and owner of Integrated Counseling Solutions in Orlando, Florida, says that when clients who are survivors of sexual assault or harassment bring up #MeToo, she uses an existential approach. “How does this affect your story? What does this mean for you?” Ali asks clients.

Her intent is to help clients focus on how hearing these stories affects their progress. In some cases, clients realize that they have handled potentially retraumatizing information better than they thought they might, says Ali, who specializes in trauma work. For others, their reactions are an indication that they have more trauma work to do. Ali notes that some of her clients who had come to her for issues unrelated to trauma realized that the #MeToo stories mirrored their own experiences — experiences they previously hadn’t recognized they needed to talk about.

Because #MeToo and other news stories related to mental health — such as the recent suicides of Kate Spade and Anthony Bourdain — can potentially have an effect on any client, Ali always raises such topics in session. She says this serves two purposes: to check in and head off trouble before it starts and to give clients an opportunity to bring up experiences they haven’t previously been ready to share.

Sometimes the triggering comes from the casual conversation of people clients are close to, Hagains points out. As people talk about #MeToo, sexual assault and harassment survivors hear a lot of opinions being shared, some of which are full of blame. It is not uncommon to hear people say things such as, “Well, she went to his apartment, so she deserved it,” Hagains notes.

Hagains tells clients that in these cases, they need to set boundaries by telling friends or family members that they do not wish to discuss the topic and that they will have to agree to disagree. In certain cases, such as with casual Facebook friends, Hagains urges clients to decide how important it is for them to stay in contact. It may be in a client’s best interests to mute those who are making hurtful statements. Sometimes setting boundaries means limiting contact; other times it may become necessary to cease contact altogether. 

What are men learning?

The larger goal of #MeToo is to change the way that men and society as a whole see — and treat — women. Is it working?

Hagains says the topic is definitely coming up in sessions with male clients. She says that about 90 percent of the men she counsels have asked her about behavior — as in what is OK and what isn’t.

“I think a lot of men are reexamining their roles,” she says. Many of them are realizing that what they thought was appropriate or complimentary to women can actually be offensive.

A familiar refrain that Hagains hears in session from male clients who are grappling with the implications of #MeToo: “I thought women liked to be complimented on their bodies.” She responds by telling them that it might be OK to say in a bar but definitely not at work.

Ali, an adjunct professor at both Central Florida University and the Chicago School of Psychology, has also heard increased discussion from men about the topic of sexual assault and harassment, both in her practice and in the classroom. Ali teaches clients and students about harassment, setting boundaries and establishing healthy relationships.

“The way I see it,” says Kessler, “is that #MeToo is not just for women. I want men to see, this is how you treat women.”

 

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Additional resources

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

Counseling Today (ct.counseling.org)

Practice briefs (counseling.org/knowledge-center/practice-briefs)

  • “Adult Child Sexual Abuse Survivors” by Rachel M. Hoffman and Chelsey Zoldan
  • “Intimate Partner Violence — Treating Victims” by Christine E. Murray

 

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

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.

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 editorct@counseling.org

 

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

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.

eyeThe 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.

 

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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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