Tag Archives: Trauma and Disaster

Trauma and Disaster

Lessons learned from a community crisis

By John Rogers and Cynthia Miller October 5, 2020

Counselors in the quiet university town of Charlottesville, Virginia, had noticed that some of their clients were anxious about their safety. As winter changed to spring in 2017, demonstrations and counterprotests at local Civil War monuments had become heated and confrontational. Now, in early summer, there was word on the street that a major pro-statue demonstration was being planned, potentially involving hundreds or even thousands of members of extremist White supremacist organizations.

Counselors did their best to help clients cope with the worrisome news flow, but none of us could have anticipated the explosion of hatred, violence and loss that occurred on Aug. 12 of that year. On that day, Charlottesville experienced a violent episode of domestic terrorism that left three people dead, scores injured and an entire community shaken to its core.

This painful episode in our nation’s recent history is also the story of one counseling community’s challenge to organize, respond and incorporate lessons learned. We offer these experiences with a sense of humility and hope that others might consider incorporating some of the lessons we learned. Our own journey as a community of counselors might help others prepare for human crises that can tear at the social fabric of a city or town. Communities, like individuals, can experience a victim-survivor-thriver cycle, but that growth includes painful introspection.

As Charlottesville residents, we were both actively involved in the counseling community’s response to the Aug. 12 violence. At the time, John was a master’s degree student at James Madison University in clinical mental health counseling and a volunteer at Charlottesville’s main homeless shelter, while Cindy was (and is) a Charlottesville-based licensed professional counselor and counselor educator. We have seen and been personally involved in the personal and collective transition from victim to survivor, and then on to the resolve and determination to thrive as a community. In the course of developing this article, we met with local and regional counselors to present our initial thoughts and to gather feedback and suggestions. While our colleagues’ input was invaluable, this article and any errors or omissions within are the responsibility of the authors.

Setting and storm clouds

Nestled in the Blue Ridge Mountains in central Virginia’s Albemarle County, Charlottesville is a university town with deep roots in the South. As home to Thomas Jefferson and the University of Virginia (UVA), our town has a complex and at times contradictory history of slavery, visionary political and philosophical leadership, support for the Confederacy during the Civil War, and upheaval during the civil rights movement. Charlottesville itself has a population of roughly 50,000 residents, whereas the surrounding county has a population of 107,000. Students attending UVA add an additional 23,000 residents to the population each year. Charlottesville’s racial diversity is broadly similar to the country as a whole, with Whites constituting 70% of its population. It is a relatively highly educated community, with more than 50% of adult residents holding a bachelor’s degree or higher (compared with the national average of 35%).

The demand for mental health services in Charlottesville far exceeds the availability of these services. Although Charlottesville has two hospitals, only one of them has psychiatric facilities. The local community services board offers a crisis stabilization unit, limited residential services and a range of outpatient services, but it is primarily devoted to serving those with severe mental illness. UVA’s two counseling centers typically operate at capacity and refer students into the community for long-term needs. Although there is a fairly large community of mental health professionals in private practice in the immediate area, most have waitlists. It is estimated that there is one mental health provider for every 116 residents in Charlottesville and one mental health provider for every 977 residents in Albemarle County.

As is the case in many Southern towns and cities, White civic leaders placed monuments to Confederate Civil War leaders in Charlottesville’s main squares during the peak years of the Jim Crow laws from the late 19th century to the early 20th century. These statues became symbols of the increasingly racially charged rhetoric leading up to and in the aftermath of the 2016 U.S. presidential election. The volume of local discussions on race rose in Charlottesville with the national trend, resulting in heated city council meetings and activism on both sides of the symbolism of the statues in town.

In February 2017, the Charlottesville City Council approved a measure to remove the statue of Confederate Gen. Robert E. Lee from Lee Park, in the center of town. Lawsuits seeking to block this action followed, and in May 2017, a march by pro-statue supporters, including self-proclaimed “alt-right” and White supremacist groups, took place in the park housing the statue. This was met with counterdemonstrations and an editorial in The New York Times denouncing the racist protest. Afterward, the Ku Klux Klan filed for a permit to hold a demonstration in Lee Park in July, and a separate filing was made to permit a “Unite the Right” rally in Charlottesville on Aug. 12. The stage was set for the event that would put Charlottesville on the front pages of newspapers across the country.

As the weather warmed and gatherings increased, local counselors began to hear from clients who had attended anti-racist rallies or witnessed the frequent pro-statue demonstrations. Clients brought their fears, determination and other emotions to the counseling room as they processed the buildup in tensions in the community. Some counselors who were connected to anti-racist information sources volunteered to provide on-site services at a counterprotest held the night of the July 8 Ku Klux Klan rally. Their experiences providing crisis counseling services led them to reach out to the local counseling community through informal channels in an effort to prepare on a larger scale for the impending Aug. 12 rally.

This unofficial network of information, in part spurred by information from clients, leads us to our first takeaway in terms of preparing for and responding to community crises:

Lesson #1: Counselors are connected to critical information sources that are often unavailable to local officials. While client confidentiality must always be protected, a counseling community that is connected internally and to official channels can use this information to support advance planning and coordination efforts.

Into the storm

As the Unite the Right rally approached, several groups — unfortunately, not connected to one another — considered how to respond. Law enforcement authorities prepared contingency plans, with questionable levels of coordination across jurisdictions. The clergy was an early and visible organizing force, coming together to offer worship services for hope and calm, places of refuge, and leadership in counterdemonstrations. Students at UVA quickly came together to respond to a racist protest, organized secretly by White supremacist groups, that occurred on the university’s grounds the evening of Aug. 11.

Anti-racist organizers operated largely below the radar to assemble demonstrators and support services in anticipation of a major rally. A small number of counselors, in cooperation with the First United Methodist Church, established an on-site presence on the edge of Lee Park. They were joined by observers from the emergency services unit attached to Charlottesville’s community services board, a major mental health care provider. In coordination with street medics and clergy, the on-site counseling team helped more than 20 demonstrators who asked for help dealing with the chaotic scene unfolding around them.

The demonstration quickly turned violent, with sustained clashes between Unite the Right demonstrators and counterprotesters, police and bystanders. The city center became a scene of destruction, fear and mayhem. The violence continued even after police ordered the downtown area cleared, culminating in the death of Heather Heyer and multiple others being injured when a Unite the Right demonstrator plowed his vehicle into a crowd of counterdemonstrators. (The driver was convicted of first-degree murder in 2019 and sentenced to life plus 419 years in prison.) During the hours of chaos, two Virginia State Police officers died when their helicopter, which was being used to coordinate law enforcement activities, crashed.

Struggling to organize

Even before the bottles, tear gas canisters and other debris could be cleaned from the streets, an online discussion group used sporadically by local counselors began to buzz with messages and questions about what had just happened and what to do next. The town convulsed with grief and anger, but there was no disaster recovery or crisis counseling plan in place. Despite informal outreach by a few counselors to authorities prior to the demonstration, there was no offer to coordinate resources.

In this vacuum, counselors from the online discussion group, including Cindy, organized a venue to convene an initial meeting of those interested in responding to the crisis. In trying to cast a broad net to area counselors, we discovered that the Virginia Counselors Association (VCA), a branch of the American Counseling Association, could help with a critical link: a database of members in the area that VCA used to send out a blast email announcing the organizing meeting. This proved to be a critical resource in communication, but the fact is that we landed on it somewhat randomly. The uncertainty and lack of direction we experienced as we struggled to organize leads us to our second major lesson:

Lesson #2: Prior planning is essential. A community crisis overwhelms individual and group coping mechanisms, but a well-thought-out plan, combined with rehearsals, can provide essential structure, guidelines and stress testing. A crisis strains already full counseling workloads, and resources must be identified before they are needed to create capacity for crisis counseling. Crisis counseling often takes place outside of the conventional office environment.

The initial meeting of counselors took place three days after the violence ended. More than 60 counselors, students and others in the helping professions showed up, overwhelming our expectations. We were surprised by the numbers and by the fact that many of those attending had never met, despite being members of the local counseling community. Much of the initial meeting was taken up with introductions, processing the trauma, venting, and making space for tears and anger.

Although this made for an unusual meeting, it makes sense in hindsight. Most of the counselors present had little training in responding to mass trauma and were focused more on providing pro bono services in their private offices than on conducting primary prevention and outreach. What time remained was used for breakout groups to brainstorm on immediate needs and steps the counseling community could take to provide help. At the end of the meeting, a small subgroup agreed to stay behind to attempt to organize a set of initiatives to respond to the needs raised in the breakouts.

By the time the main meeting broke up, it was late in the evening, and participants, already on edge and dealing with a cascade of calls from clients, were physically and emotionally exhausted. The small group that remained included leaders from the Green Cross Academy of Traumatology, an organization dedicated to training and deploying crisis counseling teams, as well as local counselors, agency leaders and a handful of students. This group took the summaries from the breakouts and prioritized several initiatives, including establishing a command center to coordinate the response, a crisis counseling center and a community communications strategy.

‘Resilient Charlottesville’ comes to life

As the small group meeting began wrapping up, the difficult question of “Who coordinates this?” still needed to be answered. Fortunately, one of our local counseling agencies had a strong communications manager who raised her hand to help. John was on summer break from graduate school and could help organize and manage the logistical aspects of a crisis counseling center. Our community services board’s emergency services leadership offered to help coordinate with other agencies and government offices. A gift from the city arrived in the form of an offer of space in the downtown Charlottesville library, with ample room for a welcome desk, consultations and rest space for counselors.

By noon the next day, we had a plan in place that we named “Resilient Charlottesville.” We began recruiting pro bono counselors from a list we had developed at the Wednesday meeting. We created a website and were communicating with counselors via the expanded group email list and with other community leaders. The Green Cross offered to deploy teams in the community for assertive outreach, and we gratefully accepted this support. We produced and distributed flyers to post in local businesses and on community buildings, and we opened the crisis counseling center that Friday at the library. This coming together of resources leads us to offer another observation:

Lesson #3: In a crisis, be flexible and open to offers of help from unexpected quarters. You will need a wide range of skills and experience. Take advantage of retirees, students and others who are willing to lend a hand. Community trauma affects counselors, and links to outside resources are essential when local capabilities are overwhelmed.

Our crisis counseling presence remained up and running for two weeks following the violent demonstrations. During that time, volunteer counselors conducted more than 70 pro bono sessions, and our outreach teams made hundreds of contacts on their “counseling by walking around” perambulations of the downtown area. Many of the people we met told us that the mere presence of a counselor (we wore orange vests with clear identification as counselors) provided a calming influence. So much trauma had occurred on the streets that many residents visited the scene of Heather Heyer’s murder to try to process what had taken place. Business owners welcomed the chance to talk with counselors about what they were dealing with. Our counseling presence served as a sign of resilience and hope.

Even as Resilient Charlottesville offered support through crisis counseling, other elements of our coming together as a community were sending down deeper roots. There was anger and sadness that more coordination had not taken place across the public and private sectors prior to the demonstrations. Some of our counselors and their sponsoring agencies committed to bridging these gaps. A communitywide “go-to” website and toll-free hotline, Here to Help, was developed as a clearinghouse for mental health needs. The Virginia Medical Reserve Corps extended its presence and recruited mental health professionals as standby volunteers for future crises. Plans for training and crisis preparation began to take shape.

From victim to survivor

As members of the counseling community came together in various settings to debrief on what we had learned, several themes emerged. One was that crisis counseling skills are a distinct form of intervention, and that without practicing them, these skills can become rusty.

Most counselors spend their days in a consulting room meeting on a predictable schedule with clients they have seen before. Crisis counseling involves outreach, walking the streets and meeting people, often in brief encounters that can help support survivors’ natural resiliency. In their book, Beyond Brief Counseling and Therapy, Jack Presbury, Lennis Echterling and J. Edson McKee remind us that brief and crisis counseling are, at heart, an attitude about change. The World Health Organization recommends psychological first aid training for mental health professionals who might be in a position to help people experiencing traumatic events. The Knowledge Center section of ACA’s website (counseling.org) offers an extensive set of links to resources, training and volunteer opportunities related to trauma and disaster mental health.

We should note that responding to a community crisis is not solely the purview of mental health professionals. We were dismayed to learn that some massage therapists were turned away from the initial organizing meeting after being told it wasn’t for them. A good response takes an “all hands on deck” approach, honoring the multiple ways in which people manage stress and welcoming the inclusion of allied professionals such as massage therapists, body workers, clergy and lay helpers. A comprehensive community response would train allied professionals and lay helpers in psychological first aid and provide multiple avenues for community members to relieve stress and receive support.

It also became obvious that while our marginalized communities were deeply affected by the presence of White supremacist demonstrators, our outreach efforts had not purposefully or effectively extended into these communities. We realize now that forming alliances with religious and community leaders in our Black and other marginalized communities is essential.

We were also chagrined to learn that our local first responders had preexisting arrangements with nonlocal providers of counseling services to support their staff members’ mental health needs. We agreed that our own “internal marketing” in the community needed to be reconsidered to raise the profile of local counselors with public agencies, including our first responders.

From surviving to thriving

The Charlottesville community experienced its own painful transition, from surviving the violence and trauma of Aug. 12, 2017, to establishing an attitude of resolve. As part of that community, the counseling profession had its own time of testing in the form of the one-year anniversary of the violence. Unlike the events of 2017, this anniversary could be anticipated. A lack of organization would be unacceptable. In retrospect, it offered us an (unwelcome) opportunity to test our determination and coordination.

The Federal Emergency Management Agency offers guidelines in what it calls the “whole community approach” to crisis planning. We took this attitude to heart. This time, there was extensive coordination between local, state and federal agencies, including the U.S. Medical Reserve Corps, the Virginia Volunteer Health System, the Virginia Department of Behavioral Health and Developmental Services, and assorted law enforcement agencies.

Our local mental health community was involved and engaged in coordinating meetings and gathering resources. We conducted training in psychological first aid and trauma-informed counseling. We also conducted community outreach to marginalized populations through the Boys & Girls Club and had school counselors briefed and standing by to offer their support and assistance. As the date approached, we deployed volunteer counselors, all trained in crisis intervention, in two locations — one in the center of downtown and another just at the edge of the downtown area. Both groups coordinated throughout the day with local officials to provide safe and secure sites for crisis counseling. The community had protocols in place to deal with large numbers of medical and mental health emergencies.

Lesson #4: Community engagement is a year-round form of preparation for crisis. The ACA Code of Ethics directs counselors to advocate, contribute pro bono resources, work effectively in interdisciplinary teams and build new skills. It turns out that these areas are also central to successful crisis planning and management as counselors.

In the end, the first anniversary of the Charlottesville violence was a relatively quiet day, with no injuries and a small number of demonstrators. Thankfully, our preparations were not put to the test. In many ways, this was an exercise in resilience and building pathways to thriving for our counseling community.

Today, we are closer together as a group of professionals than ever before. We recognize our vulnerabilities and are taking steps to prepare, practice and collaborate. We feel closer to our community, not just through one-to-one interaction with our clients, but in the sense of shared responsibility for our safety, shared participation in strengthening our city’s psychological fabric, and shared efforts to advocate for social progress. These are parts of being a counselor that perhaps we had taken for granted prior to the shattering of our illusions.

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Additional resources:

ACA trauma and disaster mental health webpage: counseling.org/knowledge-center/mental-health-resources/trauma-disaster
Green Cross Academy of Traumatology: greencross.org
National Medical Reserve Corps: mrc.hhs.gov
Beyond Brief Counseling and Therapy: An Integrative Approach, second edition, by Jack Presbury, Lennis Echterling and J. Edson McKee
A Whole Community Approach to Emergency Management: Principles, Themes, and Pathways for Action, Federal Emergency Management Agency: tinyurl.com/FEMACommunityEmergency
Psychological First Aid: Guide for Field Workers, World Health Organization: tinyurl.com/WHOPsychFirstAid

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John Rogers is a board-certified counselor and licensed resident in counseling in Virginia, where he also teaches in the graduate counseling program at Longwood University. He is a doctoral candidate in counseling and supervision at James Madison University. His practice and research interests center on homelessness and marginalization. Contact him at counseling@thehaven.org.

Cynthia Miller is a licensed professional counselor and counselor educator with a private practice in Charlottesville, Virginia. She has been a practicing counselor for almost 20 years, working with adults in university, community and correctional settings. Contact her at cynthiamillerlpc@gmail.com.

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

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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.

Climate in crisis: Counselors needed

By Laurie Meyers August 25, 2020

On a warming planet, some of the most rapid increases in temperature are being experienced in the Circumpolar North — the area within and, in some cases, just below the Arctic Circle. Overall, the average global temperature has increased by 1 degree Celsius (1.8 degrees Fahrenheit) since 1880. Two-thirds of that rise has occurred since 1975.

Since the 1990s, warming in the Arctic, in particular, has been accelerating. Researchers say the region is warming two to three times more quickly than the rest of the planet. In some areas such as Canada’s Labrador coast, the annual average temperature has increased as much as 3 degrees Celsius (5.4 degrees Fahrenheit), causing drastic changes in the weather, terrain and wildlife.

This coastal region is home to the Labrador Inuit people, who live in Nunatsiavut, a self-governing Indigenous territory with five communities — Nain, Hopedale, Postville, Makkovik and Rigolet — accessible only by airplane. The communities are not connected by roads. Instead, navigation is via paths over increasingly unstable ice, which is now prone to sudden thaws and pitted with holes. Unpredictable seasons and severe storms have also made it more difficult for the Inuit to get out on the land that has sustained them physically and spiritually for generations. Like other Indigenous peoples, the Labrador Inuit have faced displacement and forced assimilation. Traditional activities such as fishing, trapping, hunting and foraging are not just for subsistence; they are essential practices that undergird the Inuits’ culture and identity. Climate change has disrupted all of this, not only through changes in the ice, but through changes in the wildlife and plants.

But it goes even beyond that. Climate change is affecting the mental health of this region’s residents.

In 2012, the leaders of the communities of Nunatsiavut asked Inuit and non-Inuit researchers to conduct a regional study of the effects of climate change on mental health. More than 100 residents were interviewed as part of a multiyear study. The resulting report shed light on the strong emotions and reactions of the interviewees, who expressed fear, sadness, anger, anxiety, distress, depression, grief and a profound sense of loss.

One of the interviewees attempted to convey what the land represents to the Inuit: “For us, going out on the land is a form of spirituality, and if you can’t get there, then you almost feel like your spirit is dying.”

A community leader expressed an existential fear: “Inuit are people of the sea ice. If there is no more sea ice, how can we be people of the sea ice?”

Ashlee Cunsolo, a public health and environmental expert who was one of the lead non-Inuit researchers, believes that grief — ecological grief, as she and other researchers have dubbed it — is inextricably linked with climate change. She defines it as “the grief felt in relation to experienced or anticipated ecological losses, including the loss of species, ecosystems and meaningful landscapes due to acute or chronic environmental change.”

A clear and present concern

The story of the Labrador Inuit is undeniably heart-rending. Even so, most people probably feel that scenario is pretty far removed from their own lives and losses. After all, as global citizens of the 21st century, our lives are increasingly virtual, and even if we enjoy the great outdoors, the idea of everything we are being bound to a particular land or place may seem alien.

Think about it a little more though. Whether our settings are urban, suburban or rural, most of us have geographic preferences, be they coastal, mountain, bayou, prairie, desert, forest or canyon. It might be where you live now or where you grew up, but it calls to you. And it has changed. That pond where you spent your childhood winters ice-skating no longer freezes hard enough to handle your gliding blades. Your favorite beach keeps losing feet of sand to the ocean. Ski season is now short on both time and fresh powder. Fire is prohibited at your favorite campsite. The city where you live has endured a summer string of 90-plus-degree days, leaving you longing for fall, but that season of cool, crisp air is increasingly elusive. The heat lasts well into September and October, as trees in your neighborhood stubbornly stay green — until they turn brown.

Austrian environmental philosopher Glenn Albrecht calls that feeling — a sense of missing a place that you never left because it has been altered by climate change — solastalgia.

“I think place can be really underestimated, but place attachment is such a part of who we are,” says Debbie Sturm, an American Counseling Association member who serves on the organization’s Climate Change Task Force. “If there’s harm in a place or threat to a place or loss of place, it is a significant loss.”

As an example, the diaspora caused by Hurricane Katrina in 2005 was extremely traumatic, says ACA member Lennis Echterling, a disaster, trauma and resilience expert who provided mental health support in New Orleans in the wake of the storm. In some cases, people desperately fleeing the floodwaters and destruction were barely aware of where they were headed. Many of those who evacuated have never returned.

“There is still a population who have been separated from their homes — their sacred ground,” says Echterling, a professor at James Madison University in Harrisonburg, Virginia. Although that phrase, sacred ground, is most often associated with tribal populations, Echterling believes it is true for all of us — that we all have an intrinsic attachment to place. And climate change will continue to separate people from their homes, he says, citing researchers who forecast that by the year 2050, an estimated 1 billion people worldwide will be climate refugees.

Even those who haven’t been displaced or experienced climate catastrophe may find it hard to avoid a creeping sense of existential dread — or ecoanxiety — as they witness or hear about extreme weather event after extreme weather event. On June 20, the temperature in the Siberian town of Verkhoyansk reached 100 degrees Fahrenheit, the hottest temperature ever recorded north of the Arctic Circle. Researchers say such an occurrence would be almost impossible (a once-in-80,000-years happening) without climate change caused by human activity. In recent years, wildfires have reduced entire California communities to ash, with citizens up and down the coast donning masks to protect themselves from a lingering pall of smoke. In 2018, Hurricane Florence turned Interstate 40 in North Carolina into a river. Hurricane Harvey struck Houston repeatedly over six days in 2017, leaving one-third of the city underwater at its peak. Approximately 40,000 Houston residents had settled in the city permanently after evacuating from Katrina more than a decade earlier.

Every year, the signs of a climate crisis grow more alarming, and the psychic toll can be traumatic. Psychiatrist Lise Van Susteren, an expert on the mental health effects of climate change, coined the phrase “pretraumatic stress disorder” to describe the fear that many individuals are experiencing about disasters yet to come.

Since 2008, the Yale Program on Climate Change Communication and the Center for Climate Change Communication at George Mason University have been conducting national surveys biannually to track public understanding of climate change. The latest survey results, from November 2019, indicated that 2 in 3 Americans were at least “somewhat worried” about global warming, whereas 3 in 10 were “very worried” about it. A majority of those surveyed were worried about the potential for harm from extreme events in their local areas.

The mental health effects related to climate change extend beyond disasters such as hurricanes and wildfires. Research has indicated a link between rising temperatures and the increased use of emergency mental health services, not just in places that regularly experience hot weather, but in relatively cool areas as well. Higher temperatures have also been tied to increased levels of suicide.

As the ACA Climate Change Task Force reports in its fact sheet (currently under review), experts predict a sharp rise in mental health issues such as depression and anxiety, posttraumatic stress disorder, substance abuse and suicide, in addition to outbreaks of violence, resulting from coming climate crises. The task force views the counseling profession’s strengths-based approach and focus on resilience as essential to responding to those affected by climate crisis.

However, as part of a study that has not yet gone to press, Sturm, fellow ACA and task force member Ryan Reese, and ACA member Jacqueline Swank surveyed a group of counselors, social workers and psychologists about their personal and professional perceptions of climate change. Although Sturm, Reese and Swank found that these helping professionals were more likely than the average person to believe that climate change is real, very few felt the issue was relevant to their professional lives. Many respondents also said that they didn’t feel confident addressing issues related to climate change in their practice.

Climate change in the counseling office

Reese, a licensed professional counselor practicing in Bend, Oregon, believes that not knowing how to define — and, thus, recognize — climate concerns is part of counselors’ discomfort.

“What is climate change?” he asks. “Is it when you live in California and no longer have a home? … Is it a climate issue when a client is just talking about the general state of affairs and worrying about the world for their kids?”

Of course, there is also the matter of climate change being a polarizing topic, says Reese, an assistant professor of counseling and director of the EcoWellness Lab at Oregon State University-Cascades. When he is talking with clients about broader health and wellness and the topic of climate change comes up, sometimes they will tell him they think it is fake news. “What am I going to do?” Reese asks. “Am I going to impose my view? How do we find ways to introduce our wellness perspective without imposing?”

Reese’s practice is based on ecowellness, a model he co-developed with Jane Myers that revolves around a neurobiological relationship with nature. “The bridge here is, ‘Tell me about your relationship with nature,’” he says.

Reese says he does see a significant amount of ecoanxiety and fear of the unknown, especially among his adolescent clients. But they typically come in talking about depression.

Reese’s intake process includes questions about spirituality and life’s meaning and purpose. He asks clients about their outlook on the future, which is where their anxiety sometimes emerges. Questions about their relationship with nature often reveal the connection between that anxiety and their concerns about the climate.

If clients mention any angst about the environment, Reese asks whether they can unpack that a little more. He’ll follow up by asking questions about how a client spends their time outdoors, what their everyday access is to nature, where and how they feel most effective in nature, and whether they have any hobbies involving nature. He also encourages them to think about what role they can take on: “You mentioned being fearful about what your future is going to hold. What, if anything, can you do right now to address your concern about environmental crisis? … What is within your immediate grasp and control that you can do?”

Reese’s approach involves seeing what the individual’s broader landscape looks like and what their interests, passions and resources are. He urges his clients to get creative and often suggests that his adolescent clients take some kind of action at school, such as starting a recycling program. One of his adult clients took the action step of buying an electric bike and not driving his car as frequently to lessen his impact on the environment.

Reese also helps clients connect their hobbies with environmental action. For instance, if they like skateboarding, he’ll ask them what kind of impact they think that has on the environment. That may lead them to taking the action step of picking up trash around the skate park.

“It’s looking at what is the way we can increase self-efficacy in response to the environment so that it’s not abstract,” he says. “This is something I can engage in and learn and sustain this particular activity for myself and other people.”

Reese also asks clients to educate him about their activities. “For example, mountain biking is huge in Bend, but I don’t know anything about it. … What is the environmental impact? Oh, you don’t know either? Where can we find out?”

Climate change as social justice

ACA’s Climate Change Task Force notes that the resulting trauma from climate change has been and will continue to be experienced disproportionately. Black, Indigenous and people of color (and their communities), children, pregnant women, older adults, immigrants, individuals with limited English proficiency, those with disabilities, and those with preexisting and chronic medical conditions are all more likely to be affected by climate crisis and to have fewer resources to cope with its impact.

In September, the Gulf Coast will mark the 15th anniversary of Hurricane Katrina, one of the most powerful Atlantic storms on record. It wrought widespread devastation and flooding, including the overflow and eventual break of the levee system around New Orleans. As a result, 80 percent of the city was submerged underwater.

New Orleans and Katrina are important to the discussion of climate change as a social justice issue for a number of reasons, says Cirecie West-Olatunji, a past president of ACA who now lives and works in New Orleans. “Katrina was our first uber-disaster related to climate change,” she says. “It informed the world and was a global example of what was to come.”

West-Olatunji provided disaster mental health assistance in the aftermath of Katrina. “I could see the gaps,” she says. “The normal [disaster] response was not going to be sufficient.” Specifically, she recognized that the recovery period would be lengthy, the trauma and mental health challenges extensive, and the reconstruction resources unequally distributed.

Foreshadowing the 2017 tragedy of Hurricane Maria in Puerto Rico, the federal government’s response to Katrina was inadequate. It highlighted an essential barrier to recovery, namely that “whatever disparities exist prior to a disaster will be exacerbated post-disaster,” says West-Olatunji, an associate professor and director of the Center for Traumatic Stress Research at Xavier University of Louisiana.

Racial injustice, economic instability, and government funding for economic development that was distributed to certain communities and not to others were among the factors that magnified the physical and mental damage left behind by Katrina. And those factors continue to hinder recovery today. “Fifteen years later, and New Orleans is still in trauma mode,” West-Olatunji asserts.

There were multiple levee breaches, but only one adjacent neighborhood — the historically Black Lower Ninth Ward — was all but written off from the beginning of the recovery period, West-Olatunji says. Many of the residents owned their homes but faced multiple barriers to rebuilding. One of the most significant factors was discrimination in the distribution of Louisiana’s “Road Home” rebuilding funds. According to the Greater New Orleans Fair Housing Action Center (one of multiple plaintiffs in a lawsuit against the U.S. Department of Housing and Urban Development and the state of Louisiana), the program’s own data showed that Black residents were more likely than White residents to have their grants based on the much lower prestorm market value of their homes rather than on the actual cost of repair. Other displaced residents were unable to return and now cannot afford to pay their homeowners taxes, West-Olatunji says.

In the Lower Ninth, what’s left is an economic and food desert, with virtually no stores beyond a few mom and pops and only one school, she says. Developers have bought up properties, and instead of properly renovating them by gutting and bleaching the houses, in many cases they have simply repainted, leaving renters exposed to toxic mold.

In addition, much of what has been done to “rebuild” New Orleans has rendered it unlivable for those with low and modest incomes, West-Olatunji says. The city bulldozed public housing, and rent has skyrocketed. All of the city’s schools are now charter schools, which essentially makes them private schools that don’t answer to anyone other than their shareholders, she explains. “Kids are bussed all over the place … having to come out —unaccompanied — before daylight to find their way to school.”

New Orleans’ primary industry of tourism afforded a modest living to a significant number of residents for many years, West-Olatunji says. Pre-Katrina, that income could purchase a moderately priced house and even allow families to send children to state schools for higher education. Today, she says, the city is “assailed by outsiders and carpetbaggers who buy up properties. … We went from majority home ownership to rentals and Airbnbs.”

New Orleans is also a much whiter city now. Although most of the White residents who fled the city due to Katrina have returned, approximately 100,000 fewer Black people currently live in New Orleans than did before late August 2005.

West-Olatunji says there is a frequent refrain from the Black citizens who remained or returned: “I survived Katrina only to deal with the coronavirus and with the latest police brutality.”

“The trauma of Katrina was an overlay to existing and continuing stress and racial events,” she says. “It makes it really difficult to recover. … People are emotionally exhausted.”

Climate change should be of great importance to counselor practitioners, West-Olatunji says. “It’s influencing people’s behaviors and their possibility of choices. It narrows choices and creates barriers for living. Our job is to assist people in living abundantly. Climate change isn’t making that easy,” she says.

ACA member Edil Torres Rivera, a professor of Latinx studies and counseling at Wichita State University in Kansas, believes that climate change is still too frequently dismissed as a hoax. “Climate change is something that is real and … has implications for mental health,” he says, “particularly for populations like poor people, Indigenous people and people of color.”

Anyone who doubts that need only visit Rivera’s home island of Puerto Rico, where, three years after Hurricane Maria, people are still trying to recover. He says the urgent nature of the climate crisis is a primary reason that he joined ACA’s Climate Change Task Force.

In line with what happened in New Orleans after Hurricane Katrina, Hurricane Maria drove many people out of Puerto Rico, and those who remained faced multiple challenges, particularly around securing federal relief assistance and dealing with severe infrastructure deficits. Most critically, the island’s electrical grid was decimated, and it took approximately 11 months for power to be restored to everyone who lost it. But even now, Rivera says, it is still common for people to lose power for several hours whenever it rains. And this past January, a major earthquake left most of the island without power again for several days.

The trauma of Maria was compounded by the stress of the earthquake, which has been magnified even further by the coronavirus pandemic. “People are desperate,” Rivera says.

Many children in Puerto Rico are still terrified when it rains heavily and the wind rises, he continues. And since the earthquake, people are often hesitant about sleeping in their houses, so they stay in tents. This scenario will pose a major problem when a hurricane comes, Rivera says.

This past summer in Puerto Rico has been particularly hot, with some days reaching 103 degrees Fahrenheit. Rivera says this is higher than the norm when he was growing up and asserts that it again points to the effects of climate change. Typically, on hot days, people go to the beach to cool off. But the need to physically distance because of the pandemic has largely eliminated that option. Still, there are thos who, given the oppressive heat, would rather take their chances with possibly being exposed to the coronavirus. Another way that people cool off when it is hot is by having a beer, Rivera points out. He says that climate change has had a hand in sending both drinking and domestic violence rates through the roof for several years. The forced proximity of the pandemic is only exacerbating those trends, he adds.

Building resilience

Professional counselors “need to be involved and aware,” West-Olatunji says. “We can’t sit back and say that [climate change] has nothing to do with counseling.”

In fact, the counseling profession uses a holistic, ecosystemic perspective that looks at all the factors that influence behavior, she emphasizes. To take on climate change, counselors must broaden that model and consider structural interventions that target groups of people and focus on prevention. “Our discipline has always thought that prevention was at the core of wellness,” she points out.

West-Olatunji sees a great need for climate change literacy, noting that the people who most need knowledge about the climate crisis — because it is most likely to affect them either directly or indirectly — are also the least likely to have it. Vulnerable communities need to be given more information about how they can mitigate their risk and protect the health and safety of their citizens, she says.

Counselors can assist communities in building climate resilience by using their skills as facilitators to bring people together and help them work effectively as a group, says Mark Stauffer, a member of the ACA Climate Change Task Force. These groups don’t necessarily have to be focused specifically on climate change, he says. They could be formed to advocate for community needs, such as the right to clean water, or something more fun, such as establishing neighborhood gardens.

The essential aspect is to do the group work and to keep bringing people together, he says. “People coming together in times of need — we need to start practicing that now,” emphasizes Stauffer, the immediate past president of the Association for Humanistic Counseling, a division of ACA.

If counselors are personally concerned because their communities are not focused on climate change, Stauffer suggests they host a meeting of people who are interested in the topic. “See what people are thinking and where they want to go,” says Stauffer, a member of the core faculty in Walden University’s mental health counseling program. “It’s a process, but that’s the good part — connecting and building ongoing relationships. … People in the community need to get used to working together. The dialogue is just as important, if not more important, than the work.”

Stauffer thinks that counselors can play a key role in facilitating a new way of being in communities together. He believes that Western society has been living in a kind of empire culture, focused on what can be extracted. The mindset that started with Rome extracting treasures for itself from Europe and then Europe extracting treasures from its colonies has evolved into this sense that survival is about grasping and eking out a living by oneself, he says.

Stauffer says that our collective disaster survivor visual seems to be someone holding an AR-15 rifle in the air, surrounded by their supplies. “That’s not where we find joy,” he says. “Other cultures have found that surviving and being sustainable is something that we can do together.”

We need to find a way to be a part of the Earth in a generative way, Stauffer emphasizes. “The wild is not something to dominate and be afraid of,” he says.

Sturm, an associate professor and the director of counseling programs at James Madison University, urges counselors to get involved by finding out if their communities have climate resilience groups. Counselors who are unsure of where to start can bring themselves up to speed by using the U.S. Climate Resilience Toolkit (toolkit.climate.gov), a comprehensive resource that explores community vulnerabilities and climate resilience efforts.

Mental Health and Our Changing Climate: Impacts, Implications and Guidance, a 2017 report published by the American Psychological Association, Climate for Health and ecoAmerica, suggests several strategies for mental health professionals interested in promoting community well-being and helping to mitigate climate-related mental health distress. Among the strategies recommended:

Assess and expand community mental health infrastructure.
Reduce disparities, and pay attention to populations of concern.
Engage and train community members on how to respond.
Ensure distribution of resources, and augment with external supplies.
Have clear and frequent climate-mental health communication.

“Find out who is doing this in your area. Our voice has to be at the table to talk about trauma,” stresses Sturm, who is also currently earning her master’s degree in environmental advocacy. “Counselors think this is important, but they’re not doing it. … We’re not reaching out in our communities as a profession to be part of the discussion.”

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ACA members: ACA’s free CE of the month for September is a video session titled “Climate Change and Mental Health: The Role of the Counselor.” See more here: https://imis.counseling.org/store/catalog.aspx#

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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)

“Preparing for the mental health impact of climate change” by Debbie C. Sturm and Lennis G. Echterling
“Lending a helping hand in disaster’s wake” by Laurie Meyers
“Disasters and us” by Cirecie West-Olatunji
“The high cost of human-made disasters” by Lindsey Phillips
“The Counseling Connoisseur: Mental health cleanup following a natural disaster” by Cheryl Fisher
“Using nature as a therapeutic partner” by Lindsey Phillips
“Ask your doctor if nature is right for you” by Bethany Bray
“The Counseling Connoisseur: Nature-informed counseling for children” by Cheryl Fisher

Books (counseling.org/publications/bookstore)

Coping Skills for a Stressful World: A Workbook for Counselors and Clients by Michelle Muratori and Robert Haynes
Disaster Mental Health Counseling: A Guide to Preparing and Responding, Fourth Edition, edited by Jane M. Webber and J. Barry Mascari
Introduction to Crisis and Trauma Counseling, edited by Thelma Duffey and Shane Haberstroh

Continuing Professional Development: Multicultural Products (https://imis.counseling.org/store/catalog.aspx#category=multiculturalism-diversity)

“Counseling Refugees: Addressing Trauma, Stress and Resilience” with Rachael D. Goodman
“Addressing Clients’ Experiences of Racism: A Model for Clinical Practice” with Scott Schaefle and Krista M. Malott

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

Trauma and disaster
Family separation
Grief and loss

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Laurie Meyers is a senior writer for Counseling Today. Contact her at lmeyers@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 first responders’ mental health on the front lines

By Lindsey Phillips July 6, 2020

A firefighter/emergency medical technician (EMT) in Maine answers an emergency call. He grabs his gear and performs a job he knows well. The next day, he discovers that the person he helped has tested positive for COVID-19. He immediately starts worrying not just about himself but about his wife and young child, who have respiratory issues.

Amy Davenport Dakin, a licensed clinical professional counselor in Maine and a licensed clinical mental health counselor in New Hampshire, has been working with this firefighter/EMT for several years now. Before this incident, he had struggled with anxiety, depression, suicidality and posttraumatic stress disorder (PTSD), but with Dakin’s help, had successfully worked through many of these issues. This latest experience of being exposed to the virus that causes COVID-19 adds another layer of stress and anxiety that could negate his previous progress, Dakin says.

As the name implies, first responders such as EMTs, police officers, firefighters, paramedics, dispatchers and others are trained professionals who are the first to respond in emergency situations. Unless people happen to be facing an emergency themselves, this service often gets taken for granted, and little thought is generally paid to the accumulating toll on first responders’ mental health.

That calls for a reality check. “Our worst day is first responders’ every day,” points out Drew Prochniak, a licensed professional counselor (LPC) and licensed mental health counselor (LMHC) in private practice in Portland, Oregon. “Their days are filled with accidents, pain, grief, loss and trauma.”

According to a 2018 supplemental research bulletin from the Substance Abuse and Mental Health Services Administration’s Disaster Technical Assistance Center, depression and PTSD affect approximately 30% of first responders. In addition, 37% of fire and emergency medical services professionals have contemplated suicide, which is nearly 10 times the rate of American adults in general. In fact, in the United States, more firefighters die from suicide than from fires, Dakin notes.

It is easy to surmise that this population could benefit from therapeutic interventions, yet its members are often the last to ask for help. By getting to know the first responder community and tailoring approaches to match this population, counselors can break down some of the barriers that prevent these heroes from prioritizing their mental health.

Getting to know the culture

Dakin, a member of the American Counseling Association, acknowledges that it can be difficult for counselors who do not have previous experience with first responders to get a foot in the door with the community. Someone initially referred a firefighter to Dakin for counseling services, and the experience piqued her interest in working more with first responders. But first she had to earn their trust.

For approximately seven years, she attended labor union meetings, conducted trainings and presentations, rode along with first responders on calls, and hung out at their stations. This exposure allowed her to build relationships and trust within the first responder community and helped her determine that it was a population with which she wanted to work full time. Today she owns New Perceptions Inc. in Kingston, New Hampshire, a private practice that focuses on trauma and mental help treatment for first responders.

Prochniak, a former search and rescue professional and author of the book Addiction & Recovery for First Responders, agrees that establishing a relationship with a first responder department or agency is an important step toward overcoming community members’ belief that clinicians don’t understand their culture. “There’s this mystique about clinicians that we only want to talk about emotions and get in people’s heads,” Prochniak says. Building relationships with first responders outside of counseling sessions will show them that therapists are just regular people too, he says.

Prochniak, who specializes in the education, training and treatment of first responders, says there is a personality type that goes along with being a clinician who works with this population. Counselors must be able to handle hearing about grotesque experiences and communicate respect for the work that first responders do, he explains. With clients in law enforcement, this often means that counselors must be comfortable with clients having guns in session, he adds.

Prochniak cautions counselors against asking first responders about the worst thing they have seen, what type of gun they carry or whether they have ever shot someone. Instead, counselors should be curious about them as people: How long have they done this work? What led them to get into this line of work? How does their work affect their family? What kind of social network do they have? Do they hang out only with people from the first responder community? What else do they do outside of work?

Counselors will also need to be able to tolerate a dark, almost morbid, sense of humor because first responders often use that as a coping mechanism. “One of the ways we cope with trauma is with humor. And it can be really upsetting for people who don’t experience [what first responders do],” notes Carrie Whittaker, an LPC and LMHC in New York and Connecticut.

Prochniak points out that counselors must also be savvy about managing dual relationships. In addition to being a clinician in private practice, he is also a trainer and educator. At the start of every new client relationship with a first responder, he prepares them for the possibility of also bumping into him at trainings, briefings, meetings or ride-alongs. He makes it clear to these clients that he will not initiate acknowledgment of them in such circumstances out of respect for their confidentiality. “One wrong slip in acknowledging that you see someone [in counseling] or that you know someone else could cost you a client,” he explains.

In addition, counselors have to be flexible when working with first responders because they have irregular schedules, Dakin says. This might mean needing to conduct telehealth sessions or meeting with these clients outside of the typical 9-to-5 workday. There will also be last-minute cancellations, she points out. Dakin typically has a 24-hour cancellation fee, but she waives it for first responders who are stuck at work or otherwise have a good reason for not making their appointments.

In many ways, counselors may need to be on call themselves when working with first responders, Dakin says. When there is an emergency such as a line-of-duty death or an explosion, Dakin has to be prepared to drop everything, including her current caseload for that day, to respond. And if a client who is a first responder has a bad call on a Sunday, then she is also working that Sunday. Although it has happened infrequently, she has even had the labor union or clients call her as late as 10 p.m. because of an emergency.

Prochniak and Dakin both emphasize the importance of being humble when working with this population. “Although you are the professional in mental health, you’re not the professional in their field,” Prochniak explains. “Just because you know trauma or just because you know stress doesn’t mean you know this population. It shows up very differently … because this is a unique culture. So, get to know the culture. Spend time with them.”

No shame in needing help

The biggest barrier to first responders seeking help is the attached stigma — a false belief that if they need counseling, it means they are weak or unfit to do the job, Dakin says.

People often assume that because first responders signed up for the job, it means they are prepared to handle the associated trauma. But that’s not how the brain works, Dakin stresses. “The brain can only handle so much exposure to traumatic images before it’s on overload,” she says.

Joel Smith, an LPC in private practice in Denver, concurs that as a society, we do relatively little to acknowledge vicarious trauma among first responders. Although these professionals do generally possess an enhanced skill set to cope with trauma, they are still vulnerable to burnout, he says. Smith tries to normalize this reality for clients who are first responders by asking, “Has your stress been building up for a while? Is it exploding? How are you handling your stress?”

Whittaker, an ACA member who has a private practice in Manhattan and Westchester, New York, puts this idea of “being tough enough to handle it” into context for her first responder clients. She explains that being tough doesn’t mean that they never get upset or that nothing bothers them. It means processing those feelings to help themselves do their job better.

“It’s important for counselors to remind them that being tough enough to handle it doesn’t have to mean being hardened to it. It doesn’t mean that you don’t break down and cry sometimes,” she says.

First responders also have a tendency to not want to burden others with what they have experienced. Some of Dakin’s clients have said to her, “It’s a really bad call, and I don’t know if I want to put those thoughts in your head.”

Clinicians have to reassure these clients that counseling is a safe space for them to talk about their issues and experiences. When hearing difficult stories, Dakin says, counselors should refrain from sounding alarmed and making statements such as, “I can’t believe that happened! That must have been horrible.”

“While [that statement] is validating and has the best of intentions, that’s not what these people want to hear,” Dakin says. “They basically want to talk. They want to tell their story.” Counselors can validate that the client’s experience was tough without being too reactionary, she says, and that largely involves listening carefully.

Counselors should also remain aware of their facial expressions, Whittaker adds. If counselors look shocked or terrified, these clients will notice and be more likely to shut down.

Smith, a therapist at Jefferson Center (a community-focused mental health care and substance use services provider in Colorado) and an associate at Look Inside Counseling, finds motivational interviewing an effective technique when first responders are hesitant to accept help from others. For example, Smith says, counselors can ask these clients, “How can you receive help yourself?” or “How can you model receiving help?” The technique allows first responders to develop some healthy discomfort with the fact that they are simultaneously heroes who help others and people who need help with their own problems, Smith explains.

“One of the best ways they can help themselves is to feel like they have a role in helping someone else,” Smith continues. That’s one of the reasons he encourages first responders who have benefited from counseling to tell colleagues about how it has helped them.

These clients could share an effective coping skill they learned in counseling with the rest of their team, or they could model self-care at work. “If you see someone struggle, that’s one thing. But if you see them struggle and overcome it, it builds the idea that it’s possible [for you too],” Smith notes.

Tailoring counseling to fit first responders

Prochniak, the mental health professional for American Medical Response in the Portland/Vancouver metro areas, finds that mindfulness, focused breathing and meditation techniques all work well to reduce first responders’ anxiety and stress levels and build their stress resilience. Sometimes, however, these clients can be hesitant to try such techniques, either because they perceive some stigma attached to the techniques or because of the way that counselors present them.

One approach that can help break through this hesitation is finding concrete ways of translating clinical speech into first responders’ everyday language, Prochniak says. For example, if he’s working with a paramedic, he will discuss how mindfulness techniques strengthen the parasympathetic nervous system. If he’s working with a client in law enforcement, he will reference combat breathing, which is how these professionals already describe the use of deep breaths to calm down or reduce stress.

Dakin frequently convinces first responders to give mindfulness and yoga a try by explaining the science behind the exercises. She often compares how the brain processes trauma with what happens with diabetes: Just as elevated levels of glucose in the body worsen when the pancreas does not work correctly, experiencing too much trauma causes an overload of chemicals to be dumped into the brain. Then the brain responds by releasing cortisol. Breathing and mindfulness exercises help reduce that response and regulate chemical levels.

Similarly, the traditional way of presenting and explaining yoga doesn’t match with the culture of first responders, Dakin notes. When she first encourages these clients to try yoga, the response is typically along the lines of, “I’m not going into a studio wearing spandex and meditating.”

To counter this negative perception, Dakin recommends a yoga program designed specifically for first responders (yogaforfirstresponders.org). The program gears its language to fit the culture, she says. For example, it renames child’s pose as a warrior’s pose, which is a more strength-based term. Dakin now knows some first responders who practice yoga on the job to regulate their breathing and avoid going into fight-or-flight mode as quickly.

Smith has discovered that some of his clients find it helpful to conceptualize grounding techniques as a workout. They have a “grounding buddy,” and together they work on their awareness, he says.

Dakin also uses familiar language to help first responders get more comfortable with mindfulness. For example, rather than having firefighters use a numerical scale to describe how upset they are, she uses the fire danger warning scale, which estimates the existing and expected fire risk for an area. The scale is color-coded, moving from red (extreme danger) to green (low danger).

If a client says they are in the red, then Dakin has them breathe deeply while imagining their arrow moving into a safer level. She explains how each breath is calming their nervous system. This skill has become a special language that she shares with her clients. A client may start a session by saying, “I was in the red a couple of times this week, but I breathed and at least got myself into the yellow.”

Dakin also explains to clients that mindfulness doesn’t have to be limited to sitting still and taking deep breaths. It can take the form of something they normally enjoy doing, such as fishing, taking a walk, kayaking or hiking, as long as they are doing it mindfully.

Managing anxiety

First responders often get anxious anticipating what their day might hold. “Schedule and routine are the enemy of anxiety,” says Smith, who specializes in trauma, mood management, addiction, and LGBTQ-specific needs. First responders can incorporate comforting activities such as walking their dog or calling a family member at certain times throughout the day. “Having that kind of expectation in life leaves less room for anxiety to happen,” he explains.

He encourages his clients to make grounding a part of their daily routine. They can ground themselves when they wake up, when they shower or when they go to bed. They can also ground themselves on the way to work, Smith points out, taking a few minutes when they are at a red light and noticing what’s happening around them: “I’m stuck in traffic. A kid is riding a bike beside me. It’s raining. A song I like is playing on the radio.”

Smith advises clients to set phone reminders to ground themselves. Even if they can’t check their phones that minute, they will be reminded later. Then they can take two minutes before going back to work to breathe and be aware of the way their body feels, their surroundings and their emotions.

Grounding can also be a preventive measure, Smith adds. “If you walk into an emergency and you’re already grounded, then you’ll be better off on the back end of that emergency,” he says.

As clients progress with their grounding skills, Smith asks them to visualize grounding themselves during an emergency on the job. This involves visualizing the person in front of them who is having the emergency, as well as all the chaos and turmoil unfolding around them, while also being aware of their body and their role in the situation.

“It sounds counterintuitive to have them visualize chaos, but first responders are going to experience that during their day, and then they can ground themselves in the midst of this chaos,” Smith says. This is an advanced grounding skill and not appropriate for first responders who have just started therapy, he points out.

Processing the trauma

Trauma is no stranger to first responders. They see people die and watch people suffer, all while working long hours. And they often feel unable or powerless to help, Smith says.

Some first responders also wrestle with guilt over choices they made during an emergency. “When you have to make a decision in a split second, that’s something that can be really haunting. It might mean saving your life or saving someone else’s life but sacrificing something or someone else,” says Whittaker, who specializes in working with trauma.

“Trauma makes us think horrible things about ourselves and our own abilities,” Smith says. For example, a highly skilled emergency room nurse may suddenly doubt their skills if multiple people die during their shift one week. The nurse may suddenly feel out of control or useless.

Smith finds trauma-processing therapies such as eye movement desensitization and reprocessing (EMDR) and trauma-focused cognitive behavior therapy effective with the first responder population. These therapies help clients process their feelings about the trauma while learning to separate themselves from unhealthy thinking.

Because emergency situations are filled with chaos and unpredictability, it is often difficult for first responders to slow down and think about what they can realistically control, Smith says. He often has clients journal about what they can and can’t control.

“They can have control over their own beliefs about themselves and what their own purpose is. And that can be enormously helpful in a trauma environment,” Smith says. With EMDR, clients are able to look at a task that gives them anxiety, reduce that anxiety, and feel more confident to perform that task, he adds.

Behavior patterns can be telling

Dakin often detects PTSD and emotional problems by looking for behavioral shifts or irregular behavior patterns with first responders. For example, a first responder who has been working in the department for 20 years without any issues may suddenly start yelling at the fire chief and refusing to follow rules. When this happens, the labor union often asks Dakin to perform an evaluation to figure out what might be going on.

Counselors should also be aware of behavior patterns around substance use. “There’s a huge co-occurrence of substance abuse and trauma,” Smith says. “So, if you work in an environment where you’re going to see and experience trauma, then … you’re more likely to develop a substance abuse problem.”

First responders might not necessarily be battling a long-term addiction or engaging in binge drinking, Prochniak says. They might just be spending their days off work each week casually drinking because they find their home life less exciting than their work life, he observes.

Both Prochniak and Smith encourage counselors working with first responders to ask about their substance use, including amount, frequency and any changes over time. “If that problem exists, then it’s usually helpful to manage substance abuse habits before working on trauma,” Smith advises.

Prochniak also encourages clients to notice when they experience the itch to have a drink or use drugs and to think about what that itch (the substance use) is trying to scratch. Are they anxious, bored, unsettled? Together, they then figure out a plan to address the underlying issue. “Breaking it down into this smaller view of what’s behind the drinking [or substance use] can be helpful,” he notes.

Developing transition plans

All the stress and trauma of the job can spill into first responders’ personal relationships. “People who are going through trauma can be emotionally up and down, so a first responder may be angry or irritable, if not explosive, sometimes,” Smith says. “Maybe they will cry a lot or be super anxious and not be able to really be in a room with [family or friends] because they have pent-up energy.”

First responders often need help learning how to transition from work to home, where the rules may be different, Prochniak says. For example, if a firefighter works a 24-hour shift (followed by 48 hours off), their partner is in charge of the house for those 24 hours. When the firefighter returns home, they may be upset because they expect the house to be clean and organized like it is at work.

Prochniak and Smith help these clients develop transition plans to better manage the boundaries between work and home. Smith encourages his clients to perform self-checks before heading home from work. They can ask themselves, “Where am I right now? How am I feeling (angry, sad, anxious)? What do I need before I go home?” His clients often discover they need to take 30 minutes for themselves. They may go for a run, sit in the car and listen to music, read a book or grab a bite to eat before they are ready to take on the demands at home.

Prochniak recommends that first responders use the following transition strategies:

If they’ve had a rough day at work, text or call their partner to provide a heads-up.
Take 30 minutes to exercise either at a gym or on equipment they keep in their garage to process the cortisol and neurotransmitters that have accumulated over the course of their shift.
Change their clothes at work so that they don’t wear their uniform home. Prochniak often advises clients to look at the shoes they’re wearing. If they are wearing their duty or work boots, then they are at work. If not, then they are at home. This serves as a reminder of the role they are in and what their expectations should be.

Helping first responders support themselves

First responders operate in a close-knit community. “They protect each other, but they also don’t know what to do [to help one another],” Dakin says. She recalls a client who found his co-worker’s behavior troubling, but he wasn’t sure how to provide assistance because he didn’t want to get his friend in trouble or for his friend to get mad at him.

One of the best things counselors can do to support this population is to educate them on healthy ways to help one another. Dakin works with a program (offered by the International Association of Firefighters and the Professional Firefighters of Maine) that trains firefighters to look for warning signs that a co-worker may be struggling and to intervene before it turns into a mental health crisis.

According to Whittaker, peer support often works better than group therapy for this population. Group therapy places people who have been taught to swallow their feelings and just “deal with it” in a setting where they may fear what a therapist will push them to say and how their peers will react, she explains.

Peer support, on the other hand, “takes the therapist out of the room,” Whittaker says. “It is led by people who have been through it and people who can find that common ground. It feels less like therapy and more like people just hanging out and talking, which is a much safer experience for them.”

Dakin recently helped some firefighters/EMTs launch a peer support recovery group. Even if she is present in the group, she lets the first responders lead. She is there not as a counselor but as moral support, she says. If the group asks for her clinical advice, she provides a quick blurb on how the brain works or offers tips such as how to get better sleep. She then fades into the background and lets the group take control again. The goal, she says, is for the first responders to support one another.

Responding during COVID-19

The “invisible threat” of COVID-19 currently looms over first responders, Prochniak says. When they pull up on scene or respond to a call, they no longer know what to expect. They have to assume that everyone is sick or symptomatic, so they wear protective gear and practice physical distancing as best they can while still performing their jobs.

Clients have told Prochniak that although the number of emergency calls has decreased, the overall intensity of those calls has increased. More calls have been made related to suicide and domestic violence.

Most first responders are anxious about what the future holds, Dakin says. They worry about the health of their families and co-workers and their own health. They are concerned about people in the community who often rely on their services and who aren’t calling right now. And they are anxious about the types of calls they will receive once call volumes return to normal.

Prochniak is helping his first responder clients manage their anxiety over the COVID-19 pandemic by having them focus on what is in their control. They may not be able to reduce their threat of being exposed to the virus, but they can develop a plan for what they would do should they be exposed. Would they live in the garage, in a tent in the backyard, in a hotel? How would they handle child care?

Whittaker admits that listening to first responders’ experiences can be difficult, but she also appreciates that they are willing to share something so personal with her. She makes a point of ending each session on an uplifting note. They might talk about how the client demonstrated bravery, how much the client has improved at using a particular counseling skill or how an experience worked out better than the client expected.

“When you see change in somebody’s life,” Whittaker says, “it’s easier to hear these difficult stories because you have a role in making it a little better for them.”

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Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist. Contact her at hello@lindseynphillips.com or through her website at lindseynphillips.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.

Relieving the heavy burden of survivor guilt

By Lindsey Phillips June 27, 2019

Patience Carter took a bullet in the leg during the 2016 mass shooting at Pulse nightclub in Orlando, Florida — the second deadliest mass shooting in the United States — and survived. In a poem she wrote while recovering, Carter captured the devastating effects of survivor guilt: “The guilt of feeling lucky to be alive is heavy. It’s like the weight of the ocean’s walls crushing, uncontrolled by levees.”

Some people are able to grasp and admit that they are suffering from survivor guilt. Others, however, don’t necessarily realize they are wrestling with it, or they struggle to acknowledge carrying a sense of guilt. Luna Medina-Wolf, president of Professionals United 4 Parkland, was part of the mental health response team after the 2018 shooting at Marjory Stoneman Douglas High School in Parkland, Florida. She says many of the teachers sought help for their trauma after the shooting and, through therapy, also found they were dealing with survivor guilt for not being able to protect all of their students or for living when a child died.

Thus, Medina-Wolf, a licensed mental health counselor and the owner of Helping Moon Counseling, advises other clinicians to pay close attention to subtle comments clients make that may indicate they are struggling with survivor guilt. Rather than directly stating “I shouldn’t have survived,” a client may say, “How is it that my friend died?” This question infers the thought “And I didn’t die,” explains Medina-Wolf, a member of the American Counseling Association. Counselors must sharpen their listening skills and not be afraid to ask questions and dig deeper, she adds.

“Even when people are admitting [their guilt], when the words are coming out, they’re not realizing what it is that they’re admitting,” says Melissa Glaser, an ACA member in private practice in Connecticut. “They don’t know as they’re saying it that this is survivor’s guilt and that they’re stuck in a place that they can’t navigate out of.”

Glaser, a community response and recovery leader, served as director of the Newtown Recovery and Resiliency Team following the mass shooting at Sandy Hook Elementary School in 2012. She says counselors can listen for telltale comments that clients are struggling with survivor guilt. For example:

“I can’t accept the help because someone else needs it more than me.”
“I keep thinking if only I had …”
“Other people were so much more courageous while I was just hiding under the desk.”
“I became frozen and immobilized, and I still feel like I’m in that place. I’m so angry at myself that I couldn’t move or do something more.”
“Why did my child come home while another [parent’s] didn’t?”

Glaser is a consultant, a public speaker on trauma and relevant clinical applications, and a licensed professional counselor (LPC) who specializes in trauma and posttraumatic stress disorder (PTSD). She says survivor guilt typically manifests when someone feels a sense of responsibility for a loss or traumatic experience or when someone is grappling with questions of why and how (e.g., Why did this happen? Why did I react that way? How can I enjoy life when others can’t?). This is especially true if they think they could have done something differently to prevent or change the outcome.

“It’s really important for clinicians to help individuals get to a place where they are able to understand that they’ll never have the answers [and] that they can’t stay rooted on the why. … You have to find a way to project those whys into or onto something else,” Glaser says. “Otherwise, it can consume you, and it can become such a part of your identity.”

Glaser often suggests that clients picture themselves throwing their why questions into the air and they don’t come back down. If clients value spirituality, they can imagine that God is going to deal with the questions for a while, she adds.

“Survivor guilt is complicated. … [A] lot of the time, people will not even seek counseling because … they feel they don’t deserve to feel better or they’re not worthy of getting relief,” Medina-Wolf says.

She had a client who was diagnosed with cancer at the same time a friend was diagnosed. When the client survived and the friend didn’t, the client said, “My friend was such a good person. I’m not a good person like her. She volunteered and was kind to everybody. I’m not kind to people. Why did she die?”

Shame is also often intertwined with survivor guilt, adds Courtney Armstrong, an ACA member with a private practice, Real World Therapy, in Tennessee. “When there’s an element of survivor’s guilt on top of [grief], they feel ashamed or guilty for having any joy … because that’s disrespectful to this other person,” she explains. For example, when a child dies, parents may not want to change the child’s room because they feel guilty about moving forward and seemingly “dismissing” their child.

Other clients have told Armstrong, “I can’t be happy if [my loved one] isn’t here. … I feel bad for enjoying my life when they’re not here.”

The ripples and waves of guilt

Survivor guilt can set in immediately, or it can make its presence known months or even years later. This past March, roughly one year after the Stoneman Douglas High School shooting in Parkland, two survivors — Sydney Aiello and Calvin Desir — took their own lives. Aiello’s family reported that she suffered from survivor guilt. A few days later, Jeremy Richman, who lost his daughter in the 2012 Sandy Hook shooting and who later served as one of the keynote speakers at an ACA Conference, also died by suicide.

Richman, along with his wife, had created a foundation to prevent violence and build compassion through brain health research. Up until his death, Richman was actively working with Parkland families. Glaser says Richman was the last person most people would have expected to take his own life, but she stresses the importance of being aware that everybody is in a different place. Counselors “have to be well-versed in [the] signs and symptoms [of PTSD and survivor guilt] and never hesitate to reach out, never hesitate to ask questions,” she adds.

John Super, coordinator of the Community Counseling and Research Center and a lecturer of counselor education at the University of Central Florida, has observed that a person’s proximity to the traumatic event may affect how quickly he or she feels survivor guilt. After the Pulse nightclub shooting, Super, along with two other colleagues, helped organize a grassroots collaborative plan to offer supportive counseling services to those affected.

Super compares trauma and the potential for experiencing resulting survivor guilt with throwing a pebble into a lake: “It ripples out. Those [who] are the closest feel it the quickest and the strongest, but that doesn’t mean that people on the outside don’t feel it.”

Working closely with media reporters after the Pulse shooting, Super witnessed how they also experienced a sense of guilt. “Generally, reporters tend to see themselves as hardened — ‘We’ve seen and heard the worst of life so, obviously, we can’t have any guilt or emotional response to this,’” Super says. “And they would be the ones who buried it the deepest.” Some reporters felt guilt almost instantly because they knew they were prying into people’s lives or pushing people to comment who weren’t ready. Super noticed the guilt appeared later for other reporters, such as when they were writing their stories, editing a video or doing a follow-up special.

According to Jeffrey A. Lieberman, who chairs Columbia University’s psychiatry department, adolescents are particularly susceptible to the after-effects of trauma, including survivor guilt, because they are already dealing with massive changes as they move toward adulthood.

One way that counselors can help survivors is to normalize the guilt they may be feeling after a loss or traumatic event. Glaser, author of Healing a Community: Lessons for Recovery After a Large-Scale Trauma and co-author of the chapter “Disaster Recovery in Newtown: The Intermediate Phase” in the fourth edition of ACA’s Disaster Mental Health Counseling: A Guide to Preparing and Responding, points out that part of the recovery process is simply understanding what is involved. After the Sandy Hook shooting, she noticed a sense of relief when she told clients about common physical and emotional responses to trauma. The clients would look at her and say, “Oh my God! That’s why I feel the way I do. That’s why I can’t do that [activity] anymore.”

During the first session, or when clients are otherwise ready to absorb information, Medina-Wolf will show them a “window of tolerance” infographic created by the National Institute for the Clinical Application of Behavioral Medicine (see nicabm.com/tag/window-of-tolerance/). The infographic helps clients understand that what they are experiencing is a normal reaction to a traumatic event.

A person’s window of tolerance is the ideal place for coping with stressors and triggers, Medina-Wolf explains. Hyperarousal (e.g., hypervigilance, anxiety, panic, fear, racing thoughts) sits at one end of the window of tolerance, whereas hypoarousal (e.g., feelings of numbness, emptiness) sits on the other. The infographic illustrates how a traumatic experience can narrow a person’s window of tolerance, causing the person to feel dysregulated. Although most people commonly associate trauma symptoms with hyperarousal, many of the symptoms of survivor guilt — such as feeling helpless, unmotivated, immobilized, numb or disconnected — are components of hypoarousal, Medina-Wolf adds.

Medina-Wolf says she has had clients cry upon viewing the window of tolerance infographic because they realize they are not going crazy. “A lot of what people need in the beginning is just that reassurance that what they’re going through is symptoms of trauma,” she says.

In addition, recovery from survivor guilt and trauma isn’t a linear process. The guilt and grief of the loss comes in waves, not stages, says Armstrong, author of Rethinking Trauma Treatment: Attachment, Memory Reconsolidation and Resilience and Transforming Traumatic Grief. The reality is that people who are grieving typically move back and forth between loss-orientated waves, in which they feel emotionally and physically drained, and restorative waves, in which they become more task-oriented and don’t dwell on the pain, she explains. Counselors should reassure clients that experiencing grief and guilt in waves is a normal part of the recovery process, Armstrong says. Otherwise, clients who have been feeling better may wonder what is happening when they suddenly find themselves back in a loss-oriented wave.

Of course, as both Armstrong and Medina-Wolf point out, when clients start feeling better and moving through their grief, this can actually cause their survivor guilt to flare more intensely because they don’t think they should be “over it” this quickly or because they feel guilty about being happy again.

Medina-Wolf, who is certified in eye movement desensitization and reprocessing (EMDR), uses recent traumatic episode protocol (R-TEP) for early EMDR intervention with clients. If clients don’t have any underlying issues, this protocol often helps them feel better in as little as three to five sessions lasting 90 minutes apiece. This sometimes prompts them to ask, “How can I feel so good so quickly?” she says.

Of course, some clients may feel that they have their survivor guilt and grief under control, only to turn on the news and be faced with the reality of another traumatic event transpiring. This can throw survivors back into a sense of guilt, distrust and questioning why, Glaser says.

“It isn’t that [trauma] is going to be erased,” she says. “It isn’t that they are going to recover and never be triggered again or never have a day or moment where they’re feeling that extreme sadness, or they’re feeling dysregulated again, or they’re feeling things are foggy. They will experience times like that for the rest of their lives. Hopefully, it’s fewer and further between as they work through this.”

When you can’t talk away the guilt

Glaser is trained in cognitive behavior therapy (CBT), but when it comes to collective community trauma, she has found that CBT may not be the most effective approach — or not effective at all — until the client is grounded.

Medina-Wolf agrees: “Communal trauma requires specific brain-based therapeutic techniques to really be able to break some of the negative schemas that were created due to the trauma. Just doing talk therapy would really take a long time until you would be able to heal. … [A] lot of times, it doesn’t take care of it all. You just learn to cope with it, but the damage is done. And if you don’t make sure to really work on the underlying schemas, then [they] may stay with [you] for the rest of your life.”

With survivor guilt, clients experience a disconnect between what they feel and what they know, Medina-Wolf explains. They may realize on a cognitive level there was nothing they could have done to prevent someone’s death, but they still feel differently.

Medina-Wolf uses a metaphor to explain to clients how trauma shapes the way they see the world and themselves in it. If they were to put on red-tinted sunglasses, she tells them, then everything would seem reddish; once they removed the sunglasses, they would realize it was just the glasses making things appear red. Similarly, being in a state of hyperarousal or hypoarousal makes it difficult to think rationally and process one’s thoughts and emotions, which may alter a person’s perceptions, Medina-Wolf says. Thus, bottom-up approaches such as EMDR, neurofeedback and brainspotting, which allow emotions to be processed at an unconscious level, work better to treat survivor guilt and other trauma-related symptoms than does a top-down approach such as CBT, which assumes that changing thoughts will change behavior and feelings, she explains.

With EMDR, the client and counselor first identify the negative self-belief (e.g., “I could have done something more to save the person’s life”). The client then thinks about this distressing feeling while the counselor uses bilateral simulation such as eye movement, tappers or bilateral music. This technique allows clients to open a door between their conscious and subconscious minds so that they are able to figure out what happened and rewire the way they understand it, Medina-Wolf explains. By identifying the negative self-belief and reprocessing and desensitizing what happened, clients can come to terms with what occurred in a more rational way and are more in control of their emotions when they are triggered, she continues.

For example, Medina-Wolf used EMDR R-TEP with a Parkland student who felt guilty for not saving another student’s life. First, they identified the client’s negative self-belief (“I should have done something more to save the student”) and the positive self-belief she wanted to work toward (“I did the best I could”). Medina-Wolf used tappers to administer bilateral simulation, and after three sessions, the client was able to reach that goal. Her thought process was more rational, she believed she had done the best she could, and she no longer felt guilty for the person’s death.

Individuals who experience survivor guilt, complicated grief or extreme trauma reactions may not be able to organize their thoughts to tell counselors what they need, Glaser says. For that reason, she also recommends using mind-body techniques such as meditation and music therapy to regulate and ground clients. This helps them to process their story and recover the vocabulary to talk about their experience. In many instances, clinicians may need to take a layered approach — for example, doing CBT in conjunction with tapping, art therapy or brainspotting.

Glaser often reverts to something rhythmic to help ground clients. For example, she may have them tap the side of a chair or their leg in a rhythmic way or take them on a walk outside (if they feel safe doing that). This simple rhythmic work helps get clients through the initial acute stage so they can begin to hear the counselor and produce the language they need to tell the counselor what they are feeling, Glaser explains.

In session, Medina-Wolf uses aromatherapy, meditation, breathing techniques and a box filled with fidget toys, pencils and squishy toys that clients can grab and play with while they are processing the event. She also encourages clients to supplement therapy with activities such as running, swimming or cycling that encourage bilateral simulation.

Reimagining guilt

The attachment system often confuses what is imagined and what is real after a traumatic loss or event, points out Armstrong, founder of the Institute for Trauma Informed Hypnotherapy. Thus, she finds the imaginal conversation technique helpful for calming clients’ attachment systems and rewriting the negative thoughts connected to guilt.

With this technique, Armstrong has clients close their eyes and imagine what the person who died would say to them now from a place of enlightened awareness. Would the person want them to be tormented? Would this person tell them they don’t deserve to be alive? Imagining these conversations often helps clients obtain resolution, she says.

Armstrong allows clients to take the lead on these conversations. If they struggle, however, she might say, “I’m imagining they understand that you feel regret and they appreciate how much you care, but they think that being stuck in this depression and guilt isn’t the solution. It isn’t the best way to honor them.”

Armstrong had one client whose mother died by suicide and blamed the client in the suicide note. Because the client had a complicated relationship with her mother, she had a hard time being able to think with a clear, stable mind about her mother. Armstrong told the client she could instead imagine the way she would have liked her mother to be. With clients who are spiritual, counselors can have them imagine a conversation with God and God telling them everything is OK and they are not responsible for what happened, she adds.

Armstrong also has clients write letters to the deceased about their feelings. Then she has clients write an imagined response from the deceased (using their nondominant hand so they are less likely to edit it with their intellectual mind).

Counselors may also need to help clients address another common symptom of survivor guilt: recurring nightmares. Armstrong finds imagery rescripting helpful here. The technique involves rewriting or changing the ending of the nightmare. Clients first describe the nightmare to Armstrong, and then she asks how they would want to change it.

Armstrong had a client whose son died by suicide. The mother felt guilty for not somehow preventing his death — which she feared had caused him to go to hell — and for cremating him when she wasn’t sure he would have wanted that. This guilt culminated in a nightmare in which her son was asking for help as he was being rolled into a furnace, but she was unable to move her body to help him.

Armstrong asked the client, “What do you wish you could do in the dream?” The client responded that she wanted to move and go to her son. Armstrong then asked her to close her eyes and imagine a new ending — one in which her feet could move, she possessed the superpower to leave her body and go to her son, or her son was able to walk to her. The mother closed her eyes and reimagined the nightmare: The son got off the gurney and met her halfway. Then he embraced her and said, “I love you, Mom. I’m sorry I didn’t get to say goodbye. I’m going to be OK.” This revision brought an end to the client’s nightmares.

Counselors should have clients imagine their dreams and the new endings as vividly as possible, Armstrong advises. It typically requires going over this new ending several times in session and having clients imagine it again before bed. “If you just talk about the ending without imagining it as best you can, it won’t work because your emotional brain needs that imaginal experience,” Armstrong explains. The emotional brain learns through experiences, not reasoning, she says, so counselors must have clients create an experience that will allow them to heal.

Turning pain into power

According to Glaser, survivor guilt is rooted in pain. She advises counselors to help clients realize that “guilt in any of its forms is not really productive” — either for clients, for those around them or for those who are gone.

Medina-Wolf says clients often acknowledge being angry, depressed or anxious, even when guilt is the underlying cause of their problems, because it is more difficult to admit feeling guilty. “They feel like if they say it out loud, then maybe they are guilty,” she observes. “The guilt is so deep and they’re so [ashamed] of it because they’re so confident … in that negative distortion that it’s literally killing them from the inside.”

It matters where that guilt is coming from, Medina-Wolf continues. Do they think they didn’t do enough? Do they feel they are a bad person who shouldn’t have survived? Counselors can help clients process exactly what they are experiencing and identify the underlying cause of the guilt, she says.

Often, the guilt is based on a fear of not knowing how to go back into a world they no longer trust, Glaser says. So, instead, they hold on to the guilt and the awful feeling of responsibility. “When we understand that, we can start to make some inroads,” she continues. “We can help the client know where it’s coming from.”

Armstrong points out that pain is also a way for some clients to maintain a bond with their loved one, especially if they experienced the death of a child or someone’s death by suicide. Clients may assume that living without the pain would suggest their loved one’s life wasn’t important, she explains.

She encourages clients to honor their loved ones by letting their importance stay alive in a positive way. Armstrong provides a personal example: Her husband enjoyed watching Atlanta Braves baseball games with his mother, so after she died, he and Armstrong continued to go to games to honor her.

One of Armstrong’s clients had a son who died of an overdose. The client’s happiest memory was of camping in the Grand Canyon with his son, but after his son’s death, the father’s sadness and guilt stripped him of his motivation to hike and camp. Armstrong asked the client to imagine whether his son would want his father to stop hiking to prove his love for him or whether he might prefer that his father do something that served as a positive reminder of their time together. After the father’s perspective was changed through this imagined conversation, he took a small step forward by going hiking. Eventually, the father and his wife planned a trip to the Grand Canyon in their son’s honor and spread some of his ashes there.

Armstrong also recommends using the making living stories technique, in which she invites clients to bring in photos or share stories about the deceased. However, she has found that if she asks clients to tell her a story about the person, their minds often go blank. So, instead, Armstrong will ask about the deceased loved one’s favorite music or food, about a trip the client took with the person, or even what annoyed the client about the person. These silly or trivial questions often end up producing the best stories, she says.

Armstrong also prefaces this technique with the phrase “when you are ready” to ensure that discussing the loved one won’t create additional pain for the client. Counselors can put the invitation out there, and when clients are ready, they can work together to find ways to remember the loved one, she says.

There are times when the attempt to turn pain into something positive can result in others feeling even more guilt. For example, the media often praises survivors or those who have perished in mass shootings for their bravery, such as in the case of Kendrick Castillo, a student who died trying to subdue an active shooter in his school in Colorado this past May. Glaser acknowledges the desire to honor those who perform heroic acts, but she also notes this action can create something of an expectation among adolescents that it is their responsibility to react bravely and save others during a school shooting. It can also exacerbate survivor guilt among those who followed safety protocols and hid behind their desks.

Armstrong is impressed when survivors take a horrible situation and become empowered, such as with the Parkland students’ gun violence advocacy work. However, she also acknowledges that survivors sometimes need to work on healing themselves first.

One of Armstrong’s clients had a daughter who died of a childhood cancer. Soon after her daughter died, the hospital and cancer community approached the mother about having a fun run in honor of her daughter and to raise money to battle the specific type of cancer. Her daughter’s death was too fresh though, and the mother ended up experiencing survivor guilt for not wanting to help create a fun run in her daughter’s honor.

To help the client, Armstrong had the mother imagine what her daughter would say about the situation. Armstrong knew a little bit about the daughter’s personality, so she mentioned the daughter would probably say that even she didn’t have time for a fun run because she was still learning to navigate the afterlife. This helped the client put her guilt into perspective and focus her energy on healing herself.

“You don’t have to be a hero,” Armstrong often reminds clients. “If you decide to do something later, then that’s awesome. But [honoring a person’s life] may just be in little simple ways — I’m just going to take more time to appreciate a sunny day, be kinder to people or not take things for granted.”

Compassion for self, not just others

Often, it’s easier to offer compassion to others rather than to oneself. This may be especially true for counselors. Super, an ACA member who presented “The Shared Trauma of School Shootings and Their Impact on Counseling and Education” at the ACA 2019 Conference in New Orleans, admits he wasn’t good at self-care during the recovery after the Pulse shooting. As one of the coordinators of the grassroots recovery effort in Orlando, Super spent the majority of his time at different counseling centers helping survivors and supervising counselors, and at the end of the day, he often had nothing left in him to tend to his own self-care.

Months later, as he was researching and presenting on his personal experience with this large-scale traumatic event, he realized how it had affected him. “Those thoughts [of ‘it could have been me’] start coming to you, that guilt of ‘this young person … just lost their life and I didn’t.’ I think that is probably a quiet voice that sat in the back of my mind through the entire process.”

Super also witnessed counselors who experienced guilt over not feeling prepared enough or not knowing enough about trauma and the LGBTQ+ community. Other counselors felt guilty that they didn’t help with the recovery efforts because life got in the way or because they simply weren’t ready and needed to take care of themselves first, he adds.

Super would pay close attention to how counselors were responding — for example, if they didn’t want to meet with clients or walked off by themselves — and check in with them. He and the other two organizers weren’t able to be in contact with all of the mental health providers offering assistance, so they also trained counselors to be aware of colleagues’ behavior and check in with them as needed.

People don’t often think about the need for counseling supervision during a collective trauma, Super points out. “But if you have counselors out there, you really need to have supervisors who are debriefing or helping process emotions for those who are providing services in the moment,” he says. He advises counselors and supervisors to make time for self-care. Talking about their feelings with another counselor, a supervisor or someone they trust will help counseling professionals recharge, and it will minimize the residual effects down the road, he notes.

Compassion also helps clients reframe their own guilt. Armstrong stresses the importance of providing psychological first aid — which includes making the person feel supported and safe — immediately after a traumatic experience. Armstrong has had sessions in which a client cried the entire time, and she felt guilty for not doing enough — only to discover that the client thought the session was extremely helpful. Outside of the counseling space, clients typically have to hold it together, she points out, so they often appreciate having a space where they can break down and not worry about others.

Armstrong also worked with a client who dealt with survivor guilt after the 2012 mass shooting in a movie theater in Aurora, Colorado. The client had been watching a movie next door and, on her way out, almost tripped over a woman who had been shot. She didn’t know how to help the woman, so she simply held her hand and called the woman’s mother. Discussing this with Armstrong, the client said, “All I could think to do for the gunshot victim in the parking lot was to sit there and hold her hand. I am in the health care field, and I felt completely incompetent.”

Armstrong reassured the client that she had done something valuable by offering the shooting victim compassion and psychological first aid, but the client still felt guilty for not doing more. While the client described the event again, Armstrong held her hand, which created an experience to demonstrate the power of compassion. When the client finished her story this time, she noted how the simple act of Armstrong holding her hand had helped her get through the story and made it seem less scary.

A few months later, the client ran into the woman she had helped after the shooting. The woman told her that the kindness of a stranger holding her hand was what replayed in her mind — not the horror of the event.

Armstrong acknowledges that counselors frequently worry about not doing enough, not knowing what to say to clients and not being able to rid them of all their pain. “At the end of the day,” she says, “it’s just us being able to sit with [clients] through all of the confusion and the heartache that heals them.”

For many survivors, the weight of survivor guilt is heavy. But counselors can operate as levees to prevent the weight of this guilt from crushing those who survive.

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Read more in an online companion piece to this article, “Doing the groundwork after a large-scale traumatic event”

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Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist living in Northern Virginia. Contact her at hello@lindseynphillips.com or through her website at lindseynphillips.com.

Letters to the editor: ct@counseling.org

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

Doing the groundwork after a large-scale traumatic event

By Lindsey Phillips June 24, 2019

Finding and helping people suffering from survivor guilt, PTSD and complicated grief can be challenging after large-scale catastrophic events, which are becoming more common. According to Mother Jones, since 1982, there have been at least 110 public mass shootings across the United States.

John Super, one of the coordinators of the Orlando recovery effort after the 2016 Pulse nightclub shooting in Orlando, Florida, acknowledges the sad reality that it’s not if collective trauma happens but when it happens, so counselors need to be prepared and adequately trained for crisis response.

Super, coordinator of the Community Counseling and Research Center and a lecturer of counselor education at the University of Central Florida, points out that the underlying thoughts and feelings of survivor guilt are the same regardless of the type of loss. However, he adds, large-scale traumatic events carry their own additional stressors: the lack of privacy, communal trauma and the increased fear for one’s safety in public areas (such as being afraid to go to the grocery store).

Because people are in a state of pain, dysregulation, fear and distrust, they put up walls, notes Melissa Glaser, a licensed professional counselor (LPC) in private practice in Connecticut. Glaser, a consultant and public speaker on trauma and relevant clinical applications, served as director of the Newtown Recovery and Resiliency Team following the mass shooting at Sandy Hook Elementary School in 2012. “Lots of times people in helping professions, particularly clinicians, come into a situation like [a mass shooting] where there’s collective community trauma or even coming into situation where you’re working with individuals that are in the throes of their grief — complicated grief and trauma reaction — and you think that you’re going to be welcomed with open arms,” she says. “And often the opposite is true.”

Super was surprised that people weren’t showing up to the grief counseling centers after the Pulse shooting. Instead of getting angry, Super and his co-coordinators reconceptualized what their response would look like, and they literally started meeting the clients where they were. Counselors went to the blood donation lines and handed out water bottles. They attended the vigil and watched for people who were having severe emotional reactions.

The Pulse nightclub in Orlando, Florida, pictured after the shooting that killed 49 people and wounded 53 in June 2016.

They even went to local bars. A few days after the shooting, a local LGBTQ bar contacted Super asking for counselors to come to the bar because people were using alcohol to self-medicate. “Receiving that call was the lightbulb that went off,” he says. “What we found was some of our most productive counseling work happened in those environments.”

After the 2018 shooting at Marjory Stoneman Douglas High School, Luna Medina-Wolf, a licensed mental health counselor and the owner of Helping Moon Counseling in Florida, and the other therapists found themselves frustrated because they couldn’t access the survivors. The school system, with its background check and credentialing procedures, would not let them in. They decided to turn this frustration into action and figure out what they could do. Medina-Wolf, president of Professionals United 4 Parkland, reached out to Deb Del Vecchio-Scully, an LPC and trauma specialist who helped with response and recovery after Sandy Hook. Del Vecchio-Scully guided them through the process of organizing a recovery response and suggested they accumulate a list of mental health professionals who could help if the need arose.

Medina-Wolf reached out on social media to her connections and asked for trauma-trained therapists who could donate their time. Within three hours, she had 100 emails. To avoid being overwhelmed, she created a Google spreadsheet to track the names, specialties, credentials and phone numbers of the mental health professionals.

She discovered another therapist had started a similar list, so they combined their lists and eventually created the nonprofit Professionals United 4 Parkland. Through this collaboration, they have provided training sessions for therapists, parents, and educators and staff at Stoneman Douglas.

Medina-Wolf advises mental health professionals to come together, figure out existing gaps and ways that they can help, and reach out to community organizations to offer assistance. “This is a long-term healing process,” she says. “So, if [community organizations] won’t need you in the beginning, they will need you moving forward.”

That’s what is happening in Parkland now, she adds. After the initial shock, the community has had time to reflect on the long-term impact of this trauma, so they are reaching out to mental health professionals and figuring out a way to work together. For example, the first training they had for the teachers and staff at Stoneman Douglas was done independently from the school, but in January, the school reached out and requested that they host a training workshop as part of the school’s planning day. Medina-Wolf notes that they purposely called the workshop a retreat, not a training, to help reduce the stigma attached to mental health issues. The retreat included gifts, therapy dogs, breakout sessions on coping skills (such as meditation), and strategies on how to handle students and future drills.

Glaser, author of Healing a Community: Lessons for Recovery After a Large-Scale Trauma, also recommends collaborating with other professionals and organizations. “We have to get rid of the territorial aspect that the work can bring sometimes and bridge those gaps and be collaborative because one person or one organization can’t meet all the needs,” she says.

Glaser and her staff developed relationships with other professionals so they could appropriately direct those needing help. Providers would tell them when they had openings, the insurance they accepted and the therapeutic approaches they used, and new providers would provide a presentation on their services and even practice some of their techniques on Glaser and her team.

Glaser warns that clinicians can do more harm than good if they send clients to the wrong practitioner or if therapists promise things that they can’t deliver, which only undermines trust in all mental health professionals.

Glaser also stresses the importance of being hands-on and following up with clients. Because a traumatized brain can be extremely disorganized, counselors can’t simply give out phone numbers and a list of resources, she stresses. Sometimes, they have to make that call themselves and follow up with clients after they have had an appointment.

At the ACA 2019 Conference in New Orleans, Glaser spoke with school social workers from Parkland who were frustrated by their inability to help with the emotional aftermath after a lockdown drill because it wasn’t a priority to the administration. Glaser agrees that clinicians could do a better job with debriefings after a drill, and she also shared in their frustration with dealing with resistance from organizational leaders.

In fact, Glaser learned the importance of educating community leaders during her work with the Newtown community. She would invite the heads of organizations and school administration to participate when she brought in an expert or held a workshop on the importance of mental health efforts.

“We as clinicians now have the responsibility of educating from the top down,” Glaser says. “We can’t expect that the people that are following [safety] protocols and putting those measures together are necessarily well-versed in the clinical implications. So, part of our work now has to be to teach all of those involved.”

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Look for a companion piece to this article, “Relieving the heavy burden of survivor guilt” in the July issue of Counseling Today magazine.

Related reading, from the Counseling Today archives:

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Letters to the editor: ct@counseling.org

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