Tag Archives: PTSD

From Combat to Counseling: Comprehensive mental health in the military-affiliated population

By Duane France October 17, 2019

Often, when talking about mental health in the military-affiliated population, the first thing that comes to many people’s minds is posttraumatic stress disorder (PTSD). This is true of mental health professionals as well.

Once, a colleague asked me how many deployments I had in my military career. When I told her that I had five combat and operational deployments, she said, “Well, of course you have PTSD!” In reality, the number of deployments doesn’t dictate the level of traumatic events to which a service member has been exposed. A client could have multiple deployments and not have experienced anything worse than separation from family, whereas another client could have experienced only one very serious and traumatic deployment.

It is important to understand what we are talking about when we discuss mental health in the military-affiliated population. It is critical to understand the culture of the military and to understand who we are talking about. However, as mental health professionals, it is equally important to understand the potential psychological impacts that our clients have experienced.

 

PTSD

Although PTSD is not representative of everything that service members deal with after the military, it is a condition that any counselor working with the military population must understand. It has been described in a number of different ways throughout history, including “soldier’s heart” in the Civil War, “shell shock” in World War I, and “battle fatigue” in World War II and the Korean War. After the Vietnam War, the symptoms that would come to signify PTSD were called “post-Vietnam syndrome.” It wasn’t until the third edition of the Diagnostic and Statistical Manual of Mental Disorders, published in 1980, that PTSD became an official diagnosis.

There are a number of PTSD diagnostic criteria outlined in the DSM-5, the most significant of which is that the service member must have been exposed to an event that resulted in death, threatened death, actual or threatened serious injury, or sexual violence. The service member or veteran must have been exposed either through direct exposure, witnessing the trauma, learning that a relative or close friend was exposed to such trauma, or experiencing indirect exposure to details of the trauma in the course of professional duties. This is significant. Just because a service member was deployed to a combat zone does not mean that the service member was exposed to an event that meets this criterion; this was certainly true for three of my five deployments. Being able to differentiate between PTSD and other psychological conditions is critical to supporting the client.

 

TBI

Another condition emerging as an important consideration is traumatic brain injury (TBI), which is also known as a concussion or mild, moderate, or severe TBI. Military equipment and medical response have improved significantly over the past 50 years, resulting in greater survivability on the battlefield. Injuries that previously might have been fatal are now being treated quickly and effectively. While this development has reduced the mortality rate in recent conflicts, it has led to an increase in the number and severity of catastrophic injuries.

Further complicating TBI is the fact that many of its symptoms overlap with those of PTSD, and many of the conditions that could cause TBI also meet criterion A for PTSD. Whether it is a blunt force trauma concussion from a direct blow to the head or a diffuse TBI caused by blast overpressure from an explosion, the causes of TBI could also be causes for PTSD (and vice versa).

 

Addiction

Addiction is another important mental health consideration in the military-affiliated population. This of course includes substance use. Many of us who served know that the military is a drinking culture. Drinking is normalized and used to relax, to celebrate, to memorialize. Regardless of rank or branch of service, alcohol is acceptable and available.

It is problematic, however, when the reason for alcohol use changes from celebration to self-medication, or using alcohol to reduce discomfort from psychological concerns. Additionally, the opioid epidemic in the veteran population typically begins during active duty. Because of the extreme chronic pain that results from multiple injuries, pain management is a necessary consideration, and painkillers are readily available.

In addition to substance use, it is also imperative to explore process addictions in the military-affiliated population. Whether it involves gambling, viewing pornography, compulsive eating or shopping, compulsive and addictive behaviors can cover the veteran’s or service member’s underlying concerns.

 

Photo by U.S. Army Sgt. Victor Perez Vargas/defense.gov

Emotional dysregulation

Difficulty tolerating and managing emotions is another significant aspect of mental health for the military-affiliated population. While there are certainly emotional components to PTSD, TBI and addiction, it is also possible for emotional challenges to exist apart from substance use, trauma exposure or physical injury. For many service members and veterans, the typical dysregulated emotions are depression, anxiety and anger.

Among the nontraumatic causes for an inability to manage these emotions are toxic leadership and systemic harassment. An inability to escape from an adverse situation can lead to feelings of helplessness and hopelessness. I will emphasize again that there are many situations in the military that could cause anger, anxiety and depression that have nothing to do with exposure to traumatic events. It is necessary to determine whether emotional dysregulation or substance use is the result of traumatic exposure or another cause.

These aspects of mental health are not unique to the military of course. Combat trauma is not the only cause of PTSD, and any significant blow to the head can cause TBI. Addiction is not a problem just for the military population, and emotional concerns such as depression and anxiety are widespread. Additionally, these conditions follow the medical model of mental health; there is a diagnosis for each of them and corresponding medications for each of them. Although these conditions can be debilitating in and of themselves, there are other factors unique to the military population that can complicate attempts to treat service members, veterans and their families.

 

Meaning and purpose

Although service in or affiliation with the military can be difficult, it can also be extremely satisfying. There is a collective effort toward a common goal, a sense of shared culture and community, and a feeling that the work you’re doing is important. Many veterans, upon leaving the service, struggle to find the same satisfaction in their post-military careers. Many are able to build a meaningful life after the military, but it is not automatic.

There is also the challenge of navigating an identity shift. Whether it’s for four years, 14 years or 24 years, the service member’s identity is closely tied to the military. We were Soldiers, Airmen, Sailors, Marines, or Coast Guardsmen literally 24 hours a day. Even if not serving full time, as is the case in the National Guard or Reserve components, service members are always aware of a type of double life. When we leave the service, many of us ask ourselves, “Who am I if I’m not a soldier?” A friend of mine, a medically retired Green Beret, expressed this quite well when he stated, “The Army said I couldn’t be me anymore. What do I do now?

 

Moral injury

Another concept that has emerged over the past 25 years is moral injury. PTSD, at a very basic level, is an injury of the behavior. It is classic conditioning: When a triggering event occurs, a certain reaction is initiated. It is, of course, more complicated than that, but a significant aspect of PTSD is stimulus response. TBI, on the other hand, is a physical injury of the brain. Moral injury can be described as an injury of the soul: What a service member believes to be right and wrong with the world has been fundamentally changed.

In one of the first articles to fully develop an explanation of moral injury, Brett Litz and colleagues described moral injury as “perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.” There is some disagreement as to whether moral injury is an aspect of PTSD or its own distinct condition. the fact is that one can have a morally injurious event that is not traumatic, and there are a number of traumatic events that are not morally injurious. Regardless, it is beneficial for anyone interested in working with the military population to familiarize themselves with moral injury and to at least explore the concept with these clients.

 

Needs fulfillment

The military is a highly connected communal society where tasks are divided among its members. When I was in Iraq and Afghanistan, I didn’t have to worry about where my food and water would come from because there were other service members or contractors who provided that. When my family and I arrived at a new duty station, we were provided housing, and there were people on base who gave us guidance on schools for our children.

Of course, when service members leave the military, those same needs still have to be fulfilled, but now it must be done in different ways. This isn’t to suggest that service members aren’t capable on their own, but challenges related to employment and housing — those lowest levels of Maslow’s hierarchy of needs — are widely known in the veteran population. Even our psychological needs, such as belongingness and esteem, are part of the military framework. Our peer group is provided for us; like them or love them, the people you serve with are your family. Your effort is recognized with rank or reward. Outside of the military, however, we have to learn how to meet those old needs in new ways … and for some service members, that can be difficult.

 

Relationships

The final aspect of mental health in the military-affiliated population that I’ll discuss is relationships. Our mental health affects our interactions with others, and our interactions with others affects our relationships. Whether it is frequent separation, moving households every three or four years, or relationships with people who are literally on the other side of the world, the relationships of those in the military population are necessarily different from those who have never served.

When considering how military service impacts relationships and vice versa, it is important to understand that this doesn’t just refer to intimate relationships such as spouses and children, or even parents and siblings. This also includes peer relationships (friends and acquaintances) and work relationships. Understanding how to integrate into a community that has a different cultural orientation than you do is difficult. Even if none of the other psychological concerns mentioned in this article are prominent, adapting relationships to a new lifestyle can be challenging.

 

Considering all aspects of psychological wellness

It can be daunting to consider how these various aspects may interact to provide an almost never-ending combination of circumstances for members of the military-affiliated population. One thing is clear though: The more of these areas that the service member, veteran, or military family member has difficulty in, the more at risk they are.

As professional counselors, we need to be able to understand the complexity of our clients’ conditions. We need to ensure that we have a full picture of their needs and then address those needs if possible. If an area is outside of our expertise — if we are not trained in an evidence-based practice for PTSD, for example — then we have an ethical responsibility to refer that client to someone who can meet their needs.

In this way, we are providing the best possible care for those who serve, those who have served, and those who care for them.

 

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Duane France, LPC

Duane France is a retired U.S. Army noncommissioned officer and combat veteran who practices as a licensed professional counselor in Colorado Springs, Colorado. He is the director of veteran service for the Family Care Center, a private outpatient mental health clinic specializing in service members, veterans and their families. He is also the executive director of the Colorado Veterans Health and Wellness Agency, a 501(c)3 nonprofit that is professionally affiliated with the Family Care Center. In addition to his clinical work, he writes and speaks about veteran mental health on his blog and podcast at veteranmentalhealth.com. Contact him at duane@veteranmentalhealth.com.

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

Touched by trauma

By Laurie Meyers February 22, 2019

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

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

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

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

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

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

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

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

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

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

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

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

Complex trauma vs. PTSD

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Triggers and trauma responses

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

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

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

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

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

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

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

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

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

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

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

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

Traumatic environments

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

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

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

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

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

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

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

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

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

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

Body guards

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Polk provides examples of possible script dialogue:

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

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

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

Trauma education

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

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

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

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

 

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Additional resources

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

Counseling Today (ct.counseling.org)

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

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

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

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

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

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

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

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

  • Gun Violence
  • Trauma and Disaster

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

  • Traumatology Interest Network

 

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

 

Letters to the editorct@counseling.org

 

 

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

PTSD and climbing out of the valley of the shadow of death

By Shirley Porter January 31, 2019

Max came into my office and sat down. He was a big guy in his late 30s. When I asked how I could help, he responded that he believed he had posttraumatic stress disorder (PTSD). When I asked what led him to this conclusion, he said he had been a sniper in the military and had been abused as a child. (Author’s note: The name of this client has been changed, but the content is accurate in accordance with his written and informed consent to share his story.)

My approach to trauma work has evolved over the years based on what we have come to learn about trauma through research, as well as on my own clinical observations. My therapeutic approach is rooted in client-centeredness, transparency, reverence, compassion and a belief in client strength and resiliency. On the basis of these values, essential components of this approach include accessible language/education, collaboration and evidence-based practice.

When it comes to education and accessible language, the use of metaphors can provide our clients with a much-needed bridge to understanding and normalizing their experiences. Active collaboration with our clients allows them the opportunity to find their power and use it. Because the experience of trauma often involves a feeling of loss of control and having things happen against one’s will, safe and respectful practice requires that clients be informed and willing participants in all aspects of the therapeutic process. And, finally, using evidence-based interventions allows us to provide professional, competent care in helping clients to alleviate their distress, process their trauma and reclaim their lives.

Introduction to the valley of the shadow of death

I often use the metaphor of the “valley of the shadow of death” to explain to my clients the experience of PTSD and the stages of healing. Some clients recognize this metaphor from the Bible’s well-known 23rd Psalm, which begins, “The Lord is my shepherd …” However, its use does not require any spiritual or religious belief on the part of the client or the therapist. I chose this metaphor because of its power.

As I wrote in my book Surviving the Valley: Trauma and Beyond, trauma occurs in “a dark and desolate place that exists in the shadow of some kind of significant ending — a real or symbolic death. In this place, you are apt to feel a profound sense of loneliness, despair and hopelessness. … There are no obvious pathways out of the Valley. The terrain looks treacherous and foreboding. It is difficult to know where to begin.”

In the valley of the shadow of death, the sky is often starless. It can be difficult to recall better times or to hope for them in one’s future. Experiences that send one into this valley typically involve the experience of witnessed, threatened or metaphorical death (e.g., the “death” of trust, innocence, a sense of safety, the belief in fairness or justice). Hope can be elusive.

In my practice, this metaphor has proved to be a powerful means of helping clients find the words to explain what their experience has felt like. I typically introduce this concept somewhere between the first and second phases of trauma work, but I am explaining it to readers here so that the metaphor will make sense from the outset. What follows is the phases of trauma work, explained from the perspective of the metaphor of the valley of the shadow of death.

Phase 1: First things first

Max had never been assessed for PTSD previously. His symptomology was intense. At times, he could be completely dissociated from his body, such as when he walked on a broken leg for a week because he did not feel the pain.

Emotionally, Max was numb. He hadn’t felt emotions for years. He lived his life in survival mode — making him fantastic in a crisis — but Max’s body and mind were always on high alert for threats. He was exhausted, having flashbacks and starting to experience life-threatening medical issues.

We began our work together by assessing and identifying his injuries and normalizing his symptoms. I also started to reflect back his strength, resiliency and courage. At the same time, I was clear with him that he deserved, and would need, external supports along the way. We worked on connecting him with resources for veterans and with medical supports. Max found the metaphor of the valley of the shadow of death to be an apt representation of what he had been living.

 

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Once we have determined that our clients are in the valley, we need to identify, assess and begin to respond to their injuries. There also may be crises that require our immediate attention and response. 

Some clients will have landed hard in the valley. They may have physical injuries in addition to the psychological ones. Before we even think about moving forward or delving into details of the trauma, we need to identify and assess injuries by asking clients which ones are causing them the most distress currently. (I use the Traumatic Stress Symptom Screening Checklist, which I developed and included in my book Treating PTSD: A Compassion-Focused CBT Approach.) At this point, we can discuss whether mobilizing community, medical, family or peer supports might be helpful to the client. If the client needs help connecting with these supports, we may need to liaise or advocate on the client’s behalf.

Reassurance is a component of this phase. Some clients may be carrying the added burdens of guilt or shame that can come with the misunderstanding that if they were stronger, they would not have ended up in this dark place. Thus, we may need to let them know that traumatic stress reactions are not a result of weakness or character flaws; rather, these are normal reactions to what they have been through.

Given that despair and hopelessness can be part of the symptomology of individuals who find themselves in the valley, checking for suicidal ideation and intent is also essential at the start. If a client is suicidal, it is best we are aware of this at the outset so that we can conduct a risk assessment, create a safety plan with the client and mobilize appropriate resources.

Some clients will not have the strength at this point to hold on to hope. With these clients, I tell them that with all they are dealing with, I recognize that their strength might be lacking, but not to worry because I will hold on to hope for them. I further reassure them that I fully believe we will be able to get them to a point where they can effectively manage their distress and reclaim their lives. (Many of my clients in this situation have responded with relief and gratitude.)

Clients might also be living in unsafe environments that require safety planning or other interventions. This can be another piece of assessing and responding to crises in this phase.

Phase 2: Stabilization and gathering tools for the journey

Throughout the course of trauma work with Max, I provided him with information on how trauma, and specifically complex trauma, can affect the mind and body. He was familiar with the fight-or-flight trauma responses but had not realized that his capacity to respond so effectively in high-risk situations was a result of conditioning through his military training. His experiences and symptoms started to make sense to him, and thus his shame receded.

Max had learned to ignore his physical needs at an early age, which is common with children who suffer from chronic childhood abuse. The first homework assignment that I gave him had three parts to it: 1) to notice when he was hungry and to eat; 2) to notice when he had to go to the bathroom and to do so; and 3) to notice when he was tired and to go to sleep. He smiled when I gave him this assignment and asked how I knew.

Max related to the image of the “warrior spirit” (described further later in the article). Although it had meant something else in his military life, we redirected the energies of his warrior spirit to focus on protecting his healing and well-being.

 

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After assessing and attending to injuries and addressing any crises that clients might be facing, it is time to help them get their bearings in the valley and gather the tools they will need for their stabilization and containment — both for use now and on their trauma processing journey (should they choose to take this path).

Some clients will need time to rest and heal before moving on to the next phase of trauma work. We would not expect someone who has just been injured to begin what could quickly become a treacherous climb. Likewise, our clients will need to be stabilized before moving forward in trauma work. They need to be at a point at which they can successfully tolerate or reduce their distress without moving into crisis.

Education is an important component of this phase. Our clients need to know what is normal and what kinds of challenges they might encounter on their journey in the valley. Knowledge about how trauma affects the mind and body can provide our clients with footholds in the valley. We want to help them better understand trauma — specifically, what types of experiences can lead to traumatic stress responses, how people tend to react during traumatic events and the range of normal reactions following such events.

Our clients need to be aware that normal reactions following trauma might include difficulties in the physical, emotional, cognitive and spiritual aspects of their lives. During this part of the work, we are normalizing their reactions during and following their trauma experiences while empathizing with their current distress. It is important that we use easy-to-understand language and concepts in recognition that when our clients are in the throes of severe PTSD symptoms, they can handle only small, personally meaningful pieces of information. 

This part of the work also involves helping our clients identify and become comfortable using the tools and resources that will assist them in better tolerating or reducing the distress that they might encounter on their healing journeys. In my work, I have come to recognize 10 such resources or tools to support clients in their journeys.

Within the clients

1) Recognizing their “warrior spirit” within. This involves giving a name to the persona we want to encourage clients to connect with in terms of dual awareness — the strongest, wisest part of who they are that has allowed them to survive the trauma and brought them to this place.

2) Reducing commitments to reduce distress and give clients the time and space to heal.

3) Confronting or advocating with the people, systems, etc., that were involved in causing the trauma in an attempt to address these wrongs or to achieve a sense of justice (when it is safe to do so).

4) Using distraction strategies. These are actions that clients can take to remove themselves from spirals of nonproductive, stress-elevating thinking. Examples: going for a walk, texting a friend, cleaning, drawing.

5) Using mindfulness strategies. This involves moving clients’ awareness from their distressing reliving of past negative events, or their distressing fears of what might happen in the future, to the present moment via the five senses. Examples: noticing a favorite color in the room; feeling the chair one is sitting on; picking up a stone and noticing its texture, color and shape.

6) Using self-soothing strategies. This involves using the senses to calm, soothe or reenergize. Examples: sipping a hot drink, listening to music, inhaling the scents of nature, wearing soft and comfortable clothes, looking at a picture of a loved one.

Through connection with others

7) Seeking counseling support with a mental health professional who specializes in trauma work.

8) Seeking medical support to address physical or psychological pain resulting from injuries or symptoms that are causing distress.

9) Seeking spiritual support from a religious/spiritual leader or peer.

10) Accepting offers of support from caring friends, family members or peers to do household tasks, help with children or take on other responsibilities.

Phase 3: Beginning the climb

Since Max’s life seemed to go from one crisis to the next, it took some time for him to get to a place in which he wanted to start the climb out of the valley. We started with eye movement desensitization and reprocessing (EMDR), but he didn’t want to continue with it because he found the distress that ensued in the days that followed too disruptive to his academics (he was in a college program). Neither did he feel that he had time to do the homework that came with traditional cognitive behavior therapy (CBT). So, I adapted my interventions and created a compassion-focused CBT intervention that we could use in session.

Using a varied approach that met Max’s needs during any given session, we went down many paths together — grief and loss, guilt, shame, anger, dealing with relationship boundaries and so on. Over time, Max began to experience emotions again and had to learn how to manage them. He also started learning to respect his body and its needs. He became very proficient at self-care.

 

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Some of our clients will not want to proceed with the journey to climb out of the valley. For them, stabilization and containment will be enough. Given that the climb out of the valley can be life-threatening if people go into it unprepared or unwilling, we should never push our clients to take this step. Trauma is often about loss of control or boundary violations. Healing cannot be. We need to respect our clients’ decisions and inner knowing.

For those clients who wish to proceed with the climb and who appear to be strong enough and well-resourced enough to manage it, we have a number of evidence-based options to offer them. As trauma therapists, I believe we need to be skilled in more than one evidence-based trauma-processing intervention (e.g., EMDR, trauma-focused CBT, CBT). Too often I hear of clients being blamed when they don’t fit with the therapist’s approach. Being client-centered as a therapist means that we need to select or modify interventions to best fit the needs of individual clients.

Often, our clients will need to travel many pathways related to their trauma. These pathways might explore issues of grief and loss, the question of forgiveness of others and self, anger, ongoing depression and anxiety, the adjustment of relationship boundaries and so on. Each individual client’s pathway will be unique. Each individual client will lead. We will accompany, providing a safe, professional alliance and skilled interventions to assist the client in moving through, and eventually out of, the valley.

Phase 4: Living with the scars and reclaiming one’s life

Max became aware of how the trauma experiences he had survived had changed him. He learned to appreciate his resilience, adaptability and survival skills. He also came to acknowledge and embrace the truth of his strength and courage. Through accepting who he was, and is, along with his entire story, Max came to a place of peace.

During our last few sessions together, Max spoke about the newfound sense of peace he possessed. For our final session, I wrote him a letter reminding him of where he had started and highlighting his subsequent successes. I also recalled the qualities in him that I had come to admire. Finally, I reinforced in the letter the message that he possessed all that he needed inside of himself to deal with whatever challenges he encountered, but I reminded him that if he ever needed support again, he knew how to ask for it.

 

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Some of our clients will have lived in the valley for several months or years. For these clients, the thought of leaving the valley can invoke both excitement and fear because they will be learning to live in a new way. Thus, the last phase of our trauma work involves assisting clients as they learn to live with the scars (visible or invisible) of their trauma experience; reclaim their lives; acknowledge and celebrate their successes; and move forward on life’s path without us.

PTSD does leave scars, but those scars need to become part of one’s story, not all of it. In this final phase, we work with our clients on how to move forward in reclaiming their power and their lives. Sometimes we will need to assist them in identifying community resources that can continue to support them (such as peer support groups) or causes in which they can become involved that will be meaningful to their healing. Clients living with a disability or chronic pain resulting from their trauma experiences might need a team of medical professionals to provide ongoing support.

This is a time for clients to make conscious and informed decisions concerning how they will move forward in creating their lives outside of the valley. What kind of person do they wish to be? What are their hopes and dreams? Who do they want to have walk beside them on their journey? Do they have certain relationships that need to end or change? These are some of the questions that our clients might explore as they exit the valley. 

This final phase is also a time of celebration, kind of like a graduation, as we prepare and plan for the end of the therapeutic relationship. With that being said, some clients will worry about addressing future challenges without our support. In such cases, we can do some role-playing and problem-solving in advance to help alleviate their concerns regarding potential future challenges. For some clients, this might be an opportunity to rewrite their expectations regarding relationship endings. In collaboration with our clients, we can plan how our last sessions will play out.

Somewhere in this phase, we can also take the time to remind clients of where they began in the valley and where they are now, of how they have changed and what they have accomplished. Although this is something we should be doing in each session whenever there is a success, in this final phase we have a chance to summarize all of these successes at one time so that we can both appreciate the extent of their progress. This is often overwhelming for clients — in a positive, celebratory way — as they come to realize how incredible their healing journey out of the valley has been and as they start appreciating the depths of their own strength and resiliency.

 

 

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Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

Shirley Porter is a registered psychotherapist and a registered social worker who has been providing trauma counseling for more than 25 years. She currently works in the counseling department at Fanshawe College and is an adjunct clinical professor at Western University, both in London, Ontario, Canada. She is the author of two books on trauma: Surviving the Valley: Trauma and Beyond, which was written for survivors of trauma and their support people, and Treating PTSD: A Compassion-Focused CBT Approach, which was written for therapists.

Contact her at traumaandbeyond@gmail.com or via her website, traumaandbeyond.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.

Putting PTSD treatment on a faster track

By Bethany Bray August 27, 2018

An exposure-based therapy method has shown to reduce the symptoms of posttraumatic stress disorder (PTSD) in just five sessions, according to researchers.

Written exposure therapy (WET) consists of one 60-minute and four 40-minute sessions, during which clients are guided to write about a traumatic event they have experienced and the thoughts and feelings they associate with it. Researchers recently tested the method’s effectiveness alongside cognitive processing therapy (CPT), a more traditional talk therapy method that typically involves more than five sessions. Clinical trials were conducted at a U.S. Department of Veterans Affairs (VA) medical facility with adults who had a primary diagnosis of PTSD.

The researchers’ findings, published in JAMA Psychiatry this past spring, suggested that WET was just as effective as CPT in reducing PTSD symptoms.

“WET provides an alternative [treatment] that a trauma survivor might be more likely to consent to, especially if verbalizing the trauma narrative causes a sense of shame or guilt,” says Melinda Paige, an American Counseling Association member and assistant professor at Argosy University in Atlanta whose specialty area is trauma counseling. “The more evidence-based options the trauma counselor has to consider, the more options can be offered to the client. WET provides an option for written expression rather than verbal and a shorter length of treatment, which may be preferable to survivors, including [military] service members.”

“Effective trauma treatment is the antithesis of the traumatic event itself in that survivors experience person-centered core conditions such as congruence/genuineness, nonjudgement and empathic understanding, as well as a sense of control over their recovery experience,” adds Paige, a member of the Military and Government Counseling Association (MGCA), a division of ACA.

MGCA President Thomas Watson agrees that the addition of another method to a trauma counselor’s toolbox will only benefit clients. “Those involved with service delivery to service members and others diagnosed with PTSD are always enthusiastic about how applied, evidence-supported treatment approaches have the potential for effective and ethical positive change,” says Watson, an ACA member and assistant professor at Argosy University in Atlanta. “An obvious goal of the WET approach is to implement effective treatment options that are efficient for both client and clinician.”

The research study involved 126 male and female participants, some of whom were military veterans and others who were nonveterans. The participants were randomly sorted into two groups: those who received five sessions of WET and those who received 12 sessions of CPT.

“Although WET involves fewer sessions, it was noninferior to CPT in reducing symptoms of PTSD,” wrote the researchers. “The findings suggest that WET is an efficacious and efficient PTSD treatment that may reduce attrition and transcend previously observed barriers to PTSD treatment for both patients and providers.”

The researchers reported that the WET group had “significantly fewer” dropouts (four) than did the CPT group (25).

This factor is another reason for counselors to consider using WET, Paige notes. “Maintaining a survivor’s physical and emotional safety and doing no harm by utilizing evidence-based and minimally abreactive trauma reprocessing interventions is essential to trauma competency. Therefore, WET may be a less invasive and more tolerable exposure-based PTSD treatment option,” she explains.

At the same time, Benjamin V. Noah, an ACA member and past president of MGCA, was discouraged to see that the study excluded PTSD clients who were considered high risk. Individuals had to be stabilized by medication to be included in the clinical trials.

“Many of the veterans I have worked with dropped their medications [because] they do not like the side effects. Therefore, I believe the study overlooked veterans that may be higher risk,” Noah says. “Additionally, a high risk of suicide was an exclusion for being in the study. Again, this leaves out those veterans who need help the most and could benefit from a short-term approach.”

Noah, a licensed professional counselor in the Dallas area whose area of research is veteran mental health, has used written therapy methods in his own work with veteran clients and has found the methods helpful. A therapy session provides a safe and supportive environment for clients to write about traumatic experiences – particularly clients who may be trigged by the exercise when alone, he explains.

“I have had veterans triggered doing [writing] as homework; keeping the writing in session acts as a safety measure for the [client]. Helping veterans resolve their event or events — which I call the ‘nightmare’ — that led to PTSD has been a focus of my work since I was able to put my own nightmare to bed,” says Noah, a U.S. Air Force veteran and a part-time faculty member in the School of Counseling and Human Services at Capella University.

WET is one of many methods that should be considered by clinicians working with clients who have PTSD, Noah adds.

“I would like to see more research within the VA and National Institute of Mental Health on the use of Viktor Frankl’s logotherapy, solution-focused brief therapy, sand tray therapy and other approaches that counselors are using in their work with veterans,” Noah says. “There are articles focusing on other approaches, but these tend to be the experiences of a few counselors and do not have the research rigor used by [the WET study researchers]. I do applaud the authors for showing the efficacy of a brief therapy approach for use with veterans, and I do plan to look deeper into written exposure therapy and perhaps use it in my future work with veterans.”

 

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Find out more:

 

Read the research in full in JAMA Psychiatry: jamanetwork.com/journals/jamapsychiatry/article-abstract/2669771

 

From the National Institute of Mental Health: “A shorter – but effective – treatment for PTSD

 

Related reading from Counseling Today:

Controversies in the evolving diagnosis of PTSD

Informed by trauma

Exploring the impact of war

 

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Follow Counseling Today on Twitter @ACA_CTonline and Facebook at facebook.com/CounselingToday.

 

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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.

 

Becoming shameless

By Laurie Meyers April 25, 2017

You should be ashamed of yourself.” How many of us have heard — or perhaps even used — that phrase? Being on the receiving end of such a pronouncement is never pleasant. More important, experts firmly believe that attempting to wield shame as an instrument of change is both ineffective and harmful. In fact, many clinicians say that shame is intertwined with an abundance of issues that typically bring clients to counseling. Furthermore, it often stands as a significant barrier to healing.

In her book I Thought It Was Just Me (But It Isn’t), Brené Brown defines shame as “the intensely painful feeling or experience of believing we are flawed and therefore unworthy of acceptance and belonging.” The research professor at the University of Houston’s Graduate College of Social Work believes that shame has become a kind of silent epidemic in society that serves to isolate us and thus damages our sense of connection to others.

Thelma Duffey, the immediate past president of the American Counseling Association, agrees. One of her main initiatives as president focused on issues surrounding bullying and interpersonal violence, both of which can leave people struggling with a deep-seated sense of shame. “I see shame as a deeply painful feeling that people experience when they feel exposed, inadequate or especially vulnerable,” she says. “Unforgiving and powerful, shame can leave many people feeling unworthy and incapable.”

Bullied into shame

The practice of actively shaming others, particularly through bullying behaviors, is all too common in our culture, says Duffey, a practicing licensed professional counselor and licensed marriage and family therapist for more than 25 years.

“Bullying can trigger feelings of shame, leaving people feeling defenseless, embarrassed and confused,” she says. “Some feel such a strong sense of self-consciousness and become so preoccupied with avoiding shame-inducing situations that they withdraw from others, which can lead to an excruciating form of isolation.”

Without the consistent presence of love and support in a person’s life and the provision of a realistic viewpoint from others, there is no counterbalance to shame’s narrative.

“Imagine holding a broken mirror of yourself and believing that the distorted image is what you truly look like,” Duffey says. “Your perception would be off, wouldn’t it? Now imagine you are holding a broken mirror that reflects a distorted image of who you are as a person. If you believe this distortion, it won’t be easy to feel good about yourself or to connect with other people who love you. It will probably lead you to see the world as an unsafe place. In all likelihood, you’ll have to create ways of coping with these images just to survive. Too many times, these coping strategies ultimately keep us from the very connections we desire.”

Duffey says there is an antidote. “I believe that developing a sense of self-compassion is at the core of conquering shame,” she says. “Unfortunately, self-compassion is not always easy to come by, particularly when a person has been mistreated, publicly mocked or hurt, as is generally the case with any bullying situation. In fact, introducing the idea of self-compassion can actually make people wince when they live with feelings of shame, because it sheds light on their self-loathing perceptions.”

Counselors can use a variety of methods to help clients develop self-compassion, but a strong therapeutic bond is the most essential ingredient in that process, says Duffey, who is also a professor and chair of the counseling department at the University of Texas at San Antonio. One of the interventions she uses is Emotional Freedom Techniques (EFT).

“EFT has been described as a type of psychological acupressure that can help unblock distressing situations,” Duffey says. “The idea is to restore balance to the body’s energy field to move negative emotions that can keep us stuck. I also see it as a way for people to center themselves when they are in their uncomfortable emotions and to connect with themselves in a more soothing way.”

Duffey says that EFT in its traditional form has a sequence that involves identifying the problem — for example, shame — and then having clients ask themselves how they feel about the problem right now. Clients then rate the level of intensity of the problem, with 10 being most intense and zero being least intense. Next, the counselor and client come up with a “setup” statement that acknowledges the problem and follow that with an affirmation. Clients then repeat the statement and affirmation while performing a kind of “psychological acupuncture” that involves taking their hands and tapping five to seven times on the body’s “meridian” or energy points.

“A person experiencing shame and with memories of bullying might say something like, ‘Even though it is not always easy for me to see my own value, I deeply and completely love and accept myself,’” she says. “Or, ‘Even though I can still remember the horror of being made fun of, excluded and shunned, I can be on my own side now. And I am not alone. In fact, I am working on loving and accepting myself.’”

Once a person connects with the problem and the idea of loving, self-compassionate affirmations, he or she can use those affirmations to process all sorts of experiences, Duffey says. “The idea, of course, is not about thinking positively or practicing self-delusion,” she notes. “Rather, it is about really being honest about what hurts and confronting these feelings, [and then] offering affirmative statements of hope and compassion while tapping into the body’s energy using acupressure points.”

Duffey recommends the website thetappingsolution.com for those who would like to learn more about EFT.

The trauma-shame connection

At the ACA 2017 Conference & Expo in San Francisco this past March, licensed mental health counselor Thom Field presented “For Shame! The Neglected Emotion in PTSD.” In the session, he explained that shame is a significant component of posttraumatic stress disorder (PTSD), particularly in cases of interpersonal trauma, such as child abuse and intimate partner violence.

Because PTSD’s most common symptoms — hypervigilance, nightmares, flashbacks, intrusive memories and physiological hyperarousal — are all related to fear of external danger, experts in the trauma field have traditionally focused on fear as the primary emotion in PTSD, noted Field, a member of ACA. Using this assumption, therapy techniques for PTSD have focused on methods such as exposure therapy, he said. In exposure therapy, clients are asked to revisit the trauma multiple times because repetition has been shown to help lessen the physical and emotional effect of these memories.

However, new research suggests that trauma survivors often also fear being rejected and exposed as weak. This fear engenders a sense of shame, said Field, an associate professor and associate program director of the counseling master’s program at the City University of Seattle. He explained that the shame is fueled by a persistent negative self-appraisal in which clients who have experienced interpersonal trauma often berate themselves with statements such as “I am weak — an easy target”; “Something is wrong with me if I can’t prevent these things from happening”; or “Why didn’t I do something?” Trauma survivors often feel inadequate, inferior or powerless to affect their own environments, he added.

Field believes that counselors must understand the role of shame to help many of these individuals who are living with PTSD. “Shame is an emotion that arises when a person feels inadequate or corrupted by an irredeemable act or a contaminating event,” Field explained. “The person feels undesirable and unattractive and fears the perceived judgment of others.”

It is also important for counselors to differentiate shame from guilt, Field noted. He defined guilt as regret for a specific action that is bound to external circumstances. It is a feeling connected to what one has done rather than — in the case of shame — what one is, Field emphasized. Whereas guilt can motivate prosocial actions such as reparation, shame usually motivates self-protective actions such as withdrawal or lying to protect secrets, he pointed out.

Among the factors that increase feelings of shame in those who are experiencing PTSD or interpersonal trauma are the attribution of responsibility (such as the perception that having HIV or AIDS is that person’s “fault”); the level of visibility and an inability to “hide” (because of circumstances such as physical disability or disfigurement); and being marginalized, Field said.

Feelings of shame may prevent some people with PTSD from seeking counseling, and even those who do seek counseling may deny the presence or impact of trauma if a counselor asks them about it directly, Field said. Harboring a sense of shame may also make it difficult for clients to trust others, he added, so counselors must take care to proceed slowly and focus on developing the therapeutic alliance. These clients need to be made to feel safe enough to reveal their secrets and process their fear of rejection, humiliation and judgment by others, he emphasized.

An important step in the process is for counselors to facilitate client autonomy with what Field termed “pre-questions.” For instance, a counselor might say, “It seems like it might be helpful to revisit this event. How ready are you to face that?”

“If you dive in [yourself as the counselor], it feels [to the client] like it’s not voluntary,” Field explained. When counselors press the processing of shame before clients are ready, it can cause clients to, in essence, feel shame about their shame.

Counselors should also let clients know what to expect when they decide to share their trauma. For instance, Field said, “The client is going to feel physiological symptoms.”

Through client mirroring and active listening, counselors can help establish a sort of holding container for these clients’ emotions. This takes away the pressure of having to “do” anything with those emotions, allowing clients to feel safe simply “sitting” with their feelings until they are completely ready to process them, Field explained.

Like Duffey, Field thinks that self-compassion is essential to overcoming shame. The ultimate goal is to teach clients to accept their current and past experiences without self-judgment, he said. Field recommended that counselors use some of the exercises developed by psychologist and self-compassion researcher Kristin Neff. These include having clients imagine how they would treat a friend who was in the same circumstance, writing letters to themselves from a place of compassion, changing critical self-talk through reframing, keeping a self-compassion journal and practicing loving-kindness meditation.

The lasting shame of abuse

For clients who were sexually abused as children, the sense of shame is almost primal, says ACA member David Lawson, who has worked with trauma victims for more than 25 years. Time after time, women in their 30s and 40s have sat in Lawson’s office and insisted that it was somehow their fault that they were sexually abused as children.

“They say, ‘There must be something wrong with me.’ ‘I’m bad.’ ‘I’m contaminated,’” says Lawson, a counseling professor at Sam Houston State University in Texas who has conducted extensive research on trauma. “I’ve even had several people say, ‘I must be evil in some way for this to happen to me.’”

When parents are the perpetrators of sexual abuse, the abuse survivors’ sense of shame is particularly strong, Lawson says, because humans are wired to seek attachment with parental and other caregiving figures. To maintain this attachment, child victims must rationalize the abuse. As a result, these children often tell themselves that they are bad rather than accepting that the parent is not good, Lawson explains.

Another factor that contributes to these children’s feelings of shame is the perceived “benefits” they received from their abusers, Lawson says. He recounts the story of a female client in her 20s.

“She was abused from the ages of 5 to 16 by her father [until] her mother finally left the father. Years later she came into therapy, and I said, ‘Tell me about some of the best times in your life.’ She said that they were with her father: ‘At times I felt like I was my father’s girlfriend.’ There were benefits for her. He would buy her things and take her places, which he did not do with her siblings. Then, at night, the abuse would happen.”

The woman went on to confide to Lawson that the worst times in her life were also with her father. “He would tell her, ‘No one else will love you. You are worthless. No one will have you but me,’” Lawson says.

Abusers often use this technique, aware that if their victims feel there is nowhere else they can go and be accepted, there is a greater chance they will stay in the only place they seem welcome. This “acceptance” increases victims’ sense of connection to their abusers, Lawson says.

These patterns are distinct and specific to what Lawson calls the “trauma subculture.” The behaviors and beliefs of survivors of sexual trauma are so antithetical to most people’s expectations that outsiders — including many counselors — often find their reactions difficult to understand, he says.

“One of the hardest things for my students to get over is the way that [sexual trauma survivors] look at the world and the way they think about themselves,” Lawson says. “We just want to run over and hug them, but that just ramps up their shame because they don’t believe that they’re worthy.”

Early in his career, Lawson learned how premature sympathy and acceptance could backfire. He told a client that the abuse the client had suffered was not his fault, and the client got quite angry with Lawson, rejecting his help because he genuinely thought that Lawson didn’t know what he was doing.

What Lawson learned with that experience is that in immediately trying to correct clients’ beliefs about their abuse, counselors threaten to take away a major part of the identities that clients constructed as a way to survive. Today, Lawson urges counselors to move slowly with these clients and first work toward establishing a strong therapeutic bond.

“It may take many sessions just for them to feel comfortable,” he says. “These people don’t trust anyone, so to think that they’re going to trust in a few sessions is naïve and counterproductive.”

Start by accepting these clients where they are and reflecting on the dilemma they are facing, Lawson advises. “On the one hand, they feel an enormous amount of allegiance. On the other hand, they have strong feelings of hate,” he explains.

After counselors have established a relationship, they can introduce the idea of talking about the client’s experience. A counselor could say, “Talk to me about your relationship with your father and how you came to the conclusion that you’re not worthy of anyone else’s love,” Lawson suggests. He adds that counselors must give clients time to reflect and reconstruct how they came to their conclusions about self-worth.

Lawson says that once he asks those kinds of questions and lets clients unpack and narrate their experiences at their own pace, they are usually able to begin seeing how their erroneous, negative self-beliefs were shaped by what happened to them. He cautions, however, that intellectual understanding is not the same as emotional acceptance, which can take additional time. Lawson notes that some experts view this kind of shame as an annihilation of self. Survivors may feel that there is no part of themselves that is worth forgiving, he explains.

In the process of helping clients see themselves as redeemable, fully acknowledge the abuse that happened to them and grieve what was lost, counselors should be supportive, but they must also modulate their affirmation to a level that the client can handle, Lawson cautions. “If we’re too warm and nurturing, the client takes that and rejects it and sees us as incompetent because we don’t understand,” he says.

For that matter, trauma (and shame) may not be the stated concern that brings survivors of sexual abuse into counseling in the first place. Instead, the presenting issue may be depression, anxiety, relationship difficulties or something else, Lawson says. “I deal with whatever they present with and try to help them get some relief from those things,” he says.

But along the way, Lawson introduces the idea of addressing and processing the trauma with clients. He may approach it in a very general way at first, perhaps by asking clients to talk about the trauma as if it happened to someone else.

Lawson may also use a “lifetime line.” He starts by asking clients to pick a year of their lives and talk about everything they can remember about it — good and bad. By doing this, clients are not only processing trauma, but also remembering that there were positive events in their lives too, he says. Lawson also has clients write down all the positive memories to help remind them, as they construct their life narrative, that the abuse does not encompass their entire life.

Lawson says he finds narratives, either written or spoken, vital in treating clients’ shame. By showing compassion for their narratives, counselors can help clients start to feel compassion for themselves, he says.

Shame beliefs

Gray Otis, a licensed clinical mental health counselor in Cedar Hills, Utah, believes that shame is typically a component in traditional mental health disorders such as depression and anxiety. In fact, he says, shame likely underlies most issues for which clients come to counseling.

“Typically, the individuals who come for treatment have strongly held negative core beliefs about themselves,” says Otis, who has extensive postgraduate training in trauma treatment. These negative core beliefs are not just about behavior, he adds, but actually inform people’s sense of who they are.

Otis, whose counseling approach is centered on positive behavioral health, thinks that these beliefs stem from incidents that evoke a sense of shame in the person. Such events typically take place in childhood or adolescence, but adults can experience them too. These incidents may or may not be described as “traumatic.” Negative core beliefs can be caused by an accumulation of painful events, such as consistently being criticized as a child or going through a divorce. The resulting beliefs can take many forms, Otis says, but they generally revolve around reinforced themes — for instance, a person growing to believe that he or she is stupid, unworthy, undeserving and unlovable.

Otis believes the key to addressing clients’ mental health issues is uncovering and dispelling their shame-based negative core beliefs. The difficulty counselors may face in unraveling a client’s core beliefs will vary depending on the person and the complexity of his or her presenting issues. However, Otis says he finds it relatively straightforward to uncover many of these beliefs. When he asks clients to identify some of the things they believe about themselves that are not positive — Otis directs them to use “I am” statements — they can usually identify five or more negative beliefs, he says.

What is particularly potent about the beliefs underlying these “I am” statements is that people tend to perceive them as being inherent, unchangeable personal traits, Otis says. Many of these core beliefs are subconscious, he adds. By helping clients bring them to the surface and recognize that they are beliefs, not traits, counselors can assist clients in replacing negative beliefs with positive core beliefs.

Otis does this by having clients explore the origins of one of their negative beliefs, asking them when they started believing this internalized truth about themselves and what happened that contributed to that belief. Otis then asks clients to focus on one of their most distressful experiences and “freeze” it, as if it were a photograph. He then urges them to describe the emotional sense of the experience, identify their degree of distress and state the shame-based negative core belief (such as “I am never good enough”).

The next step is for clients to specify the positive core belief they desire. Otis then helps them identify life events that reinforce the new, positive core belief. He asks clients to remind themselves of these reinforcing events daily as a way to continue strengthening their positive belief. Next, Otis has clients revisit the experience that engendered the negative belief, and he talks with them about how the event was misinterpreted.

Otis says he also uses methods such as sand tray therapy, eye movement desensitization and reprocessing, and cognitive behavior therapy not only to help clients develop more positive beliefs but also to become more resilient. He emphasizes, however, that the most important factor when working with shame-based negative core beliefs is a strong therapeutic alliance.

Ultimately, he says, helping clients rid themselves of persistent shame is what opens the door to healing.

 

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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.