Tag Archives: trauma

Tapping into the benefits of EMDR

By Lindsey Phillips September 27, 2021

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

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

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

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

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

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

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

How EMDR differs from other approaches

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

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

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

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

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

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

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

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

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

When to use (and not use) EMDR 

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

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

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

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

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

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

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

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

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

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

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

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

Case example with complex trauma

Larisa Lomaeva/Shutterstock.com

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Be fluid, not rigid

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

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

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

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

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

Don’t rush the process 

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

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

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

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

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

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

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

Adapting to the client’s needs  

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

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

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

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

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

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

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

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

 

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

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

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

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

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

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

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

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

(Information adapted from EMDRIA)

 

****

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

****

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.

Trauma stabilization through polyvagal theory and DBT

By Kirby Reutter September 14, 2021

From my perspective, polyvagal theory has thus far provided us with the best working model of how trauma affects the brain and the body. According to this model, trauma has an impact on both branches of the autonomic nervous system (sympathetic and parasympathetic), which includes both branches of the parasympathetic nervous system (ventral and dorsal). 

The sympathetic branch of the nervous system is associated with physical and emotional acceleration (such as increased fear, anger, breathing and heart rate); in the case of danger, this means “fight or flight.” In contrast, the parasympathetic branch of the nervous system is associated with physical and emotional deceleration. More specifically, the ventral branch of the parasympathetic nervous system is associated with social engagement, while the dorsal branch is responsible for “rest and digest” functions and, in the case of extreme threat, “freeze.” Freeze occurs when the organism either mentally dissociates or, in even more extreme cases, faints.

When presented with danger, the various branches of the autonomic nervous system are affected in a specific order. The first branch to be affected is the ventral sub-branch of the parasympathetic nervous system, which is responsible for social engagement. In other words, when presented with threat, functions related to social connectivity — laughter, smiling, empathy, attunement, the ability to provide validation — go offline. If the danger persists, the next branch to be affected is the sympathetic nervous system, which results in fight or flight. When neither fight nor flight can mitigate the threat, the dorsal sub-branch of the parasympathetic nervous system is activated, resulting in freeze (some sort of either mental or physical collapse, such as dissociating or fainting). The following actions summarize this sequence:

  1. Danger is sensed.
  2. Social engagement goes offline (ventral parasympathetic nervous system).
  3. Danger persists.
  4. Fight or flight is triggered (sympathetic nervous system).
  5. Danger cannot be mitigated through fight or flight.
  6. Freeze response activates (dorsal parasympathetic nervous system). 

The two pedals

Think of the sympathetic nervous system as the accelerator and the parasympathetic nervous system as the brakes. As we drive down the highway, we need both of these functions. If the drive is smooth, sometimes we will gently accelerate and sometimes we will gently brake. The same process applies to our physical, mental and emotional functioning. If the “drive” is smooth, our mind and body enjoys a gentle oscillation between accelerating and braking. 

This is even reflected in our heart rhythm. A healthy rhythm is indicated by a consistent repetition of fast/slow, fast/slow, fast/slow. The reason for this gentle pendulation is so that the entire organism, at a moment’s notice, can either further accelerate or further break, as needed. A heartbeat that is either consistently fast or consistently slow or irregularly fast/slow is not a healthy rhythm because these circulation styles cannot allow for the gentle oscillation between accelerating and braking that is required for a smooth ride.

Let’s return to our driving analogy. If you are driving down the highway and a truck carelessly swerves right in front of you, you will probably have all of the reactions represented by the polyvagal theory: You may swear and flash various fingers (social engagement goes offline), you may suddenly accelerate, or you may slam on the breaks. But after the danger is averted, you will most likely return to your baseline of gently oscillating between accelerating/braking as needed — until the next threat again requires more extreme action.  

Now let’s assume you have experienced so many roadside perils that you decide never to let down your guard. You are poised at every moment to yell and scream at other drivers, unpredictably accelerate and unpredictably brake. If you are really frazzled, you may even attempt to accelerate and brake simultaneously. Over time, this becomes your new default driving style, regardless of the driving conditions: cuss everyone out, suddenly accelerate, suddenly brake. (You may have noticed that in some major cities, this sort of driving is common.) Do you see how this will lead to a wild ride? Even if the driving conditions would otherwise have been relatively smooth, they won’t be anymore. And even if no danger would otherwise have been present, now there is. You are off to the races …

A breakdown in dialectics

This driving metaphor describes what happens to people who have experienced chronic trauma: too much accelerating, too much braking, and loss of social engagement to boot. This leads to a vast variety of responses that are either “too much” or “too little,” resulting in a host of life complications. This tendency toward too much or too little especially affects the following domains:

  • Awareness
  • Thoughts 
  • Emotions 
  • Reactions 
  • Relationships 

For each of these domains, it is possible to have either too much (overuse of the accelerator, or sympathetic nervous system) or too little (overuse of the brake, or parasympathetic nervous system). Too much awareness leads to hypervigilance, whereas too little leads to dissociation. Too much thinking leads to obsessive rumination, whereas too little leads to impulsive decision-making. Too much emotional stimulation leads to overwhelm, whereas too little leads to numbness. Too much reactivity leads to even more crises, whereas too little leads to paralysis. Even relationships can be either too much or too little, resulting in either overdependence or under-dependence on others.  

In short, trauma results in all of the following possibilities: over-awareness versus under-awareness; overthinking versus under-thinking; overemoting versus under-emoting; overreacting versus underreacting; and over-relating versus under-relating. Because both the sympathetic and parasympathetic nervous systems have been hijacked, the driver is constantly over-accelerating and over-braking in each of these domains — and often doing both at the same time.

bestber/Shutterstock.com

Restoring balance 

Dialectical behavior therapy (DBT), which was developed by Marsha Linehan, is all about reconciling “dialectical dilemmas” (binary extremes resulting in dysfunction) by teaching specific behavioral skills to forge a “middle path” between those extremes. In particular, DBT teaches the following five skill sets: mindfulness, distress tolerance, emotion regulation, dialectical thinking and interpersonal effectiveness. These skill sets teach the middle path between each of the dialectical dilemmas mentioned in the previous section.

As long as clients are existing and operating at these extremes, it is extremely difficult for them to do even basic counseling — much less trauma work and much less life. That is why DBT as a treatment model is entirely skills focused. DBT teaches the foundational skills one needs to optimize counseling, stabilize for trauma work and then thrive in life — “building a life worth living,” in the words of Linehan. Among dozens of skills that could be highlighted, I would like to present five simple acronyms to help clients find — or forge — each of these middle paths.

The RAIN dance: One path to mindfulness 

Mindfulness, by definition, is always a combination of both awareness and acceptance. The RAIN dance helps clients increase both awareness and acceptance of intense emotions and other triggers in a highly practical and applied manner. RAIN stands for Recognize, Allow, Inquire and Nurture.  

The purpose of this acronym is to help clients know precisely how to apply mindfulness in a real-life situation. Let’s suppose you want to help a client become more mindful of their anger. First, teach your client to recognize their anger — and especially where they notice it in their bodies (e.g., clenched jaw). Next, teach your client to allow their anger (instead of judging or resisting it, which will make it only more difficult to manage in the long run.). Then, teach your client to inquire about their anger — with curiosity, empathy and maybe even humor. (Fear and anger are neurologically incompatible with empathy, curiosity, and humor.) Finally, teach your client to engage in some sort of nurturing (i.e., self-soothing) behavior to release the anger in an appropriate manner (such as taking a long walk through the woods). The emotional energy will need to become appropriately discharged, especially if the intense emotion has resulted from a fight-or-flight response; otherwise, this energy will simply become frozen — and then continue to resurface when triggered. 

The basic idea behind this skill is simple: Learn to “dance” with your emotions rather than avoiding, resisting, suppressing or judging them.  

TIP the balance: One path to distress tolerance 

DBT distress tolerance is all about learning to cope in the moment without making it worse. It is about replacing impulsive, addictive, risky or self-injurious behaviors (in other words, any behavior that leads to even more of a crisis orientation) with more-effective coping strategies.  

One of my favorite distress tolerance skills has to do with finding ways to TIP the balance. Because there is such a direct and obvious mind-body connection, often the quickest way to shift your mood is to quickly shift something in your body. If you can “tip” your body chemistry, you can also “tip” the balance on your emotions. There are three ways to quickly TIP your body chemistry: Temperature, Intense exercise and Paced breathing/Paired muscle relaxation (this refers to tensing your muscles as you inhale and relaxing your muscles as you exhale). 

Although each of these techniques is effective on its own, they can be even more effective when done together. For example, one way I personally TIP the balance in my own life is by riding my bicycle. This activity helps me to quickly change my body temperature, involves intense physical exercise, and helps me synchronize my respiration (inhale/exhale) with my musculation (tense/relax) through the cyclical nature of pedaling.

Sow your SEEDS: One path to emotion regulation

Whereas distress tolerance refers to short-term coping in the moment, emotion regulation refers to a long-term lifestyle change that will ultimately support much healthier emotionality. When I teach emotion regulation skills to clients, I use an extended garden analogy. For example, if you want to have a healthy garden of flowers, would it make any sense to scream and swear at the flowers? Ignore the flowers? Shame the flowers? Coerce or manipulate the flowers? Of course not. Your flowers do not need to be controlled — they need to be cultivated. 

The same concept applies to our emotions. Instead of trying to control them, we need to care for them — like beautiful, delicate flowers. (By the way, it makes me cringe every time that I hear therapists — and even DBT practitioners, no less — paraphrase emotion regulation as “controlling your emotions.”) There are several things you need to do to care for a real garden: plant the right seeds, do some weeding, check the soil, continue to care for the garden even when you feel like giving up, and fertilize. Each of these activities represents a specific way to care for our emotions as well. Here, I will simply introduce the first one: You need to plant the right SEEDS.  

Planting the right SEEDS refers to five ways of taking care of your physical body: Symptoms, Eating, Exercise, Drugs and Sleep. If you want to have a healthy garden of emotions, you will need to plant each of these seeds by addressing physical symptoms, finding healthy eating patterns, getting moderate exercise, monitoring which drugs enter your body, and getting adequate sleep. After helping my clients develop a specific plan for each of these “seeds,” I often have them provide me with a quick SEEDS report at the beginning of each session, as part of their weekly check-in. 

Working the TOM: One path to dialectical thinking  

Dialectical thinking is all about letting go of the extremes, learning to think more in the middle, learning to be more flexible with your cognitions, learning to see things from someone else’s perspective, learning to see things from multiple perspectives in your own head, and learning to update your beliefs when presented with new information.  

When I teach dialectical thinking to clients, I use a very simple process: We work the TOM, which stands for Thought, Opposite and Middle. First, we identify the original problematic thought. Next, we identify the complete opposite extreme of that cognition. Finally, we brainstorm a possible belief somewhere more in the middle.  

Let’s assume a client has the original problematic thought of “I am not good at anything.” The complete opposite extreme would be: “I have never once made a mistake. I am absolutely flawless. I am the most competent human specimen that has ever existed.” And something more in the middle might be: “There are some things I am OK at, but there are also lots of things that I need to work on.”  

The purpose of this exercise is to help clients quickly identify a cognition that is most likely much more accurate than the original belief. Clients may not always be able to come up with a middle thought on their own, so it is completely fine to help them at first. Eventually, however, it is better if clients can generate their own middle thoughts because whatever they produce will inherently be more believable than whatever you come up with. Even if the client insists they do not believe the middle thought that they generated, chances are that part of them does — because those words came from their mind. Regardless, your job is not to try to convince your client that the middle thought is more accurate; it is simply to plant the seed for that thought and then let it germinate on its own.
In fact, the more the client wrestles with the middle thought, the more they are thinking about it, therefore reinforcing the new cognition.  

DEAR Adult: One path to interpersonal effectiveness 

Whereas all the other skills mentioned so far are about self-regulation, interpersonal effectiveness inherently involves both the self and someone else. Therefore, interpersonal effectiveness inherently subsumes the other skill sets. After all, you can’t possibly deal with another person if you can’t even deal with yourself yet. 

Here, I would like to introduce perhaps the most comprehensive of the interpersonal effectiveness skills: DEAR Adult. D stands for Describe: First, describe the situation that needs to be addressed. State only the facts, and truly focus on the situation, not the person. Next, Express how you feel about the situation. Use “I feel” statements. Once again, truly express how you feel about the situation, not the person. Sometimes it can be helpful to use a “float back” and express how you have felt about similar situations previously so that both you and the other person understand that there might be more history beyond the current situation. If you want to be especially dialectical, also use this E to Empathize with the other person’s perspective.  

Now you are ready to move on to A, which stands for Assert. When asserting, use “I need” statements. In particular, explain what you need in positive terms, not negative ones; explain precisely what you need the other person to do, not what they should stop doing. If you want to be even more dialectical, also use the A to Appreciate the other person’s perspective and even Apologize for your role in this situation.  

R stands for Reinforce. You want to end on a positive, upbeat note by reinforcing both your request and the relationship itself. In my opinion, the best way to reinforce both is to explain how what you are requesting is a win-win proposition. You simply want what is best for both parties. Therefore, you are willing to further negotiate and compromise as necessary.  

Finally, you want to do all of this using the Adult Voice, which is the dialectic (the middle ground) between the Parent Voice (yell, lecture, berate) and the Child Voice (whine, pout, throw a tantrum). The Adult Voice is when you communicate in a manner that is calm, composed and collected.

Summary 

Ongoing trauma results in overstimulation of both the sympathetic and parasympathetic nervous systems (accelerator and brake), resulting in a variety of responses that are either “too much” or “too little.” The five skill sets taught in DBT help restore the balance between these extremes by providing a middle path, which includes reactivation of the social engagement system. That’s why when I am explaining DBT to my clients, I usually dispense with clinical jargon and simply refer to this model as “developing balance therapy.” In this article, I have briefly introduced five skills (among legion) as examples of these middle paths: RAIN dance as a form of mindfulness; TIP the balance as a form of distress tolerance; sow your SEEDS as a form of emotion regulation; work the TOM as a form of dialectical thinking; and DEAR Adult as a form of interpersonal effectiveness. 

To be clear, DBT was not designed to resolve the original trauma. Myriad models have been developed for trauma processing. Some models focus more on verbal processing and are generally referred to as “top-down models.” Other models focus more on somatic processing and are generally referred to as “bottom-up models.” Some clients prefer verbal forms of processing, some clients prefer somatic forms of processing, and most clients can benefit from both, so it is not necessary (in my opinion) to engage in endless debate or pointless turf wars on this point. My recommendation is simple: Be trained in at least one form of trauma processing that is mostly top-down and at least one form of trauma processing that is mostly bottom-up — and become proficient in both. (Another dialectical dilemma resolved.) 

However, no form of trauma processing can be completely effective when the individual is actively in crisis, experiencing ongoing danger or constantly dysregulated. That’s where DBT comes in. DBT (which I like to call “developing balance therapy”) provides the necessary skill set to help individuals sufficiently stabilize or self-regulate in order to then proceed with deeper trauma work.  

If you would like to learn more about how to use trauma-focused DBT with a variety of trauma-based disorders, I recommend the following resources to get started:  

  • The Dialectical Behavior Therapy Skills Workbook for PTSD: Practical Exercises for Overcoming Trauma and Post-Traumatic Stress Disorder by Kirby Reutter, 2019
  • “DBT for Trauma and PTSD” (DBT Expert Interview series at psychotherapyacademy.org/dbt-interviews)
  • Survival Packet: Treatment Guide for Individual, Group, and Family Counseling by Kirby Reutter, 2019
  • “The Journey From Mars: Brain Development and Trauma” webinar (youtube.com/watch?v=WSFqHS_axOc)

 

****

Kirby Reutter is a bilingual clinical psychologist and licensed mental health counselor who contracts with the Department of Homeland Security to provide mental health services for international asylum seekers. He has provided four trainings for the U.S. military, is a TED speaker and is the author of The Dialectical Behavior Therapy Skills Workbook for PTSD: Practical Exercises for Overcoming Trauma and Post-Traumatic Stress Disorder. Contact him at Kirby.reutter@gatewaywoods.org or through his website at drkirbyreutter.com.

 

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, visit ct.counseling.org/feedback.

****

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.

Restoring relationships with survivors of human trafficking

By Lindsey Phillips August 4, 2021

Jenna Hershberger, a licensed associate professional counselor, was working on a crisis response team for a regional human service center in North Dakota when she received a call from a young woman reporting physical abuse. The woman was forthcoming about her medical complaints but not the state of her mental and emotional health. Hershberger could tell there was more to the woman’s story, so she asked to meet her in real life to discuss things further. The woman agreed.

During their in-person meeting, Hershberger, a therapist at the Village Family Service Center in Fargo, North Dakota, noted signs of potential sex trafficking. “Her presentation was really concerning. She was very tearful,” Hershberger recalls. The woman also kept mentioning how her “friends” had forced her to do things while she was under the influence of substances. The more the woman shared, the more convinced Hershberger grew that the people being referenced were human traffickers, not friends. When Hershberger asked where the woman was staying, she revealed that she was currently homeless.

After talking for a while, the woman finally acknowledged that she had been forced into sex trafficking and wanted to get out. She was scared and didn’t know what to do. Fortunately, Hershberger did. She found the woman a safe shelter for the night and helped her locate mental and physical health services.

“I’m in North Dakota … [where] prevalence rates [of human trafficking] are lower, yet it’s still happening,” says Hershberger, a member of the American Counseling Association. “The tragedy where I am and in Midwestern, rural areas is that people just seem to say, ‘Well, this doesn’t happen here.’”

Jared Rose, a licensed professional clinical counselor and supervisor with a private practice, Moose Counseling and Consulting LLC, in Toledo, Ohio, has also encountered a “that doesn’t happen in my community” mentality when it comes to human trafficking. He began working in anti-trafficking about 15 years ago when someone involved in an anti-trafficking organization in Toledo approached him because of his work with the LGBTQ+ community and with people infected with, affected by or at risk for contracting HIV, both of which often intersect with trafficking. When conducting trainings in rural Ohio counties, Rose has heard law enforcement say, “That’s not happening here.” This statement makes Rose cringe because he knows firsthand from his work with individuals who have been trafficked that it is happening.

Human trafficking, in fact, is more common than we think. The International Labour Organization reported that approximately 40.3 million people were in modern slavery globally in 2016. Sometimes people incorrectly assume that human trafficking is a problem only in developing countries, but the National Human Trafficking Hotline identified 63,380 survivors of human trafficking in the United States from 2007 to 2019.

Rose, an ACA member who wrote an ACA fact sheet on human trafficking awareness for school counselors in 2019, finds that too many counselor clinicians also remain unaware of the definition and signs of trafficking. “You could have the epitome case sitting in front of you,” Rose says. “And if you don’t even know what trafficking is, you’re going to miss it.”

Recognizing the Signs

The U.S. Department of Homeland Security defines human trafficking as the use of force, fraud or coercion to obtain some type of labor or commercial sex act. Rose, an assistant professor of counseling at Bowling Green State University, advises counselors to stay alert to signs of force, fraud or coercion with clients. “Take note of who they are with and where the power and control lie,” he says. For example, is someone else benefiting — often financially — from the client’s actions? Does someone else seem to be in charge or making all the client’s decisions for them?

Hershberger, a doctoral candidate in the counselor education and supervision program at North Dakota State University, also looks for visual signs such as bruising, scarring or branding. Individuals who are being or have been trafficked are often branded with “ownership” tattoos with the name of their trafficker or with symbols such as a star or cowboy hat. Because sex acts place a lot of strain on the body, survivors often discuss medical complaints such as dental issues, migraines or urinary tract infections, she adds.

Clients who have been trafficked “may appear overly compliant and submissive, or they might appear really abrasive and abrupt,” Hershberger points out. Counselors must recognize “that those strategies were adaptive at one time but they’re not right now.”

As it relates to falling victim to trafficking, Rose notes that the No. 1 risk factor for children is being unhoused. He prefers the term unhoused to runaway, he explains, because children are often abandoned or “thrown out” by their families. “Within a matter of two to three days of being out of the home, kids are approached [by traffickers], and one-third of those [unhoused] kids are going to get trafficked,” he says. “So, that piece of being unhoused — couch surfing, staying at a shelter, living on the street or whatever the case may be — puts them at significantly higher risk.” Children who are already vulnerable may easily fall prey to an adult who shows them attention or what they initially perceive as support, he adds.

Other risk factors include lower socioeconomic status, past trauma (sexual, physical, emotional, verbal or spiritual), being differently abled, substance use, and belonging to a racial or sexual minority group, Hershberger says. Given the complex trauma that these individuals experience, they often present with comorbid disorders such as substance use, bipolar and severe depression, she notes.

Counselors may overlook or miss signs of trafficking when they take the client’s circumstances or presenting issues at face value, notes Paige Dunlap, an associate professor of counseling at North Carolina Agricultural and Technical State University. For example, if a client is homeless or doesn’t have any identification, counselors may start to talk about the emotions, behaviors and social systems surrounding the client’s chronic homelessness and help them come up with a plan to find a more stable environment. But in doing this, clinicians may miss the larger picture, stresses Dunlap, a licensed clinical mental health counselor with a private practice in Greensboro, North Carolina. Perhaps the client was forced into sex trafficking after being taken from their home or fleeing an unsafe environment.

“There’s a lot of different risk factors. There’s a lot of different things to look for. There’s a number of populations that we are particularly concerned about, but at end of day, it all boils down to vulnerability,” Rose says. For that reason, he stresses that counselors need to be cognizant of that vulnerability piece in connection with their clients.

Sometimes counselor practitioners worry that they won’t be able to recognize the signs that someone has been trafficked, Rose says, but he reassures them they know how to read interpersonal reactions. They know when someone is looking to another person for answers. They notice when people’s stories do not match up.

Counselors also need to consider what a trafficking survivor might look like in their particular clinical setting, Hershberger says. For example, if a counselor is doing crisis work, they might have someone who is in denial about being trafficked or confront a situation that appears to be domestic violence.

The office setting may determine the likelihood of a practitioner encountering an individual who is currently being trafficked or who has gotten out. Counselors who work in public health settings or hospitals are more likely to see individuals who are currently being victimized when these individuals come in for a medical issue such as testing for a sexually transmitted disease or injury from abuse, Rose notes. Counselors working in private practice or at a community agency will typically see these clients after they have been extricated, he says.

Establishing trust and safety

People who have been trafficked may find it difficult to trust others. Before thinking about clinical treatment plans, counselors need to establish a sense of safety and a healthy therapeutic rapport with these clients, Hershberger stresses. These individuals have experienced “complex trauma in the sense that it’s repeated for long duration and often comes from people who should be caregivers,” she explains, “so it makes it really hard for survivors of trafficking to trust us. We need to be really authentic because survivors will pick up on it if [we’re] not.”

Hershberger, president of the North Dakota Association for Counselor Education and Supervision, advises clinicians to maintain an open-door policy with survivors of human trafficking, especially when they are working on engagement with the client. People who are dealing with significant trauma may be more prone to canceling sessions, so adhering to a policy of termination after two missed sessions will not help build engagement and rapport with these clients, she cautions.

Counselors’ innate desire to help clients heal can sometimes be an impediment to build-ing this relationship. Rose sees counselors who want to dive right into the trauma work before first building strong therapeutic and strategic foundations, which can take a long time. “The minute we try to push too much — even if our best intentions are there — is when someone can have [a negative] reaction” and feel that the counselor is forcing them to do something they don’t want or are not yet ready to do, he says.

Rose has also witnessed the inverse: clients who get frustrated when counselors don’t jump straight into the trauma work. When this happens, he explains to clients that although they may feel ready, their whole system may not be. To further illustrate the point, he compares trauma work to a physical wound: “If I start poking around at a wound and you don’t trust me yet or your entire system isn’t ready to allow that yet, you’ll immediately pull back and you’re not going to want me to go near it,” he tells clients. “And the same [thing] is happening cognitively and emotionally with trauma. If we start poking around and you’re not ready, then it’s going to fall apart on us.”

The need for clinical trauma care

Rose asserts that counselors are in a prime position to provide clinical psychotherapy and trauma-focused work. Rose is an executive member of the Lucas County Human Trafficking Coalition, and he was awarded the Social Justice Leader Award from the Human Trafficking and Social Justice Institute in 2017.

Mental health services geared toward survivors of trafficking are great at managing clients’ symptoms through art or expressive therapy or group work, but Rose finds this is often where their treatment ends. “It has to be more. It has to be evidence-based trauma work,” he stresses. “We can’t just treat symptoms. We have to treat the whole person, and we have to treat the trauma.”

“Folx that have been labor trafficked have all sorts of layers of trauma damage. … Sex traffic victims have all of the symptoms of domestic violence, emotional abuse, physical abuse, sexual abuse — all rolled into one very unpleasant package,” he continues. “And expressive therapy is not going to treat that trauma; it’s going to treat the symptoms. If we really want to help folx, we have to go deeper, and that’s where counselors really need to come into play.”

Rose, a certified therapist in eye movement desensitization and reprocessing (EMDR), recommends that counselors use an evidence-based trauma treatment that follows a triphasic approach that a) establishes a foundation, b) reprocesses and works through the trauma and c) plans for the future. Rose often uses EMDR when he’s working with this population because he finds it helpful to treat the root cause of the trauma. He also recommends trauma-focused cognitive behavior therapy, especially when working with children and adolescents.

Take the relational approach

Hershberger points out that traffickers differ from other sexual offenders (who are often described as socially awkward and desire a sense of belonging) in that they are often socially intelligent, charismatic and good at forming relationships. They gain the trust of vulnerable individuals by initially fulfilling their need for love, connection and belonging, she explains. For example, the trafficker could be the first person in the individual’s life to recognize and celebrate their birthday or give them special attention, such as taking them to get a manicure.

These acts can cause some survivors to form bonds with and defend their traffickers — a condition often referred to as Stockholm syndrome. Hershberger and Dunlap point out that something similar sometimes happens with individuals who experience domestic violence. “Survivors will often defend their trafficker because they didn’t have that sense of belonging or that family growing up. So, this is the first time they’re experiencing that — along with horrible kinds of trauma — but it’s hard for them to differentiate that,” Hershberger explains.

According to Hershberger, these trauma bonds illustrate survivors’ desire for human connection. Traffickers thwart this connection by exploiting this desire for their own gain.

“Human sex trafficking is the ultimate anti-relationship,” argues Hershberger, who recently presented on this topic at ACA’s Virtual Conference Experience. Survivors of sex trafficking have been forced “to exist in a world absent of authentic, growth-fostering relationships,” she explains. Thus, she recommends that counselors use a relational-cultural approach with this client population to foster an authentic growth-fostering connection.

To explain this approach, Hershberger presents Marie, a fictional client: When she was 14 years old, Marie lived in an abusive home where her mother’s boyfriend molested her. So, Marie was excited when Jake, a 24-year-old man, approached her and promised a better life as his “girlfriend.” He bought her nice things and told her she was “amazing in bed.” One day, he told Marie some money hadn’t come through at work and asked if she would help him by having sex with a few guys. When she resisted, he beat her until she complied. He forced her into sex trafficking, and she was having sex with as many as 10-15 men a night. (See Hershberger’s 2020 article, “A relational-cultural theory approach to work with survivors of sex trafficking,” published in the Journal of Creativity in Mental Health, for a more detailed discussion of this case study.)

Following a relational-cultural framework, Marie’s counselor first establishes a sense of safety and trust, and they are authentic, empathetic and consistent in their interpersonal interactions, Hershberger says. So, if the counselor makes a mistake by showing up late for session, they own that mistake, apologize and ask Marie how they can make up for it.

Marie may have internalized negative beliefs or self-blame such as “I’m only good for my body and others’ use” or “I’m not worthy of being loved.” The counselor can help Marie first identify and name these beliefs, and then they can work together to challenge these negative beliefs. The therapeutic relationship further challenges Marie’s distorted thinking about herself and relationships, Hershberger notes, and models what a healthy relationship entails.

To challenge Marie’s belief, the counselor could use self-disclosure and tell Marie, “I experience you as a creative, confident individual who is worthy of being loved.” Hershberger recommends that counselors use the client’s own words when reflecting positive attributes to help the client identify and own their strengths.

As Hershberger points out, traffickers try to keep victims in a constant state of uncertainty about their environment, safety or identity. So, the counselor’s role is to identify moments or thoughts that are unclear, such as Marie’s negative perception of her self-worth, and help her add clarity to them.

Hershberger names bibliotherapy and narrative therapy as useful approaches for empowering survivors of trafficking and helping them find their own voice. For example, the counselor could ask Marie what name her trafficker gave her and the name she wants to use moving forward. Then, Marie could journal about this new identity and the qualities associated with it.

The counselor could also add in creative techniques such as collage or relational imagery. For example, Hershberger once had a client who identified with the image of a wounded deer because they too had been hurt and abandoned. The wounding paralleled their own trauma around the physical abuse they had experienced while being trafficked. Later, Hershberger used this image to help the client think about what they wanted their future identity to be and to create a collage of their strengths.

The therapeutic relationship becomes a healthy relationship — one that is safe, dependable and empowering and that counters the disconnection and uncertainty survivors experienced when they were trafficked, Hershberger says.

Preparing to work with this population

The best way to understand what is going on with human trafficking in a specific area is to get involved and volunteer in the community, Rose says. One place to start is joining or attending meetings of local, regional or state trafficking coalitions and task forces. “You can learn more about what agencies are providing services for this population,” he says. “They need to know where mental health providers are, and you need to know where additional services are for survivors.”

Rose advises counselors to approach these partnerships with an attitude of wanting to learn and help. Communities don’t respond well to people who think they know what is best or have all the right answers, he says. Instead, inform these organizations of the crucial skills they may be missing. Counselors have “the clinical piece that a lot of these places need and strive for,” Rose notes. “There’s a lot of social workers, nurses and different helping professionals, but clinical mental health treatment may not be what they have.”

In addition to attending monthly meetings of North Dakota’s trafficking task force, Hershberger prepared to work with this population by reading case examples and familiarizing herself with these tough stories. She also reached out to other clinicians in the field to hear about their experiences. As she points out, “It’s one thing to hear terminology, but it’s another thing to hear somebody’s story.”

Rose and Dunlap recommend that counselors limit their caseloads (if they have that option) when working with this population. “You can’t hear the thing of nightmares for three, four or eight hours a day and expect to be OK by 6 or 7 o’clock at night,” Rose says. Both he and Dunlap, an ACA member who researches and works with youth with disabilities, survivors of human trafficking and criminal populations, have had to learn how to balance their clinical schedules better. They intentionally leave time between these difficult sessions so they can reflect, reenergize and regroup before seeing their next client.

Counselors must also remember that not every client-counselor relationship is the right fit, Rose says. For example, someone may refer a female survivor of sex trafficking to him because of his expertise in EMDR, but if she has been abused by men her entire life, she may not want to work with Rose regardless of his qualifications and reputation as a counselor.

“These clients have had people treat them really poorly their entire lives,” he points out. “Part of that therapeutic relationship is recognizing maybe I’m not the best counselor for every person I want to help, and that’s OK. Just giving [clients] that freedom and autonomy will help them along in their journey. They don’t have to work with me to fix the problem.”

Rose reminds counselors there are other ways to help serve this population without working directly with clients. Counselors can get involved in local agencies that work on human trafficking, provide education and trainings, or work on prevention, he says.

Hershberger understands how difficult it can be when counselors must refer a client. Because she was part of a crisis response team when she met the woman who was a survivor of human trafficking, she wasn’t able to continue working with her. The woman was referred to another clinician who worked for the human service center. “That was hard,” she recalls. “I couldn’t stay with her, and having that continuity of care would have been nice.”

Hershberger did have a chance to meet with the woman a few months later. With the help of her new counselors, she was making progress toward creating healthier relationships.

fizkes/Shutterstock.com

****

Working with perpetrators of human trafficking

Paige Dunlap, a licensed clinical mental health counselor in Greensboro, North Carolina, once worked with an agency in Detroit that assisted individuals who no longer wanted to be engaged in gang activity. In sharing their stories, some of the group members disclosed that they had been directly or indirectly involved in trafficking other individuals. After recovering from the initial shock of hearing that, Dunlap started to think and educate herself about ways counselors could help perpetrators of trafficking.

“We as counselors don’t really talk about this hidden population” of perpetrators, she says. “We don’t know too much about them.”

Often people’s biases can cloud their judgment about these individuals. The more Jenna Hershberger, a licensed associate professional counselor in Fargo, North Dakota, researched and worked with cases of sex trafficking, the more she discovered the dichotomous thinking attached to it: People consider traffickers to be “bad” and survivors to be “good.” But it’s more complicated than that, she says.

“In the literature, we see that traffickers and survivors experience the same kinds of childhood traumas, such as sexual, emotional, physical and spiritual abuse,” she explains. But for individuals who become traffickers, “there is a distortion that happens in the way that they respond to the trauma.” Hershberger, a doctoral candidate in the counselor education and supervision program at North Dakota State University, acknowledges this is an area of research that mental health professionals do not fully understand yet. But initial clinical findings, as well as Hershberger’s own professional experience, indicate that traffickers often seem to have empathy deficits and endorse trafficking myths such as “people like this way of life.”

Dunlap, an associate professor of counseling at North Carolina Agricultural and Technical State University, says that traffickers and victims of trafficking often get enmeshed in that world for similar reasons. “There is a need for belonging in all of these individuals,” she says. Both groups often lack support systems, have limited work opportunities and are tempted by the promise of a “better” life, she explains.

Once individuals get involved in trafficking, it becomes difficult for them to leave, Dunlap points out. “It becomes almost an institutionalization for them too. … They don’t know how to function outside of that.”

“Getting those individuals into your office to do this hard work is really going to be tough,” she admits. “If you’re a counselor and you do happen to have these clients, the last thing they need is for your own biases to be stopping them from getting help, because they’re doing good just to be there.”

Hershberger hopes counselors continue to research ways to better help both the survivors and perpetrators of human trafficking. In doing so, she encourages counselors to consider a larger question: How as a society are we creating spaces in which people don’t know what a healthy relationship looks like so that they’re seeking out this subculture for a sense of belonging?

 

****

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

****

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.

A hero/heroine’s journey: A road map to trauma healing

By Federico Carmona July 8, 2021

American mythologist Joseph Campbell dedicated decades to studying ancient texts and oral stories told in different cultures around the world. Campbell realized that most mythological quests in every culture followed a pattern he called the “monomyth.” 

This thematic tool was conceived with the notion that all of humanity, in all its diversity, reflects similar existential pursuits and living experiences. They are all part of an unknown larger universe or state of existence. In this pattern, a hero embarks on a journey to slay a monster, recover a precious artifact or rescue someone — the main objective always being to save the world from the end of times or from a great evil. 

This journey is full of challenges that threaten both the hero’s known inner world and the present mission, whatever that may be. Each obstacle the hero overcomes thematically shows a different lesson from which one can learn. The hero thus grows in skills and self-awareness as the journey continues. By the time the hero confronts the problem, or whatever serves as the primary antagonist of the story, they have evolved into a more superior version of themselves, a progression that doesn’t stop as the hero returns with the prize. This evolution holds the hero in an enlightened state of grace, able to understand and deal with the mundane and transcendent way of life.

Campbell described this idea in the book that made him renowned in the literary and artistic communities, The Hero With A Thousand Faces. Published in 1949, Campbell’s three-part presentation of the hero’s journey encompasses departure (embracing the journey), initiation (confronting and accepting change) and the return (maturing and moving forward). This echoes the stages of development of the human psyche, which involves transitioning from childhood to adulthood to the individuation or full realization of Carl Jung’s vision of the human psyche’s developmental climax — emotional maturation and connection with the transcendent.

In her book The Post-Traumatic Growth Guidebook: Practical Mind-Body Tools to Heal Trauma, Foster Resilience and Awaken Your Potential, Arielle Schwartz introduces the idea of looking at trauma recovery as a hero/heroine’s journey. Schwartz describes Campbell’s hero’s journey as a classic plot structure that has inspired a variety of literary and cinematographic works for generations. Schwartz contends that Campbell’s hero’s journey can also be applied to trauma healing. People can relate to this journey as they find themselves triggered into a crisis due to a traumatic event, the accumulation of stress or memories of abuse or neglect. 

Emotional crises usually take us into dark and painful places. The hero’s journey, Schwartz argues, encourages people to transform that pain and fear into a guiding wisdom toward self-awareness and emotional growth.

Healing is a journey

We tend to perceive and pursue healing, happiness, meaning and self-fulfillment as a linear and clear destination. However, these quests are meant to be experienced as a journey and not as one’s end goal. In the progression of the journey, one can experience healing and continue to pursue it. That is because there will always be something to heal in our physical, emotional and spiritual selves. Life never stops giving us challenges that provide us with valuable experiences.

Overcoming psychological trauma, while growing emotionally, intellectually and spiritually, is a journey that can be viewed as both challenging and rewarding. I would go so far to say that healing from trauma is a sacred journey. It requires venturing into the deep self to plant the seeds of healing, ultimately bringing forth a better version of one’s self. However, this journey requires a hero. The person affected by trauma is the one who embarks on this journey, and there is no vicarious substitution for the journey.

Venturing into the unknown is scary. Worse, becoming a hero is a terrifying task and a huge responsibility. Thus, many people would prefer to decline the invitation or call to healing because there is something comparatively cozy about that state of trauma. People who have lived parts of their lives in trauma are used to that state because it provides familiarity. Therefore, some will embark on the hero’s journey on their own, others will do so at a time when they have more support, and others will never respond to the call.

Therapeutically speaking, counselors walk along with clients who decide to take the journey of healing from trauma. Counselors also patiently prepare and encourage those clients who are doubtful about embarking on the journey because of its tremendous responsibility. Likewise, counselors understand and comfort those clients who refuse the journey because they are terrified of the pain and paralyzed by fear of the unknown.

Trauma-informed counselors understand that trauma is a neurobiological and emotional response to a frightening and upsetting experience. Trauma can be either a one-time or prolonged experience that affects a person’s outlook, beliefs, emotions and behaviors in their day-to-day life. Treatment plans include goals that deal with the most distinctive consequences of trauma:

  • Sense of powerlessness
  • Nervous system dysregulation
  • Self-devaluation
  • Disconnection from self

Clients who make the adventurous yet painful decision to embark on this journey will notice that they are building resources and improving their self-awareness with every step. This emergent growth is critical when confronting inner and outer obstacles while embracing change. As clients grow in resources and self-awareness along the way, they will also notice a developing improvement in the way they see themselves, others and the world. People living in trauma are reactive to life’s circumstances, whereas people living beyond trauma are proactive to life’s circumstances.

What kind of hero is needed?

Campbell set the record straight for doubters. The hero archetype is for anyone who finds the strength to embrace the call to the journey and perseveres in it, despite the overwhelming circumstances that may be facing them. This is because they believe in the healing purpose of the journey or are looking for something that is more significant than themselves. 

The hero is expected to learn an important lesson from the journey — that life is a constant and contradicting experience of good and bad things, all of which must be lived through willingly. Campbell also depicted the archetypal hero in different roles: as a warrior, lover, emperor/tyrant, redeemer and saint. Each of these roles represents a stage of the cosmogonic cycle, a mystical realm in a pure spiritual form transitioning to a physical manifestation and returning to the beginning.

The hero-warrior slays the monsters and tyrants of the hero’s past and present, ushering the hero’s community into the future. This hero-type promotes the renewal of life as the living God does. The hero-lover represents the connection with the transcendent, the relationship of humanity and the divine. The hero-emperor rules the earth as the living manifestation of the mystic realm. Human after all, the emperor becomes a tyrant as he learns to love flattery more than the relationship with the divine. The new hero-tyrant then is no longer the mediator between the human and the divine. The hero-redeemer bears more than a likeness to the divine, as they are one. In this oneness and incarnation with the divine, the redeemer is above the typical temptations of the flesh and ego. This hero’s mission is to save the world by confronting the divine tyranny that the hero-tyrant imposed on the world. After teaching “a new way of being in the world,” the hero-redeemer confronts such tyranny by sacrificing themself. The saint is a spiritual role and is the highest calling of a hero. This hero’s story is the beginning and end of the cosmogonic cycle — the spiritual creating the physical, which in time returns to its source.

The journey of trauma healing is a mixed bag of the mythic (fighting the beasts in the unconscious), the spiritual (believing and trusting in something bigger than oneself), the emotional (knowing and loving oneself), the intellectual (understanding and embracing change) and the practical (living beyond trauma). Every hero’s role is an aspect of the archetypal hero in Campbell’s monomyth. But do we need them all to achieve enlightenment?

This healing journey requires slaying the monsters and tyrants (one’s ill attachments) of the past and present so that one can move forward with renewed life. Love is also needed to connect with the self and the transcendent. This connection brings wisdom, order and redemption to the chaos of the unconscious. Whatever the task may be — e.g., healing from the wrongness of others or the self, rescuing the child-self frozen in time, healing from intergenerational trauma — the journey of trauma healing requires specific qualities and steps. These are:

1) Determination to let go of insecure attachments and tendencies.

2) Love to connect with oneself in the emotional and transcendent.

3) Wisdom to understand and integrate the self.

4) Pragmatism to live sensibly yet realistically beyond trauma.

A road map to healing

Living in trauma is living in emotional extremes, which is an impairment to one’s self-regulation. Thus, overcoming trauma requires two basic things: 

1) Regaining nervous/emotional self-regulation, which is the ability to face and make sense of one’s feelings and emotions rather than avoid them or shut them down.

2) Understanding and accepting one’s inner self rather than ignoring it. 

One-third of trauma work is teaching clients what trauma does and how the human body responds to it. The second third is reconstructing clients’ lost sense of safety, even in the face of uncertainty, and fostering reconnection with the self to reclaim control over it. As this process develops, clients grow in trust and self-compassion, which are key elements in overcoming self-imposed isolation due to the negative perception of self, others and the world around them. The final third of trauma work is integrating the traumatic experience by changing the narrative of the adverse experience in the here and now.

The proposed road map to trauma healing works well in 12-week psychoeducational groups of 90-minute sessions. The idea is to empower qualified participants with a concrete structure and strategies to do the work on their own. Each session is designed to introduce group members to new coping skills and life strategies to help them:

  • Establish a sense of safety
  • Achieve emotional regulation
  • Integrate traumatic experiences
  • Move beyond trauma

In his book Modern Man in Search of a Soul, Jung wrote, “The shoe that fits one person pinches another; there is no recipe for living that suits all cases.” The same holds true for various trauma treatments. Thus, this road map to trauma healing is adaptable. It is based on a variety of experts’ work in the interdisciplinary field of interpersonal neurobiology, which seeks to heal trauma by stimulating the brain’s neuroplasticity with positive persuasion and support.

Stage I: Establishing safety and competence

>> Step 1: Understanding oneself and one’s world. Clients are introduced to a short self-assessment and the art of journaling. The six-domain self-assessment is to be filled out with short phrases or single words to provoke enthusiasm for journaling. Clients are encouraged to revisit it as needed throughout the journey. Find the assessment at https://tinyurl.com/3yumcynf.

>> Step 2: Understanding the journey of healing. Clients learn about what trauma is and does and how the body responds to it. The Adverse Childhood Experiences (ACEs) study is introduced so that clients can find their ACEs score. The positive power of resilience is introduced to bring hope and direction to such a complex topic.

>> Step 3: Changing one’s story. Clients are introduced to the unhelpful thinking styles that prevent them from envisioning a better version of themselves and to the ABC model (adversity or activating event, beliefs about the event, consequences) in order to challenge and modify their cognitive distortions. Clients are also introduced to setting meaningful goals based on healthy personal values and beliefs. They learn that it is better to depend on new healthy habits than on motivation alone.

Stage II: Establishing self-regulation

>> Step 4: Learning to relate to others healthily. Clients are introduced to the topic and practice of healthy boundaries. They learn the degree to which setting healthy boundaries can ease their inner conflict in saying “no” while boosting their self-esteem and improving their relationships.

>> Step 5: Improving self-reflection and introspection. Attachment theory is introduced to foster self-reflection on patterns of thinking, behaving and relating to others and self. Identification with a dominant attachment style is critical to understanding what is needed to move toward a more secure attachment adaptation. Dan Siegel’s concept of “mindsight” is also introduced.

>> Step 6: Learning self-regulation (body and emotions). Clients are introduced to the skills of tracking, resourcing, grounding and others from the Community Resiliency Model to become familiar with their bodies, emotions and resources. Clients are also introduced to the practice of mindfulness. This step requires two group sessions.

Stage III: Integration of the traumatic experience

>> Step 7: Composing the narrative of trauma. Clients are introduced to the process of creating a coherent narrative. Techniques from narrative therapy, narrative exposure therapy or trauma narratives can be tailored to the group’s need (type of trauma) in this step.

>> Step 8: Reframing the trauma narrative. Clients are guided to see their narratives from the vantage point they have in the here and now. At this point in the journey, clients have grown enough in knowledge, self-awareness, skills and coping strategies to make favorable comparisons and lower the intensity of their fears and other negative emotions.

>> Step 9: Building self-acceptance. Clients learn to accept and integrate their reframed adverse experiences while facing the emotional consequences of trauma (e.g., shame, guilt, self-loathing). Strategies from acceptance and commitment therapy, cognitive processing therapy, transactional analysis or internal family systems can be helpful depending on the group’s need. In individual counseling, consider referring clients who feel stuck processing their negative emotions to a therapist trained in eye movement desensitization and reprocessing. This step requires two sessions.

Stage IV: Consolidation

>> Step 10: Transcending trauma. Clients learn that helping others is self-care. Love and connection with oneself and the transcendent facilitate acceptance and integration. Clients are invited to reflect on their journey from victim to survivor. Siegel’s mindsight levels of integration are lightly introduced to motivate clients to persevere in their healing journey to thrive in life.

Conclusion

Everyone faces and grieves their adverse circumstances in their own way. Some people become more resilient and wiser the more hardships they face. Other people become trapped in trauma and the victimizing sequel of their adverse circumstances, even after those circumstances have passed. 

People who overcome trauma grow emotionally, intellectually and spiritually from their adverse experiences. They are better prepared to face life circumstances and make better choices. They understand that helping others is critical to their own healing and well-being. People trapped in trauma remain focused on surviving their recurring adverse circumstances and their ensuing cycles of emotional turmoil. 

Applying this road map to healing also works well in individual counseling, although it takes much longer because clients’ current circumstances tend to dominate the sessions. In any case, therapy is an art. Counselors can help clients link their current and past experiences and do the work suggested in the steps that target their needs. Thus, individual counseling can use the road map as it fits clients’ needs and expectations. Consider that Stage I is the foundation of the work ahead and that trust, not rush, is the foundation of a successful therapeutic relationship.

 

****

Federico Carmona is a certified clinical trauma professional working as a trauma therapist at Peace Over Violence in Los Angeles. Federico works with survivors of domestic and sexual violence and child abuse who are experiencing the devastating effects of posttraumatic stress disorder, complex trauma, trauma bonding and related psychological afflictions. Contact Federico at fcarmona@mac.com.

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, visit ct.counseling.org/feedback.

****

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

There’s nothing small about trauma

By Bethany Bray June 24, 2021

When talking about trauma, Hillary Cook, a licensed clinical professional counselor (LCPC) with a solo private practice in Boise, Idaho, has a saying that she often imparts to clients: It’s as possible to drown in a puddle as in the depths of the ocean.

Trauma is often lumped — some would even say oversimplified — into “big T” or “little t” categories. Big T trauma encompasses what many people think of when they hear the word trauma: large-scale, life-shattering events such as living through a war or natural disaster. Little t trauma includes more common events such as pet loss, work stress, parenting struggles or racial microaggressions, which on the surface may seem smaller. However, trauma is a complex issue, and all traumatic events — no matter how big or how small they may appear to others on the “outside” — have the potential to negatively affect clients’ mental health.

Cook, like many counselors who specialize in trauma, has seen clients who minimized their little t, everyday traumatic experiences or failed to even recognize them as traumatic. Even when clients seek counseling because they recognize that something is causing them distress and disrupting their life, they sometimes are unable to pinpoint or verbalize why, she says. Others may harbor feelings of shame or insecurity about how they feel. Cook has often heard clients, unsure of whether their experience warrants counseling, preface their stories by saying, “I don’t want to waste your time.” 

Cook, a member of the American Counseling Association, has also worked with clients who dismissed their traumatic experiences by stating, “I didn’t go to war,” “It wasn’t violent” or “I don’t know why this is bothering me.” She explains to these clients that the sticking point is not the traumatic incident itself but rather how it is stored in their brain. Counseling won’t take that traumatic memory away, but it can change how it is stored, enabling the client to carry it in a less painful way, Cook explains.

Providing psychoeducation is a critical first step when working with clients who have experienced little t traumas, says Debbie Millman, a licensed professional counselor and director of a trauma therapy practice in Madison, Wisconsin. It is helpful to explain to clients the depth and breadth of trauma, which can range from something catastrophic or systemic, she says, to “someone who didn’t get picked for the kickball team [in childhood] and it cut deep, and they still dwell on it today.”

“I see trauma as anything that affects how you see yourself or feel now. No matter how big or small it seems, it’s worth revisiting that [in counseling],” notes Millman, an ACA member.

She helps clients understand the importance of recognizing and addressing trauma — even everyday ones — with the following illustration: Trauma is like pushing a ball under the surface of the water in a swimming pool. You don’t know where it’s going to resurface, but it always will. The same rule applies to trauma: You can’t keep it buried; it will always resurface. The key is to process it.

Jessica Tyler, a professional counselor licensed in Alabama and Georgia, considers trauma to be “any experience that shifts your perspective on self, others or the world.” For one person, that experience might be tied to surviving a horrific car accident. For another person, it might trace back to feeling humiliated when they were called on by their first-grade teacher to read something aloud in class. The important point to communicate is that all of these experiences are valid, she says.

“I am very adamant [with] my clients that it serves no one to compare suffering,” Tyler says. “Suffering is suffering is suffering is suffering, and if we stop comparing the validity of our suffering, we can get to work on how these experiences can expand us as individuals versus define us and our worth.”

What lies beneath

Everyday trauma can dovetail with grief and loss, attachment issues, racial or cultural issues, panic attacks, self-esteem struggles, depression, suicidal ideation, eating disorders and many other challenges that clients present in counseling. For clinical practitioners, the key is not to take those presenting concerns at face value because unprocessed trauma may be a contributing factor or even the root cause, says Susan Gabel, an LCPC at a trauma-focused group practice in the Chicago suburbs.

If a client comes into counseling with symptoms of social anxiety, for example, clinicians should not limit their counseling work to addressing those symptoms or viewing the client simply as socially anxious, because then they may miss some of the larger reasons behind those symptoms, Gabel explains. 

“There can also be things that they won’t identify as trauma, such as a parent who was invalidating,” she continues. “It’s not a big T trauma, but if you add that up over and over and over again, they internalize it, and it becomes a powerful negative cognition of how they view themselves and expect people to respond.”

Low self-esteem, conflict avoidance and people-pleasing behaviors can be common among clients who have experienced trauma, Gabel notes. Because of this, practitioners must be mindful that clients may exhibit people-pleasing behaviors in therapy toward a counselor. This behavior can show up in a number of ways, she says, including when clients are not completely honest in sessions because they want to agree with their counselor, avoid conflict, or tell the counselor what they think the counselor wants to hear. These clients may also apologize frequently during sessions. 

Gabel points out that this fear of conflict can stem from clients having people in their life who had a pattern of responding negatively to their needs or feelings. Thus, they may reflexively expect that response from others, including their counselor.

“For a lot of people, [trauma] tends to lean into larger issues, including their views of themselves, views of others and fear responses,” says Gabel, an ACA member who holds two trauma certifications. “Difficulty with assertiveness can [indicate] a pattern of having relationships where their needs were not met, or they needed to appease or do what the other person needed.” 

Tyler, an assistant clinical professor and coordinator of the clinical mental health counseling program at Auburn University, notes that a client’s self-talk can also yield clues that the person experienced trauma in their past. Drawing from the work of North Carolina licensed clinical mental health counselor Candice Creasman, Tyler urges practitioners to listen closely for a client’s “wounded inner child,” which Creasman defines as the voice of their unhealed hurts. Exploring how this voice influences a client’s beliefs and decision-making can reveal the lived experience that generated the client’s problematic thoughts, Tyler explains.

“In my experience, this typically appears as the inner critic that we, as counselors, hear in a client’s hostile and harsh self-talk narrative,” says Tyler, an ACA member who counsels adult clients at a private practice in Columbus, Georgia. “In clients, this can also appear as anger, frustration, [or] controlling or needy behavior in therapy. The wounded inner child tests their therapist’s [ability] to show up with care, acceptance and compassion despite [the client’s] behaviors. This inner child is often the impulsive and risky part of a client that ‘acts out’ despite the potential for adverse consequences.”

Gabel often hears clients use language about feeling worthless, being “never enough” or assuming they are a bad person. Counselors can learn more about a client’s history, she says, by challenging those negative beliefs in counseling and asking when and where the client first heard those statements.

Gabel and Cook also note that somatic complaints can indicate that unrecognized trauma lies beneath a client’s presenting concern. Cook finds this especially true for symptoms that clients have explored with a medical specialist — such as hives with an allergist — without any cause
being identified.

Both physical responses and unresponsiveness can be connected to unprocessed trauma. Carrying any kind of tension in the body, including headaches, stomach troubles or sensations such as feeling a tightness in the chest, can be signs of untreated trauma, Gabel says. At the same time, past trauma can cause a client to talk about an experience that would typically elicit an emotional response in a disconnected or unemotional manner, she says.

If left unprocessed, little t trauma can become problematic in myriad ways, Tyler says, and treating it requires counselors to go beyond symptom management with clients. For example, a client’s self-protective behaviors could manifest as codependency and people-pleasing in romantic relationships to validate their security and worth as a person. This can make the client vulnerable to partners who are controlling, manipulative and even abusive, Tyler explains. 

“Focusing on behavior modifications and symptom management may bring short-term relief for a specific life situation. However, I find that clients often have difficulty applying these coping skills to new challenges that emerge in their lives,” Tyler says. “I have found more success in therapy when I can identify the cognitive key, or core beliefs that filter how a client sees and reacts to the world, others and themselves. This cognitive key may serve as a survival measure at first — [for example] avoidance, mistrust, perfectionism — but over time can create barriers to the client living a thriving life. … If a cognitive key can be discovered in therapy, the client learns how to adjust that ‘filter’ and see the world, others and themselves in the most flexible, rational way.”

Tyler illustrates this process through an example of a client who experiences panic attacks whenever she is away from her small child. The client may find relief after a few sessions if the practitioner focuses on breathing exercises, medication management and mindfulness with the individual. This may look successful on the surface, Tyler notes, but the root cause of the client’s distress remains unaddressed.

Instead, Tyler says, she would take a deeper look at the underlying issues by using Socratic questioning. This process helps the client “discover a long-held core belief that ‘I only feel safe when I am in charge,’ [which] can give us important data to work with to help address the client’s filter that goes beyond mothering and extends to other parts of her life,” Tyler says. “Here, I find the most potent change in clients.”

fran_kie/Shutterstock.com

Handle with care

Regardless of whether a client has experienced big T or little t trauma, the brain is interpreting what happened as harmful to the client in some way, Cook explains. What matters is not how “bad” the event was but how maladaptively it was stored in the brain.

“The type of trauma, or how bad it was, doesn’t change the approach [in counseling]. What the client needs will change the approach,” Cook says.

She advises considering whether the client has adopted healthy or maladaptive coping mechanisms or if the client has a strong social support system. If not, the counselor should focus on those aspects before diving into deeper work to help the client process the underlying trauma, she says.

The clinical practitioners interviewed for this article use a variety of techniques, including brainspotting, eye movement desensitization and reprocessing (EMDR), hypnosis, internal family systems (IFS) therapy and cognitive behavior therapy (CBT), to help clients who have experienced trauma. These practitioners stressed, however, that counselors should focus on self-regulation and social connection with clients and establish coping mechanisms before deploying techniques to process clients’ trauma. This is especially true with clients who have experienced everyday trauma and do not recognize the effect it is having on their presenting concern.

As a licensed mental health counselor who specializes in trauma work, Christine Smith has an extensive toolbox of coping mechanisms to equip clients with depending on their needs. Coping mechanisms not only help clients with emotional regulation but also instill containment skills they can use to manage their feelings and carry on with everyday life after heavy counseling sessions that deal with raw or troubling memories, she explains.

“People tend not to use their coping skills until their hair is on fire,” Smith says jokingly. She works with clients to instead ensure that coping skills become part of their everyday life, sometimes even assigning them as homework in between sessions.

She encourages clients to keep a list of coping mechanisms they find helpful on a piece of brightly colored paper in a visible spot in their home, such as the refrigerator door or bathroom mirror. She also recommends that they move this list around periodically, so they don’t begin tuning it out.

“Coping mechanisms themselves are trauma work in a way. I tell clients, ‘We’re going to do safety, safety, safety until you are rolling your eyes, and then we’re going to do it some more.’ If you don’t have a good foundation [before doing deeper trauma work], you’re building a house of cards,” says Smith, an ACA member with a solo private practice in Saratoga Springs, New York. “The best coping mechanisms are the ones that are so integrated in a client’s life that they don’t think of it as coping.”

Smith says this early work helps forge a therapeutic bond with clients and offers the practitioner a chance to ask questions that plant seeds about a possible connection between a past experience and the discomfort that caused the client to seek counseling. Questions such as “When was the first time you felt like that?” can help both the counselor and the client begin to make connections, she adds.

Gabel agrees that coping skills should be tailored to a client’s individual needs. Deep breathing or mindfulness may be helpful for some clients, whereas others may need to work on skills that they haven’t fully developed, such as interpersonal communication or problem-solving skills, because of their trauma history.

When starting trauma work, Cook often uses EMDR and hypnosis for immediate relief of nightmares, flashbacks and intrusive thoughts to help clients find stability. Only afterward do they unpack trauma and other related issues such as grief.

Millman begins trauma work by talking through clients’ life timelines, making note of events that shaped them and have stuck with them. She also devotes significant time to doing case conceptualizations and asking clients about their strengths, personality and likes/dislikes. This helps her with gaining a holistic understanding of the client and forging a therapeutic bond, she says.

Similarly, Cook recommends asking questions that help to paint a picture of a client’s framework, including their social supports and how they deal with intense feelings. Knowing more about a client’s background might also inform counselors about cultural and racial issues that can dovetail with everyday trauma that is systemic in nature.

Millman notes that it can be helpful to encourage clients who have experienced trauma to maintain “emotional margins” around each session. This means not rushing to a counseling session from work or after picking their children up from school. Instead, she encourages clients to engage in calming rituals, such as having a cup of tea or doing some deep breathing exercises, before and after sessions.

Millman, a doctoral student in the counselor education and supervision program at Liberty University, also advises counselors to keep trauma clients in mind when outfitting their office spaces. She emphasizes the importance of being intentional about what counselors expose their clients to. For example, having fashion or health magazines in the waiting room could potentially be triggering for clients whose trauma histories or related behaviors are connected to body image or disordered eating. Instead, Millman suggests striving to create an atmosphere that is warm and calming.

“All counselors have to be prepared to come across trauma; it’s at the root of so many mental health concerns and disorders,” Millman says. “Everyone needs to have some trauma-informed care training [and] be aware of what triggers clients and what phrases or buzzwords you might be using that could be problematic for someone. Especially in regard to race, be aware of the words you’re using. Getting culturally competent, trauma-informed care is really connected to [addressing] the daily trauma that people are facing right now.”

Digging deeper

In counseling sessions, a client’s past trauma will “come up when it needs to come up,” Millman says. For some individuals, that will happen right away, and it will come out “like a volcanic eruption.” For other clients, it may be a year into therapy before they’re ready to talk about it. But when they do, Millman says, she “can almost feel the relief in the counseling room,” especially for clients who associate feelings of shame with their trauma. “It’s like a weight has lifted, disempowering that hold it has over [them] now that someone else knows about it and can carry it with [them],” she says.

In trauma work, Smith adds, it’s not uncommon for clients to broach a traumatic subject by saying, “I’ve never told anyone this but … ” When that happens, Smith tells the client she is honored that they trusted her with this information.

“I try not to ever forget how much courage it takes to walk into a therapist’s office,” Smith says. “I try and be really encouraging, positive and respectful of that and recognize the wins that they have that other people aren’t going to recognize.”

Smith finds that work that focuses on emotional regulation can be especially helpful for this client population. In some cases, this involves simply talking through and processing interactions and events clients have experienced since their last counseling session. It can be helpful to “move at a glacial pace,” slowly unpacking an incident the client found distressing down to the minutiae, Smith says. This allows the client to identify the exact moment they started to feel triggered and lost the use of their self-regulation skills. Then, the counselor and client can talk about what the client could do differently the next time this type of scenario arises.

EMDR can be particularly helpful to work through troubling scenarios and feelings with clients who may not recognize a past experience, such as little t trauma, as the root of their discomfort, Cook says. However, these clients will be able to name the challenge that caused them to seek counseling, such as relationship trouble, work stress or panic attacks. EMDR allows the practitioner to target and heal clients’ distressing feelings and triggers without having to relive the trauma that lies underneath, she explains. The beautiful thing about EMDR, Cook says, is that it allows the practitioner to target a distressing pattern that the client is experiencing, which, in turn, targets anything else that is in that neural pathway, including related trauma.

During EMDR, the client engages in bilateral stimulation, such as rhythmic tapping, while talking through a scenario with the practitioner. The process rewires the client’s brain and creates a new neural pathway, revising the pattern into one that is free of distress, Cook says.

EMDR allows clients to “see themselves in a scenario in a different way and imagine how they want to feel … without having to go through it” and relive the trauma, she explains. 

This was the case for an adult client whose presenting concerns involved relationship issues and anxiety related to dating. Cook was able to use the client’s specific anxieties surrounding first dates as a target in EMDR. Cook guided the client to talk about the details of how they felt during their worst dating experiences. 

“All of a sudden, it went much [further] back, and we realized there were some parenting issues [involving verbal abuse] from many years ago in childhood,” Cook recalls. “It was really hard for them to hear at first. There was a lot of denial, [saying] ‘that’s not trauma.’ But then I used an illustration: If you could imagine a small child that’s not you and this was happening to them, how would you feel? Then it sunk in, and they realized how awful it was.”

Cook continued to use EMDR, as well as CBT, to focus on the client’s self-worth and to build healthy boundaries. This therapeutic approach built up the client’s coping skills so that on dates, they were able to focus more on the other person and be less “in their head,” Cook says. When the client worried less about what the other person was thinking about them, they were able to instead focus on finding connection.

EMDR, along with a combination of other therapies, was also helpful for a past client of Tyler’s whose presenting concerns were low self-esteem and anxiety. As they began to unpack things in counseling, the client also disclosed a history of self-harming behaviors and chronic suicidal ideation.

“She was successful in her career yet presented with chronic and relentless self-talk that was significantly cruel and self-blaming. Everything was her fault and everything terrible that had ever happened to her resulted from her failures; she was convinced that she was unlovable and worthless,” recalls Tyler, who co-presented the session “Trauma-Informed Care: Working With Trauma-Related and Survivor Guilt” at ACA’s Virtual Conference Experience in April.

In counseling, Tyler gently probed with questions to identify where and how this client learned such hypercritical self-talk. The client reported that it was simply “something she had always done,” Tyler says.

Tyler gently challenged this thought with psychoeducation that infants are not born with self-hatred; it is something they learn from their environment. Through that lens, she explained to the client how life experiences may reinforce negative beliefs and feelings of rejection. Over time, the client was able to reprocess several early childhood and adolescent experiences that she had previously believed were “not traumatic enough” to cause her mental health to dip to its current state, Tyler recalls.

“However, in examining these experiences through the lens of how young, vulnerable and impressionable she was as a child, it made sense how one thing spiraled into another, which then turned into years of confirmation bias,” Tyler says. “Using a careful combination of EMDR, CBT and IFS, she communicated with her younger self and realized that, in reality, being worthy was her birthright and that she was allowed to make mistakes and learn from them just like everyone else. Moreover, every time she damaged herself emotionally or physically, she betrayed that younger version of herself that was not adequately protected from the harm and toxicity of others.”

This change occurred gradually over one year of counseling. Eventually, the client’s self-harm and suicidal ideation ebbed, Tyler says, and she adopted a lens of “gratitude for the younger versions of herself who endured — and her present adult self who now had the control and power to make choices to nurture and soothe her along the journey of life’s challenges.”

Not so little

Gabel thinks it is more helpful to view client trauma on a spectrum rather than sorting experiences into either “big T” or “little t” boxes. She urges counselors to keep an open mind, regardless of how severe a client’s experience may — or may not — seem.

“Little t traumas can add up and hold a lot of power. Complex, relational trauma can be little t’s that add up and become overwhelming,” Gabel says. “A lot of times [counselors] are trying to make logical sense of it — if this [experience] is affecting [the client], it must be connected to a past event (e.g., peer conflict as an adult and past bullying as a child) — when in reality, that’s not how our brain wiring works. It doesn’t always make logical sense.” 

Smith also encourages counselors to keep an open mind about what qualifies as traumatic. Something that on the surface appears to be a smaller trauma, such as the death of a pet, can be a huge loss to someone who didn’t have healthy attachments growing up, she notes.

“It’s not up to me to decide what’s a small t trauma versus a large T trauma. Something that’s small might be linked to something that’s not so small,” Smith says. “What I’m looking at is someone who has experienced some kind of disruption or loss that they’re having trouble getting over. You and I could have the exact same experience, and you might come out unscathed, and I might really suffer, and we don’t always know why that is. … Just keep yourself open and curious [in counseling sessions]. My clients are my greatest teachers, and if I listen very carefully, they know exactly what they need to heal.”

 

*****

Referring and co-treating

The nonprofit organization Mental Health America offers an online mental health screening each year on its website. In 2020, nearly 2.5 million people took the screening, and past trauma was second only to loneliness as the most reported cause of mental distress.

This data illustrates what many counselors see in their daily work: Trauma is ubiquitous and can have a profound effect on mental health. With that in mind, clinical practitioners must be mindful of when a client’s trauma goes beyond their expertise. The counselors interviewed for this article stressed that trauma is a complex issue and clinicians who do not specialize in this realm need to be ready to seek additional training or supervision, consult with colleagues or refer clients for specialized trauma work.

Seeking outside help is especially important when a client is no longer making progress with their counselor, says Hillary Cook, a licensed clinical professional counselor in Boise, Idaho.

A strong, trusting therapeutic relationship is crucial in trauma work, Cook notes, and a referral doesn’t necessarily mean this bond is broken. Clients can continue to work with their original counselor while being co-treated by a specialist. In this scenario, the client would need to grant permission for the two clinicians to consult with each other.

“We can’t be all things to all people,” agrees Christine Smith, a licensed mental health counselor who specializes in trauma work at her private practice in Saratoga Springs, New York. “If a counselor doesn’t have specialized training in dealing with some of the more complex trauma issues, don’t be afraid to refer out.”

Consult Standard A.11. of the 2014 ACA Code of Ethics at counseling.org/ethics for more on the ethical guidelines surrounding the referral process.

 

*****

Action steps to learn more

****

Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

****

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.