Tag Archives: Trauma and Disaster

Trauma and Disaster

The Counseling Connoisseur: Enough: A call to action

By Cheryl Fisher July 20, 2018

“Thou shalt not be a  perpetrator, thou shalt not be a victim, and thou shalt never, but never be a bystander.” ― Yehuda Bauer

 

The sun warmed my body. Blissfully fatigued following several laps around the pool, I stretched out on the chaise lounge chair. I sipped my cool lemonade and haphazardly lifted my phone which had been vibrating endlessly. Who on earth was trying to reach me? I had prepared my clients for weeks regarding my vacation. I had set my away message on my phone. Who could possibly need me right now? My eyes squinted at the list of messages. “Are you ok?” “Where are you? I am worried?” “Please tell me you are safe?!”

My lazy summer mental fog abruptly dissipated as I sat up in my chair and began to read through the barrage of inquiries. What on earth is going on? I quickly tapped my responses. “I am fine. At the beach. What is happening?” I read the responses over and over waiting for the punch line, but there was none. My beloved community of Annapolis joined the ever-growing fraternity of gun violence and those men and women who reported the daily news were the target this time. The Capital Gazette was under attack with several fatalities and multiple injuries.

Reaction

I have been a counselor for twenty-plus years. I am a volunteer for the American Red Cross disaster mental health team and Maryland Responds Medical Corps. I have been deployed and provided crisis intervention to victims, and offered crisis debriefing to first responders. Professionally, this work is not new to me. However, to watch the devastation and suffering of my community from one hundred miles away was excruciating. I watched as the first responders whom I had brought homemade cookies to during the holidays risked their lives to enter the building under attack. I witnessed people I know being escorted from the building — the same building I had visited a week earlier for an endodontist appointment. I observed the swift and definitive execution of the emergency plan play out on national television. including scenes of the ambulance taking victims to the emergency room where I had served as an on-call counselor for 10 years. These were my people! The agony was palpable even from the safety of the beach. Rumors flooded social media, and I waited for news of missing persons.

I took inventory of my internal status. I am, after all, a therapist. I felt frightened for the families who had to sit with so many unknowns about the well-being of their loved ones. I felt helpless being so far away. I felt angry that we continue to experience this type of violence. Enough is enough! It is past time for counselors to make decisions and act.

Action

Counselors have a unique role following a disaster in that we are called to help heal a community’s trauma. We counsel survivors and families and debrief first responders. We help bring agency back to a community that may feel disempowered and devastated. The safety once experienced, crumbles and we aid in the creation of a new normal.

My first act was to contact Maryland Responds to see if we were going to deploy. The local Warmline — a non-emergency helpline that offers immediate counseling or referral services — had begun advertising grief counseling services and I knew that the first responder employee assistance programs would soon reach out for aid in debriefing the responders. However, like many communities, the Annapolis area is tight-knit, so the traumatic effects of the tragedy would be widespread. One of the local mental health networking groups spearheaded the creation of a list of providers willing to volunteer both medical and mental health services over the next several weeks. Clinicians from all over the county responded, zealous to do their part to help in the recovery effort. As clinicians, we know that initially there are rituals, memorials, vigils and casseroles that remind us of the solidarity of experience in these losses. However, when people attempt to resume their previous lives, they trip over metaphorical landmines that they don’t expect. Counselors can help clients to anticipate and disarm the mines.

Change

On February 27, ACA adopted a resolution supporting and highlighting the role that school counselors and other professional counselors play in addressing the anxiety, stress and trauma students experience after a school shooting.  The resolution also calls for adequate federal funding for research into the public health impact of gun violence and evidenced-based strategies for preventing and addressing gun violence.

In an Annals of Epidemiology article published in 2015, researchers Jeffrey W. Swanson, E. Elizabeth McGinty, Seena Fazel, and Vickie M. Mays reviewed research on the relationship between violence and mental illness. They found that the presence of mental illness is not an effective predictive factor for violence against others. Instead, they advise policymakers to focus on evidence-based risk factors such as previous violent behavior. They advocate for “time-sensitive risk assessment for violence as the foundation of evidence-based criteria for prohibiting firearms access, rather than focusing broadly on mental illness diagnoses and a record of involuntary psychiatric hospitalization at any time in one’s life.”

The authors’ conclusions highlight the need to train all mental health providers in violence assessment. The use of evidence-based criteria — rather than a diagnosis of mental illness — to prohibit firearm access requires a change in current policies and procedures. Saying “enough!” in the face of gun violence is neither a partisan statement nor an opposition to the Second Amendment. It’s a call for an end to the death and trauma. Gun violence permeates our society in multiple ways — not just in mass shootings but also through gun-related crime and suicide. Complex issues surround this violence, but there are definite steps we as a society can take such as reexamining gun control policy, demanding further research on predicting violent behavior, addressing insufficient access to mental health care and reducing the stigma attached to seeking care.

As counselors, we are trained to be value-neutral. We support the goals of our clients even when they directly oppose our own beliefs. We offer a non-judgmental presence. Regarding mental health care accessibility and gun violence, we need to dare to have an opinion. We need to know the platforms of our representatives and have their office number on speed dial. We need to use the strength of our collective voices and demand change.

Conclusion

Annapolis, Maryland, USA downtown view over Main Street with the State House.In the wake of the attack, I heard my community’s resounding cry of solidarity with all the victims of gun violence. Naptown Strong! We love you, Annapolis! And just like every other school, church, concert, movie theater and community affected by gun violence, we are striving to put the pieces back together from a horror that will forever inform our narrative. Enough is enough! Prayers and thoughts must be followed with action!

Annapolis and the Capital Gazette will not be defeated by violence. In the immediate aftermath of the shooting, the staff at the Gazette refused to be silenced. “I can tell you this: We are putting out at damn paper tomorrow,” tweeted reporter Chase Cook. And they did. Let us all be inspired by the courage and the conviction of these journalists.

 

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Resources from ACA relating to gun violence and trauma for, both counselors and consumers: counseling.org/knowledge-center/gun-violence-trauma-resources

 

 

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Cheryl Fisher

Cheryl Fisher is a licensed clinical professional counselor in private practice in Annapolis, Maryland. She is director and assistant professor for Alliant International University California School of Professional Psychology’s online MA in Clinical Counseling.  Her research interests include examining sexuality and spirituality in young women with advanced breast cancer; nature-informed therapy: and geek therapy. She may be contacted at cyfisherphd@gmail.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.

 

Behind the book: Disaster Mental Health Counseling: A Guide to Preparing and Responding

Compiled by Bethany Bray July 2, 2018

Superstorm Sandy. Newtown. The Pulse nightclub. Counselors were there to help people through all of those disasters, plus countless others, both natural and human-caused, through the past decade.

Disaster mental health counseling has grown and become more standardized in the process. With each disaster, practitioners learn the subtleties of what survivors and communities most need, both immediately after the fact and in the later aftermath.

With that in mind, the American Counseling Association published an updated edition of Disaster Mental Health Counseling: A Guide to Preparing and Responding this year. The book shares insights from counselors who have served on the ground in disaster-relief efforts in a variety of situations, from work with refugees and veterans to school, university, community and international settings.

Counseling Today recently sent the book’s co-editors, Jane M. Webber and J. Barry Mascari, questions via email to learn more. Webber and Mascari are licensed professional counselors and counselor educators at Kean University in Union, New Jersey. The couple are married and present together often on disaster mental health, crisis response and trauma counseling.

 

Q+A: Disaster mental health counseling

Responses co-written by editors Jane M. Webber and J. Barry Mascari, as noted

 

As specialists in disaster mental health, you give presentations and trainings on this topic often. What are some common questions you get from attendees? What are people most concerned or curious about?

 

Mascari: The ripple effect of the growing body of evidence gets questions from various audiences, including law enforcement. So many people are interested in learning emotion regulation, and we are getting more requests to address techniques to help counselors prevent vicarious traumatization. One of my favorite questions related to these techniques is, does this stuff really work? Then they tell us how amazed they are.

Webber: Over the years at Learning Institutes on disaster mental health counseling [at ACA’s annual conference] and state trainings, one question arises quickly: What do I say or do next? Especially after events of mass violence, responders ask, how do I respond in moments of crisis or terror?

Many are fearful of retraumatizating survivors or asking intrusive questions. Counselors also ask how to integrate trauma assessment and counseling with psychological first aid (PFA) as nonintrusive, compassionate lurkers while being alert to survivors in need. Probably the question most often asked is how to respond to families after mass shootings or bombings, particularly when children are killed or injured.

 

Disaster mental health is becoming a more prevalent and growing focus within the counseling profession. Besides your book, what resources would you recommend for counselors who want to “come up to speed” in this area – especially for counselors who did not cover this topic in graduate school?

 

Mascari: Taking online courses from the Federal Emergency Management Agency (FEMA) for sure. Also, there are a lot of online programs and great books. Many of the important works have not hit the journals but are in paperbacks that appear every day. Counselors cannot operate without being trauma informed and, at best, I would certainly like to see all our colleagues become trauma competent.

Everyone works with trauma survivors. [But some practitioners] either don’t look for or ask about trauma and then treat symptoms that could be more easily resolved if the causes were addressed.

Webber: I agree with Barry: ICS 100 (Incident Command System) and ICS 700 (National Incident Management System) are FEMA organizational courses [that can help] counselors know what to expect at any disaster site anywhere in the country. The Psychological First Aid Online course provides foundational knowledge and skills for delivering PFA in the immediate aftermath of a disaster (learn.nctsn.org). A must is to download the Psychological First Aid: Field Operations Guide to your laptop. Resources and handouts in the guide’s appendices are invaluable, especially the charts with what to say to people at different developmental levels (children, adolescents, adults). Also, the TIP 57: Trauma-Informed Care in Behavioral Health Services manual is our go-to book for trauma-informed counseling. All are free.

 

Do you feel the average counselor practitioner is adequately prepared for the possibility of a disaster — either natural or human-caused — occurring in his or her community? Generally speaking, is there a “that could never happen here” mentality among counselors, or a healthier viewpoint?

 

Mascari: No! There are many skilled, well-meaning counselors who could not serve alongside other mental health responders just because they do not have the basic knowledge expected of the American Red Cross or FEMA.

PFA, the preferred FEMA modality immediately after a disaster, is not counseling in the traditional sense. Therefore, being trained to respond as part of a recognized unit means following established protocols and putting away some of the more invasive counseling techniques. This is based on the idea that people are experiencing a normal reaction to an abnormal event, and that the majority of people return to normal in a relatively short time … My students often say that they feel like their skills have been “dumbed down” [for PFA] at first, then they realize these are valuable tools and incorporate them in their counseling.

As far as the head-in-the sand view, I don’t think most counselors see it that way. We do need to do more from a leadership level to make disaster and trauma more of a priority and more central to what we do. Many times, I look at what I know and what I can do and feel like, “If I only knew this when I worked with clients a few years back.” The new skills promise “better, stronger, faster” in terms of treatment and recovery.

Webber: The misbelief of “that could never happen here” has been destroyed by the deaths of students and teachers across the country [in school shootings]. Like suicide prevention and intervention, every counselor must be trained and prepared for disaster and mass violence that might occur in our communities and schools.

 

Much has changed – in the counseling profession and the world at large – since the last edition of this book eight years ago. Briefly, tell us what it took to update the material and why you felt it was worth rereleasing this text now, in 2018.

 

Mascari: The update was a huge undertaking, basically a redo and reconceptualization of the chapters and the style of the book. It is more scholarly and evidence based and not as raw as the articles that came from the heart and experiences in the earlier book. The field is becoming professionalized, and it appeared to be time to change the focus. Our [ACA VISTAS] article on the Council for Accreditation of Counseling and Related Educational Programs (CACREP) Standards and disaster received a large number of reads, so we know other counselor educators are struggling to include these standards in their teaching. The book brings everyone up to a new standard.

Webber: We all [the book’s close to 30 contributors] worked as a mini think tank with much discussion and debate to document the rapid growth of this counseling field. It was challenging for our authors to revise and update chapters seamlessly into the book and to emphasize the critical relationship between trauma and disaster counseling.

PFA has been a vital development for disaster response. Yet, for a few years, trauma counseling and disaster response were split. We have reintegrated the practice of trauma and disaster counseling to move the profession forward.

 

What interests you, personally, in this topic?

 

Mascari: My interests are described in the book (in a section of chapter 13, “In Our Own Words: I Never Thought I Would Become So Focused on Disaster and Trauma”), but briefly: I have been responding to disaster and traumatic events throughout my career, before there was a name for this type of work.

Webber: For me, trauma-informed practice has been an ongoing commitment since I was chairwoman of the ACA Foundation during Sept. 11. Responding to disaster survivors is an existential risk that defines who I am as a counselor. I can choose to respond with courage or shy away from helping. Disaster training is essential for our profession to stay on the cutting edge of mental health counseling, especially in an era of mass violence.

 

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Disaster Mental Health Counseling: A Guide to Preparing and Responding, fourth edition, is available both in print and as an e-book from the American Counseling Association bookstore at counseling.org/publications/bookstore or by calling 800-347-6647 ext. 222.

 

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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.

 

 

The high cost of human-made disasters

By Lindsey Phillips March 1, 2018

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

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

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

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

Rebuilding trust, regaining control

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

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

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

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

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

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

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

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

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

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

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

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

Bridging cultural differences

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

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

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

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

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

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

Making meaning of human-made disasters

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

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

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

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

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

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

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

Self-care and counselor fatigue

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

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

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

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

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

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

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

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

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

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

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

Lessons learned

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

Letters to the editorct@counseling.org

 

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

The mental health aftermath of Harvey, Irma

By Bethany Bray September 18, 2017

Residents of the Caribbean and the southern United States are still grappling with the aftereffects of two immensely powerful and destructive hurricanes — Harvey and Irma — both of which caused widespread damage and left millions of people displaced. Rebuilding what the hurricanes destroyed will be a long and painful process, but counselors who live and work in the hardest hit areas have seen people from within and without the damaged communities come together to help each other. This sense of community and resilience will help many of those affected to recover without signs of mental health problems, but counselors also caution that some residents of the storm-wrecked areas may experience greater trauma and require more time to recover.

Maureen C. Kenny, a professor of counselor education at Florida International University in Miami, has seen Hurricane Irma spur a significant amount of anxiety in her area, from worry over whether to evacuate to the stress of having children home from school for an unknown length of time.

“For many parents, they may need to return to work but the children are not [back] in school yet, so child care is an issue. Many families are without power and still dealing with hot weather, uncomfortable living situations and limited ability to cook or eat,” Kenny, an American Counseling Association member with a part-time counseling practice in Fort Lauderdale, said in the days following the storm.

At the same time, Kenny said she’s seen community members come together to help one another, such as neighbors helping neighbors install hurricane shutters and fix generators.

“Since people are often without power for extended periods of time, they spend time outside talking to their neighbors. People are out walking dogs, kids are riding bikes and neighbors are sharing storm stories,” Kenny said. “In a strange way, it brings people together. Without electricity, people are forced outside and have more contact with one another.”

NASA satellite image of Hurricane Irma passing Cuba on Sept. 8.

Harvey was a Category 4 hurricane as it made landfall near Corpus Christi, Texas, on Aug. 25. The storm then stalled over southeast Texas for days, bringing heavy rainfall and catastrophic flooding. Irma — one of the most powerful Atlantic storms ever recorded — was a Category 5 hurricane when it razed many of the islands in the northeastern Caribbean and “skirted” Puerto Rico, leaving 1 million residents without power. The storm had dropped to a Category 4 hurricane when it made landfall in the Florida Keys Sept. 10 and began its slow march up the Sunshine State.

Forecasters are also keeping an eye on two more hurricanes, Jose and Maria, which are currently churning in the Atlantic Ocean.

The barrage of catastrophic weather has brought weeks of news coverage and warnings to evacuate or stock up on emergency supplies.

“With technology’s advance notice of hurricanes, it allows people to get ready but also adds a lot of anticipatory anxiety,” Kenny said. “Schools and businesses were closed several days before

ACA Member Maureen C. Kenny took this photo of near-empty shelves in the bottled water aisle at a Winn-Dixie grocery store in Cooper City, Florida on Sept. 6, which was four days before Hurricane Irma made landfall.

the storm actually hit. This left people waiting for the storm to hit and unsure of what exactly would happen. … As days grew closer to the storm, there were long gas lines [at gas stations], the shelves at the stores were empty and people may have not been able to get supplies.”

ACA member Jeffrey Kottler also saw people pushed to their limits during the time he spent as a disaster mental health volunteer at Houston’s George R. Brown Convention Center in the days after Hurricane Harvey. At the peak of the crisis, the facility sheltered more than 9,000 people.

Kottler, a clinical professor of psychiatry at Baylor College of Medicine in Houston, worked with psychiatry colleagues from Baylor in a tent at the convention center, offering support and a sympathetic ear. They did everything from offer psychological first aid to help people contact family members, refill medications and get a new driver’s license because theirs was lost in the flooding and chaos that followed the storm.

When a distraught person would enter his team’s tent, Kottler said his approach was to pause, calm the person down and give the person time to tell his or her story, even if that meant walking around the conference center with the person or finding a quieter place to talk.

People were overwhelmed on many levels, Kottler said. Not only were they reeling from the loss of homes, vehicles and other personal property, but they were crammed in close quarters with complete strangers.

“[The convention center] was the most chaotic environment imaginable, and people’s brains were going off like fireworks,” Kottler said. “It’s hard to describe the chaos of what it was like to be there, seeing [thousands] of beds, with dogs barking and babies crying. People were just in shock.”

“Imagine having a car, a job and a home, and then in one day, it’s all gone and you’re living with 9,000 people. Those were most of the people that I was spending time with [as a disaster mental health volunteer].”

Kottler noted that the center featured a large police presence – alongside many, many volunteers and aid agencies – for safety and to ensure that weapons, alcohol and other banned items were not brought into the facility. For some, this added to the tension of an already anxious situation.

Kottler, a keynote speaker at ACA’s 2015 Conference & Expo in Orlando, Florida, recently moved to Texas to start a new position at Baylor College of Medicine and to serve in a volunteer role (consultant and staff trainer) at the Alliance for Multicultural Services, a refugee resettlement agency. Previously, he was a professor at California State University, Fullerton.

Kottler said he has been struck by the resilience of his new hometown – from grocery store cashiers asking if he’s OK to the local American Red Cross chapter having too many volunteers.

“I am new to Houston, and I’ve just been blown away by how the city and community have come together to help each other selflessly,” Kottler said. “What I found so personally disturbing is [the realization] that this could happen to any of us.”

Many in Houston have now begun the process of clearing out damaged homes and rebuilding lives after Harvey. In Florida, some residents are waiting for utility service to be restored, one week after Irma. Residents are still displaced and emergency shelters are still open in both Texas and Florida.

In Miami, Kenny said she had power in the days after Irma, but no phone or internet service. Classes resumed at Florida International University Sept. 18 after a nearly two-week closure. Some of the school’s facilities were being used as shelter for evacuated residents of the Florida Keys, Kenny said. Professors have been advised to be flexible with deadlines and assignments.

In her role as a counselor educator, Kenny said she has also witnessed anxiety among some counseling students who are concerned about the loss of internship hours because clinical sites were closed in the storm’s upheaval. In her private practice, Kenny had numerous clients cancel appointments prior to the hurricane because they were busy with preparations or didn’t want to travel for fear of using gasoline that might be needed later.

“Thankfully, cell phones [are currently working], so you are able to check in with clients and see who can return,” she said. “Many clients – those who were able – left town and still have not returned. Thus, practice remains slow. For some clients without power, coming to an air-conditioned office for an hour to cool off and vent is a welcome relief.”

Although hurricanes are part of the reality of living in South Florida, the upheaval that Irma brought has stirred up difficult memories for some longtime residents, Kenny noted. For others, watching Hurricane Harvey’s devastation from afar was equally troubling.

“For some in South Florida, [Irma] was also a reminder of Hurricane Andrew 25 years ago. For those [individuals], it definitely brings up posttrauma issues. These are people who lost their entire homes, businesses, etc., and were fearful of the same thing happening again,” Kenny said. “Others who are living here but have lived through storms in other parts of the country were also triggered by this storm. Some [of my] clients had family in Texas [who] had just survived Hurricane Harvey and were still dealing with them when this storm was approaching. For those clients, the back-to-back storms seemed overwhelming. I had a client who was able to arrange for evacuation of a family member in Texas through Facebook. The family member was elderly and in need of medical attention post-surgery but was in a completely flooded area. A stranger responded to the request and used their boat to get the relative to a hospital. This type of kindness demonstrates how a community can come together.”

 

The road ahead

For people who are directly impacted by a natural disaster, the aftermath can be marked by feelings of loss, fear, panic, grief or guilt, said Anka Vujanovic, an associate professor and director of the Trauma and Stress Studies Center at the University of Houston. Counselors may hear clients talk about strong feelings of irritability, anger or guilt, having difficulty sleeping or a sense of wanting to do more for their community because they made it through the storm relatively unscathed.

“There may be guilt in those who are not severely impacted – survivor’s guilt of ‘why them, why not me?’” said Vujanovic, a licensed clinical psychologist and co-director of the University of Houston’s Trauma and Anxiety Clinic.

Other clients may be in shock right now and focused on the immediate needs of putting their life back together in the storm’s aftermath, Vujanovic said. Mental health struggles can surface weeks, months or even years later when triggered by another natural disaster or traumatic event.

“Once they’re past the crisis, they may have symptoms. … Once things settle down, they have their house [renovated], they’re back to ‘normal’ and life has settled down. They may feel the aftershock even months later,” Vujanovic said. “People may or may not experience symptoms until the next rainstorm with high winds, or [next year’s] hurricane season. That may trigger people and activate some of their difficult memories.”

“It’s something to check in about for practitioners, especially if they work with people who were directly impacted. Keep in mind that there may be things that crop up. Clients may not be ‘over it’,” Vujanovic said.

Counselors may see clients develop panic attacks, intensifying anxiety or depression, loss of interest in things they normally enjoy, mood fluctuations or increased substance abuse. People often use alcohol or drugs to cope with feelings of stress, loss and grief after a natural disaster, Vujanovic said.

It’s vitally important for counselors to check in with clients in affected areas to see how they’re coping in the storm’s aftermath and to monitor their symptoms. Practitioners should encourage clients to maintain social connections with friends and family and “fight the urge to isolate,” Vujanovic said.

“Take time for self-care, which can be incredibly difficult if you’re living in a shelter. Take time for appropriate sleep, exercise, social activity – whatever is important to that person,” she said.

Vujanovic’s area of research is posttraumatic stress disorder (PTSD). Although 30 to 40 percent of people who are directly impacted by a natural disaster will develop PTSD, it is important to note that a majority of people who survive a natural disaster will not develop mental health symptoms, she said.

A number of factors – from whether individuals have pre-existing mental illnesses to how much social support and financial stability they have – contribute to whether they might struggle after a natural disaster. “All of those things will go into the complex equation of who develops a problem [after a natural disaster]. These factors up the risk, but it doesn’t mean they definitely will,” Vujanovic said.

 

Businesses in Miami Beach, Florida, board up windows on Sept. 7 in preparation for Hurricane Irma.

 

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Related reading

 

Counseling Today’s August cover story, “Lending a helping hand in disaster’s wake

 

From Counseling Today columnist Cheryl Fisher, “Mental health cleanup following a natural disaster

 

 

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Bethany Bray is a staff writer for Counseling Today. Contact her at bbray@counseling.org

 

Follow Counseling Today on Twitter @ACA_CTonline and on 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.

 

 

 

 

 

 

The Counseling Connoisseur: Mental health cleanup following a natural disaster

By Cheryl Fisher September 14, 2017

“The sole meaning of life is to serve humanity.” ~ Leo Tolstoy

 

As I sit on my patio, warmed by the early autumn sun, I breathe in the alchemy of rosemary, thyme and oregano and a variety of mints — aromas from my herb garden. The squirrels chatter as they scamper across the trapezelike branches of the old maple and majestic oaks that provide me with shade and provide entertainment to a variety of creatures. Blue jays, robins and cardinals flit back and forth, foraging end-of-the-season strawberries. Finches hover overhead just long enough to steal a sunflower seed (or two) from the heads of the long stalks that have faded and now hang low. It is a beautiful September morning.

Yet, several hours away, nature has taken a different turn, spinning up water and winds of 185 mph, decimating lands and destroying lives. Hurricanes Harvey, Irma and Jose have created havoc on the Gulf and East Coasts, while fires have engulfed the West. An earthquake has devastated parts of Mexico. In each instance, homes have been lost and families separated. The same Mother Nature that offers me such solace during this early morning has wreaked havoc elsewhere.

As with any traumatic experience, I seek meaning, attempting to make some sense out of these tragedies. I try to identify who is to blame for such suffering and loss. Finding very little peace from my efforts, I turn to what I know best. I dive into my counseling toolbox for guidance and I DO something.

 

1) Volunteer

As mental health professionals, we offer skills that are much needed in cultivating calm and defusing crises. We can help by listening to the narratives of survivors, validating their experiences and providing tools for immediate coping. We can provide basic care and help them reconnect with loved ones. I have been a disaster mental health volunteer for the American Red Cross (redcross.org/take-a-class/disaster-training) for decades. (The American Counseling Association is an official American Red Cross disaster mental health partner organization.) It is a privilege to serve in local and national deployments. Additionally, we can assist local efforts through church or club affiliations. I am a member of the Maryland Responds Medical Corp, and I support the efforts of my faith affiliation.

 

2) Contribute to resource efforts

There have been many times when I have been unable to deploy. This is extremely frustrating because part of my healing is feeling that I have DONE something to help. I have found that numerous organizations accept both supplies and monetary contributions. Participating in these efforts allows me to feel that I have been actively involved in the effort toward recovery.

 

3) Gather with like-minded/like-hearted people

Being in the company of other compassionate advocates can lighten the load. Sharing the emotional burden may not only provide ease but may also promote collaboration and generation of innovative recovery strategies. For example, a group may want to craft a GoFundMe page, create a local fundraiser or organize an event in memory of those who were lost and in honor of the survivors.

 

4) Pray or hold intention

Regardless of one’s faith or belief system, lifting prayer and good intentions on behalf of another is an active service of compassion and kindness. It is (excuse the double negative) “not nothing.” In addition to a faith-based perspective, prayer and intention place the person or people in the forefront of our thoughts, reminding us of our connection with all humanity regardless of nation, culture, ethnicity, creed, age, gender, sexual identification or able-bodiedness.

 

5) Seek help

As advocates and first responders, we are not immune to the effects of tragedies. Viewing hours of social media in anticipation of the storm’s arrival, watching the desperate efforts of firefighters dousing the flaming forests of Washington and Oregon, or seeing the devastation in the Caribbean can take its toll on even the most resilient counselor. Seek professional help to aid in the development of strategies to provide nourishment and sustenance while buffering the abrasive nature of responding to traumatic events.

 

Conclusion

Nature provides us with endless sources of joy, wisdom and companionship. However, there are times — as with any living force — when disaster strikes. Counselors can contribute to the recovery plan in numerous ways that cultivate a sense of unity and community. It is a privilege to serve in times of need.

 

Satellite photo of Hurricane Katrina on August 28, 2005.

 

 

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Cheryl Fisher

Cheryl Fisher is a licensed clinical professional counselor in private practice in Annapolis, Maryland. She is affiliate faculty for Loyola and Fordham Universities. Her research interests include examining sexuality and spirituality in young women with advanced breast cancer, nature-informed therapy and geek therapy. Contact her at cyfisherphd@gmail.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.