Tag Archives: trauma

Understanding and treating survivors of incest

By David M. Lawson March 6, 2018

Adults with histories of being abused as children present unique challenges for counselors. For instance, these clients often struggle with establishing and maintaining a therapeutic alliance. They may rapidly shift their notion of the counselor from very favorable to very unfavorable in line with concomitant shifts in their emotional states. Furthermore, they may anxiously expect the counselor to abandon them and thus increase pressure on the counselor to prove otherwise. Ironically, attempts at reassurance by the counselor may actually serve to validate these clients’ fears of abandonment.

The motivating factor for many of these clients is mistrust of people in general — and often for good reason. This article explores the psychological and interpersonal aspect of child sexual abuse by a parent and its treatment, with a particular focus on its relationship to betrayal trauma, dissociation and complex trauma.

Incest and its effects

Child abuse of any kind by a parent is a particularly negative experience that often affects survivors to varying degrees throughout their lives. However, child sexual abuse committed by a parent or other relative — that is, incest — is associated with particularly severe psychological symptoms and physical injuries for many survivors. For example, survivors of father-daughter incest are more likely to report feeling depressed, damaged and psychologically injured than are survivors of other types of child abuse. They are also more likely to report being estranged from one or both parents and having been shamed by others when they tried to share their experience. Additional symptoms include low self-esteem, self-loathing, somatization, low self-efficacy, pervasive interpersonal difficulties and feelings of contamination, worthlessness, shame and helplessness.

One particularly damaging result of incest is trauma bonding, in which survivors incorporate the aberrant views of their abusers about the incestuous relationship. As a result, victims frequently associate the abuse with a distorted form of caring and affection that later negatively influences their choice of romantic relationships. This can often lead to entering a series of abusive relationships.

According to Christine Courtois (Healing the Incest Wound: Adult Survivors in Therapy) and Richard Kluft (“Ramifications of incest” in Psychiatric Times), greater symptom severity for incest survivors is associated with:

  • Longer duration of abuse
  • Frequent abuse episodes
  • Penetration
  • High degree of force, coercion and intimidation
  • Transgenerational incest
  • A male perpetrator
  • Closeness of the relationship
  • Passive or willing participation
  • Having an erotic response
  • Self-blame and shame
  • Observed or reported incest that continues
  • Parental blame and negative judgment
  • Failed institutional responses: shaming, blaming, ineffectual effort
  • Early childhood onset

Incest that begins at a young age and continues for protracted periods — the average length of incest abuse is four years — often results in avoidance-based coping skills (for example, avoidance of relationships and various dissociative phenomena). These trauma-forged coping skills form the foundation for present and future interpersonal interactions and often become first-line responses to all or most levels of distress-producing circumstances.

More than any other type of child abuse, incest is associated with secrecy, betrayal, powerlessness, guilt, conflicted loyalty, fear of reprisal and self-blame/shame. It is of little surprise then that only 30 percent of incest cases are reported by survivors. The most reliable research suggests that 1 in 20 families with a female child have histories of father-daughter child sexual abuse, whereas 1 in 7 blended families with a female child have experienced stepfather-stepdaughter child sexual abuse (see the revised edition of The Secret Trauma: Incest in the Lives of Girls and Women by Diana E. H. Russell, published in 1999).

In 1986, David Finkelhor, known for his work on child sexual abuse, indicated that among males who reported being sexually abused as children, 3 percent reported mother-son incest. However, most incest-related research has focused on father-daughter or stepfather-stepdaughter incest, which is the focus of this article.

Subsequent studies of incest survivors indicated that being eroticized early in life disrupted these individuals’ adult sexuality. In comparison with nonincest controls, survivors experienced sexual intercourse earlier, had more sex partners, were more likely to have casual sex with those outside of their primary relationships and were more likely to engage in sex for money. Thus, survivors of incest are at an increased risk for revictimization, often without a conscious realization that they are being abused. This issue often creates confusion for survivors because the line between involuntary and voluntary participation in sexual behavior is blurred.

An article by Sandra Stroebel and colleagues, published in 2013 in Sexual Abuse: A Journal of Research and Treatment, indicates that risk factors for father-daughter incest include the following:

  • Exposure to parent verbal or physical violence
  • Families that accept father-daughter nudity
  • Families in which the mother never kisses or hugs her daughter (overt maternal affection was identified as a protective factor against father-daughter incest)
  • Families with an adult male other than the biological father in the home (i.e., a stepfather or substitute father figure)

Finally, some qualitative research notes that in limited cases, mothers with histories of being sexually abused as a child wittingly or unwittingly contribute to the causal chain of events leading to father-daughter incest. Furthermore, in cases in which a mother chooses the abuser over her daughter, the abandonment by the mother may have a greater negative impact on her daughter than did the abuse itself. This rejection not only reinforces the victim’s sense of worthlessness and shame but also suggests to her that she somehow “deserved” the abuse. As a result, revictimization often becomes the rule rather than the exception, a self-fulfilling prophecy that validates the victim’s sense of core unworthiness.

Beyond the physical and psychological harm caused by father-daughter incest, Courtois notes that the resulting family dynamics are characterized by:

  • Parent conflict
  • Contradicting messages
  • Triangulation (for example, parents aligned against the child or perpetrator parent-child alignment against the other parent)
  • Improper parent-child alliances within an atmosphere of denial and secrecy

Furthermore, victims are less likely to receive support and protection due to family denial and loyalty than if the abuser were outside the family or a stranger. Together, these circumstances often create for survivors a distorted sense of self and distorted relationships with self and others. If the incest begins at an early age, survivors often develop an inherent sense of mistrust and danger that pervades and mediates their perceptions of relationships and the world as a whole.

Betrayal trauma theory

Betrayal trauma theory is often associated with incest. Psychologist Jennifer Freyd introduced the concept to explain the effects of trauma perpetrated by someone on whom a child depends. Freyd holds that betrayal trauma is more psychologically harmful than trauma committed or caused by a noncaregiver. “Betrayal trauma theory posits that under certain conditions, betrayals necessitate a ‘betrayal blindness’ in which the betrayed person does not have conscious awareness or memory of the betrayal,” Freyd wrote in her book Betrayal Trauma: The Logic of Forgetting Childhood Abuse.

Betrayal trauma theory is based on attachment theory and is consistent with the view that it is adaptive to block from awareness most or all information about abuse (particularly incest) committed by a caregiver. Otherwise, total awareness of the abuse would acknowledge betrayal information that could endanger the attachment relationship. This “betrayal blindness” can be viewed as an evolutionary and nonpathological adaptive reaction to a threat to the attachment relationship with the abuser that thus explains the underlying dissociative amnesia in survivors of incest. Under these circumstances, survivors often are unaware that they are being abused, or they will justify or even blame themselves for the abuse. In severe cases, victims often have little or no memory of the abuse or complete betrayal blindness. Under such conditions, dissociation is functional for the victim, at least for a time.

Consider the case of “Ann,” who had been repeatedly and severely physically and sexually abused by her father from ages 4 to 16. As an adult, Ann had little to no memory of the abuse. As a result of the abuse, she had developed nine alternate identities, two of which contained vivid memories of the sexual and physical abuse. Through counseling, she was able to gain awareness of and access to all nine alternate identities and their functions.

Although Ann expressed revulsion and anger toward her father, she also expressed her love for him. At times, she would lapse into moments of regret for disclosing the abuse, saying that “it wasn’t so bad” and that the worst thing that had happened was that she had lost her “daddy.” During these moments, Ann minimized the severity of the abuse, wishing that she had kept the incest secret so that she could still have a relationship with her father. This was an intermittent longing for Ann that occurred throughout counseling and beyond.

Thus, understanding attachment concepts is critical for understanding betrayal traumas such as incest. Otherwise, counselors might be inclined to blame survivors or might feel confused and even repulsed by survivors’ behaviors and intentions. For many survivors, the caregiver-abuser represents the best and the worst of her life at various times. She needs empathy and support, not blame.

Dissociation

As defined in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, dissociation is “a disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, perception, body representation, motor control and behavior.” Depending on the severity of the abuse, dissociative experiences can interfere with psychological functioning across the board. Survivors of incest often experience some of the most severe types of dissociation, such as dissociative identity disorder and dissociative amnesia (the inability to recall autobiographical information). Dissociative experiences often are triggered by perceived threat at a conscious or unconscious level.

As previously noted, betrayal trauma theory holds that for incest survivors, dissociative amnesia serves to maintain connection with an attachment figure by excluding knowledge of the abuse (betrayal blindness). This in turn reduces or eliminates anxiety about the abuse, at least in the short run. Conversely, many survivors of childhood incest report continuous memories of the abuse, as well as the anxiety and felt terror related to the abuse. Often, these individuals will find a way to leave their homes and abusers. This is less frequently the case for survivors who experience dissociative amnesia or dissociative identity disorder.

Depersonalization and derealization distort the individual’s sense of self and her sensory input of the environment through the five senses. For example, clients who have experienced incest often report that their external world, including people, shapes, sizes, colors and intensities of these perceptions, can change quickly and dramatically at times. Furthermore, they may report that they do not recognize themselves in a mirror, causing them to mistrust their own perceptions.

As one 31-year-old incest survivor stated, “For so many years, everything within me and around me felt and looked unreal, dull, dreary, fragmented, distant.” This is an example of depersonalization/derealization. She continued, “This, along with the memory gaps, forgetfulness and inability to recall simple everyday how-tos, like how to drive a car or remember the step-by-step process of getting ready for the day, made me feel crazy. But as I improved in counseling, my perceptions of my inside and outside worlds became clearer, more stable, and brighter and more distinct than before counseling. It all came to make more sense and feel right. It took me years to see the world as I think other people see it. From time to time I still experience that disconnection and confusion, but so much less frequently now than before.”

Initially, some real or perceived threat triggers these distorted perceptions of self and outer reality, but eventually they become a preset manner of perceiving the world. Reports such as this one are not uncommon for survivors of incest and often are exacerbated as these individuals work through the process of remembering and integrating trauma experiences into a coherent life narrative. For many survivors, a sense of coherence and stability is largely a new experience; for some, it can be threatening and trigger additional dissociative experiences. The saying “better a familiar devil than an unfamiliar angel” seems to apply here.

The severity of dissociation for survivors of incest is related to age onset of trauma exposure and a dose-response association, with earlier onset, more types of abuse and greater frequency of abuse associated with more severe impairment across the life span. Incest is associated with the most severe forms of dissociative symptoms such as dissociative identity disorder. Approximately 95 to 97 percent of individuals with dissociative identity disorder report experiencing severe childhood sexual and physical abuse.

Fragmentation in one’s sense of self, accompanied by amnesia of abuse memories, is particularly functional when children cannot escape the abuse circumstances. These children are not “present” during the abuse, so they often are not aware of the physical and emotional pain associated with the abuse. Yet this fragmented sense of self contributes to a sense of emptiness and absence, memory problems and dissociative self-states. Many survivors of incest are able to “forget” about the abuse until sometime later in adulthood when memories are triggered by certain events or when the body and mind are no longer able to conceal the memories. The latter results from the cumulative effect of lifelong struggles related to the incest (for example, interpersonal problems and emotional dysregulation). It takes a great deal of psychological and physical resources to “forget” trauma memories.

Dissociation, especially if it involves ongoing changes in perceptions of self and others, different presentations of self and memory problems, may result in difficulty forming and maintaining a therapeutic alliance. Dissociation disrupts the connection between the client and the counselor. It also disrupts clients’ connections with their inner experience. If these clients do not perceive themselves and their surroundings as stable, they will mistrust not only their counselors but also their own perceptions, which create ongoing confusion.

Thus, counselors must remain alert to subtle or dramatic fluctuations in survivors’ presentation styles, such as changes in eye contact or shifts in facial features from more engaged and animated to flat facial features. Changes in voice tone quality and cadence (from verbally engaged to silent) or in body posture (open versus closed) are other signs of possible dissociative phenomena. Of course, all or none of these changes may be indicators of dissociative phenomena.

Complex trauma

Incest, betrayal trauma and dissociative disorders are often features of a larger diagnostic categorization — complex trauma. Incest survivors rarely experience a single incident of sexual abuse or only sexual abuse. It is more likely that they experience chronic, multiple types of abuse, including sexual, physical, emotional and psychological, within the caregiving system by adults who are expected to provide security and nurturance.

Currently, an official diagnostic category for complex trauma does not exist, but one is expected to be added to the revised International Classification of Diseases (ICD-11) that is currently in development. Marylene Cloitre, a member of the World Health Organization ICD-11 stress and trauma disorders working group, notes that the new complex trauma diagnosis focuses on problems in self-organization resulting from repeated/chronic exposure to traumatic stressors from which one cannot escape, including childhood abuse and domestic violence. Among the criteria she highlighted for complex trauma are:

  • Disturbances in emotions: Affect dysregulation, heightened emotional reactivity, violent outbursts, impulsive and reckless behavior, and dissociation.
  • Disturbances in self: Defeated/diminished self, marked by feeling diminished, defeated and worthless and having feelings of shame, guilt or despair (extends despair).
  • Disturbances in relationships: Interpersonal problems marked by difficulties in feeling close to others and having little interest in relationships or social engagement more generally.
    There may be occasional relationships, but the person has great difficulty maintaining them.

Early onset of incest along with chronic exposure to complex trauma contexts interrupts typical neurological development, often leading to a shift from learning brain (prefrontal cortex) to survival brain (brainstem) functioning. As explained by Christine Courtois and Julian Ford, survivors experience greater activation of the primitive brain, resulting in a survival mode rather than activation of brain structures that function to make complex adjustments to the current environment. As a result, survivors often exhibit an inclination toward threat avoidance rather than being curious and open to experiences. Complex trauma undermines survivors’ ability to fully integrate sensory, emotional and cognitive data into an organized, coherent whole. This lack of a consistent and coherent sense of self and one’s surroundings can create a near ever-present sense of confusion and disconnection from self and others.

Regular or intermittent complex trauma exposure creates an almost continual state of anxiety and hypervigilance and the intrinsic expectation of danger. Incest survivors are at an increased risk for multiple impairments, revictimization and loss of support.

Treatment issues

Although a comprehensive description of treatment is well beyond the scope of this article, I will close with a general overview of treatment concepts. Treatment for incest parallels the treatment approaches for complex trauma, which emphasizes symptom reduction, development of self-capacities (emotional regulation, interpersonal relatedness and identity), trauma processing and the addressing of dissociative experiences.

Compromised self-capacities intensify symptom severity and chronicity. Among these self-capacities, emotional dysregulation is a major symptom cluster that affects other self-capacity components. For example, if a survivor consistently struggles with low frustration tolerance for people and copes by avoiding people, responding defensively, responding in a placating manner or dissociating, she likely will not have the opportunity to develop fulfilling relationships. The following core concepts, published in the May 2005 Psychiatric Annals, were suggested by Alexandra Cook and colleagues for consideration when implementing a treatment regimen for complex trauma, including with incest survivors and with adaptations for clients with dissociative identity disorder.

1) Safety: Develop internal and environmental safety procedures.

2) Self-regulation: Enhance the capacity to moderate and rebalance arousal across the areas of affective state, behavior, physiology, cognition, interpersonal relatedness and self-attribution.

3) Self-reflective information processing: Develop the ability to focus attentional processes and executive functioning on the construction of coherent self-narratives, reflecting on past and present experience, anticipation and planning, and decision-making.

4) Traumatic experiences integration: Engage in resolution and integration of traumatic memories and associated symptoms through meaning making, traumatic memory processing, remembrance and mourning of traumatic loss, development of coping skills, and fostering present-oriented thinking and behavior.

5) Relational engagement: Repair, restore or create effective working models of attachment and application of these models to current interpersonal relationships, including the therapeutic alliance. Emphasis should be placed on development of interpersonal skills such as assertiveness, cooperation, perspective taking, boundary and limit setting, reciprocity, social empathy and the capacity for physical and emotional intimacy.

6) Positive affect enhancement: Work on the enhancement of self-worth, self-esteem and positive self-appraisal through the cultivation of personal creativity, imagination, future orientation, achievement, competence, mastery seeking, community building and the capacity to experience pleasure.

Typically, these components are delivered within a three-phase model of counseling that is relationship-based, cognitive behavioral in nature and trauma focused:

  • Safety, self-regulation skill development and alliance formation
  • Trauma processing
  • Consolidation

The relational engagement component is particularly critical because for many survivors, to be attached often has meant to be abused. Furthermore, accompanying feelings of shame, self-loathing and fear of abandonment create a “failure identity” that results in low expectations for change. Additionally, it is important for counselors to attend to client transference issues and counselor countertransference issues. Courtois suggests that ignoring or assuming that such processes are irrelevant to the treatment of survivors can undermine the treatment process and outcome.

In addition, strength-based interventions are critical in each phase to help survivors develop a sense of self-efficacy and self-appreciation for the resources they already possess. A strength-based focus also contributes to client resilience.

For some clients, dissociated self-states or parts will emerge. Counselors should assume that whatever is said to one part will also be heard by the other parts. Therefore, addressing issues in a manner that encourages conversation between parts, including the core self-structure, is critical. It is also important to help parts problem-solve together and support each other. This is not always an easy proposition. A long-term goal would be some form of integration/fusion or accord among alternate identities. Some survivors eventually experience full unification of parts, whereas others achieve a workable form of integration without ever fully unifying all of their alternate identities (for more, see Treating Trauma-Related Dissociation: A Practical, Integrative Approach by Kathy Steele, Suzette Boon and Onno van der Hart).

Finally, it must be mentioned that repeated exposure to horrific stories of incest can overwhelm counselors’ capacity to maintain a balanced relationship with clear boundaries. A client’s transference can push the boundaries of an ethical and therapeutic client-counselor relationship. Furthermore, the frequent push-pull dynamics between counselor and client can be exhausting, both physically and mentally for counselors. Therefore, it is important for counselors to frequently seek supervision and consultation and to engage in self-care physically, psychologically and spiritually.

 

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

David M. Lawson is a professor of counselor education and director of the Center for Research and Clinical Training in Trauma at Sam Houston State University. His research focuses on childhood sexual and physical abuse, complex trauma and dissociation related to trauma. He also maintains an independent practice focusing on survivors of posttraumatic stress disorder and complex trauma. Contact him at dml3466@aol.com.

Letters to the editorct@counseling.org

 

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

 

Beyond words

By Nevine Sultan September 28, 2017

Attempting to work from a purely cognitive or emotional perspective with clients who have experienced sexual trauma is like trying to build a sturdy house without laying down a solid foundation. Facilitating recovery from sexual trauma demands the inclusion of the site of the original wounding — the body.

A clinical vignette

“Jerry” arrives seven minutes late for his intake appointment. He appears disoriented and confused.

“Please,” I say, inviting him to take a seat. When our eyes meet, he turns his gaze to the floor and explains, “I think I stopped at a gas station on my way here.”

Jerry’s face is flushed and his nostrils are fluttering. Although his head seems to be the most active part of him, I am drawn to Jerry’s feet, legs and hands. The rigidity in the lower half of his body is intense. Jerry’s left foot is twisted outward in a painfully supinated position. His hands are imprisoned beneath his thighs, and his shoulders are hunched forward. The word concave comes to mind. I feel a sense of hollowness in my core as I realize that Jerry is holding his breath like a dam straining to hold water that might cause irreversible damage if released all at once.

We talk briefly. Jerry tells me about his anxiety, the panic attacks that have besieged him up to twice daily over the past few months, his ceaseless hypervigilance, the memories that haunt him, the persistent need to wash his hands and the nights dotted with brief slumber from which he is jarred awake by horrific nightmares. “I’m also having problems with my girlfriend,” Jerry says. “I know I can trust her. It’s just … I can’t shake that feeling.”

As Jerry speaks, his voice is jittery and his lips tremble. His breathing shifts from closed to ragged. “I was out taking a walk in my neighborhood one night. A guy drove up to the sidewalk and asked for directions to the community pool.” Jerry’s pitch lowers, his articulation becomes less sharp, and he drifts inside himself. I shift in my chair to gently facilitate his return to the here and now. He looks up before continuing.

“As soon as I started talking, he got out of the car, opened the door to the backseat, and then … I don’t know. It happened quickly.” He pauses. “I woke up in a hospital. My wrists were really bruised.” Jerry scans the room with his eyes, which are filling with tears. “I couldn’t save myself.” He weeps, pulling his hands out from beneath him and rolling them up into fists.

My stomach clenches, and I feel a sting in my eyes. I am all too familiar with this narrative. Many of my clients who have suffered sexual trauma describe similar experiences of numbing and freezing and an overwhelming sense of self-betrayal. I take a deep breath and redirect my attention to Jerry, who is still sobbing. I give him a few minutes. As he recovers from his outburst, he returns to holding his breath.

“Jerry?” I say gently. He looks up. “Thank you for trusting me with that. See if it’s OK to exhale. Slowly.”

Understanding dysregulation

Every word that Jerry says matters. I note his narrative. It is significant. I also note the paranarrative — the cauldron of sensations, emotions and racing thoughts bubbling beneath the surface of his quivering demeanor. This agitated vessel is holding a fusion of fear, isolation, shame, avoidance, mistrust, physical and emotional numbing, negative beliefs, impulsivity, diminished agency and an outright inability to tolerate the present.

While Jerry’s thoughts and emotions are overly active, his body is entirely ignored. Consequently, he is caught in the unconscious frenzy of persistent fear and some terribly unforgiving stories: The world is dangerous. I will never be safe. I can’t protect myself.

The harm Jerry has endured did not compromise his thinking or his emotions alone, however. Jerry has suffered a severe wounding to his body; hence, his collapsed posture, his irregular breathing and his restricted movement, coupled with his overall sense of being overwhelmed and his inability to maintain a state of calm.

As French phenomenological philosopher Maurice Merleau-Ponty pointed out in his seminal text, Phenomenology of Perception, our bodies are the agents by which we exist in the world. They are also the receptacles of memories that, often vanished from our conscious awareness, are still deeply etched within our being. When those memories are triggered, we experience suffering at a highly existential level that transcends consciousness. Facilitating the recovery of clients who have experienced sexual trauma must include opportunities for repairing connections with all dimensions of their being.

John Hughlings Jackson, known as the “father of English neurology,” outlined a human nervous system composed of three parts: social, sympathetic and parasympathetic, which has since inspired Stephen Porges’ polyvagal theory. Jackson’s model is hierarchical: The higher elements inhibit the lower elements. When a higher element on the hierarchy fails, a lower component takes over.

The highest element of the nervous system is the social one, responsible for relational contact and communication. Lower on the hierarchy is the sympathetic nervous system, which kicks in when we experience a disturbance in our inner or outer environment, thus activating our fight/flight/freeze/dissociate response. Should we not fight or flee, we plunge into freezing, immobility and dissociation. Unless the parasympathetic nervous system is reactivated, we remain frozen, incapable of responding to our environment.

Paradoxically, nonthreatening surprise situations are likely to elicit a sympathetic nervous system response, whereas threatening situations are likely to elicit a parasympathetic response, which is why many of us freeze or dissociate when confronted with a seemingly hostile situation. A healthy nervous system is one that self-regulates through a balance of sympathetic and parasympathetic functioning — that is, an arousal-activation event is followed by a period of rest and digest. An unhealthy nervous system, on the other hand, remains in either hyper- or hypoarousal, giving rise to startle, panic, hypervigilance, restlessness and emotional flooding, or to emptiness, exhaustion, disorientation, dissociation and emotional numbing, respectively. Clients who have not resolved traumatic events are often stuck in hyper- or hypoarousal.

In the aftermath of a traumatic event, survivors are likely to develop generally maladaptive coping symptoms that offer temporary relief from dysregulation. These coping symptoms include various process and substance addictions, obsessions and compulsions, and self-harm. Regardless, clients suffer the following interruptions:

  • Physical/perceptual (inaccurate kinesthetic reactions to perceived threat, anxiety, dissociation, collapse)
  • Contextual (difficulty perceiving and making sense of surroundings)
  • Emotional (fixation on fear, rage or sadness)
  • Cognitive-behavioral (intrusive, racing thoughts; memory loss; self-destructive patterned behavior)
  • Spiritual/existential (loss of sense of self)

Jerry tends to cycle between hyper- and hypoarousal, as evidenced by his frequent experiences of hypervigilance and panic attacks, and his often collapsed and frozen posture. When agitated, he attempts to manage his dysregulation in a number of maladaptive ways, including engaging in impulsive (e.g., breaking up and making up with his girlfriend repeatedly) and compulsive behaviors (e.g., continually washing his hands).

Although traditional cognitively and emotionally oriented psychotherapy approaches may help Jerry ease some of these coping behaviors, they do not include methods for addressing his dysregulation. Working with Jerry’s physical process allows me to help him identify when he is in hyper- or hypoarousal and bring himself back to what leading neuropsychiatrist and interpersonal neurobiologist Daniel Siegel refers to as one’s “window of tolerance,” or the zone in which our arousal state is balanced.

Honoring the somatic narrative

The somatic approach to healing trauma was inspired by a phase-oriented model for treating trauma and dissociation that was established in the early 20th century by French psychotherapist Pierre Janet. The somatic approach requires an understanding of how nervous system dysregulation is activated as a consequence of trauma and which parts of the body and brain are involved. The counselor uses this information to help clients create a sense of safety, to facilitate clients’ use of internal resources to regulate arousal and enhance self-efficacy, and to help clients address traumatic memories and explore novel ways of being in the world. Interventions include focus on nonverbal experience, kinesthetic awareness and reshaping body movement.

In the aftermath of his traumatic assault, Jerry’s ability to organize his experience was compromised, resulting in dysregulation of arousal, challenges tracking his surroundings and increased cognitive and emotional processing. This sent his thoughts and feelings into overdrive, making it difficult to control his impulsivity. With his inability to self-regulate, Jerry is virtually incapable of remaining connected with his present moment, and specific trauma-related (and sometimes neutral) stimuli can trigger an immediate impulsive response.

According to Pat Ogden, the pioneer behind the popular attachment-based somatic approach to healing trauma known as sensorimotor psychotherapy, a primary task faced by counselors working from a somatic approach is to help clients create a balance among the various processes used to organize experience. This is done using a bottom-up model that views human experience as an initially sensory process that informs emotion, which then informs thought and behavior. Focusing on the here and now is especially important when using a body-centered approach because it allows the counselor to address how a past event is manifesting in the present.

Finally (or perhaps first and foremost), when working with the somatic dimension, high levels of therapist presence and attunement are needed to support a therapeutic alliance with appropriate boundaries that is built on safety and trust.

Creating shared space

Essential to facilitating Jerry’s connection with his physical process is my personal embodiment — that is, my ability to be in contact with and present in my own body. By anchoring myself in my body and my present-moment experience, I am better able to create an empathic space for our encounter.

I use my sensory experiences to inform the therapeutic process and guide me toward a well-rounded understanding of how Jerry exists in the world based on how he exists in the therapy room. Understanding the experience of my body when I am in contact with Jerry helps me reach out within our intersubjective space with the deepest respect for his pace while acknowledging that I am affected by his experience. From this place of compassion and empathy, sharing and being, and phenomenological engagement, an integrative somatic process begins in which I serve as a bridge between Jerry and the rest of the world.

“When you are ready,” I say to him in gentle invitation.

Organizing the client’s experience in the here and now

I listen to Jerry’s verbal narrative. I also attune to the story his body is telling and how my own body is receiving that. What body postures does Jerry fall into as he recounts specific parts of his story? What gestures accompany certain words, phrases or recollections in the here and now?

Such physical manifestations are indicative of how Jerry’s body has encoded certain events implicitly. Jerry is physically manifesting content from his implicit (unconscious), somatic memory of the traumatic event that may or may not be congruent with his declarative (conscious) memory. Keeping in mind the fallibility of declarative memory, working from a somatic approach supports access to Jerry’s implicit memory, which offers us additional insight into his experience.

Attending to Jerry’s somatic narrative, I notice that his fists hold the highest energy. My own fists are wound so tightly that I can feel my nails digging into my palms. I also notice that I am holding my breath in anticipation. I release my breath, unfold my fingers and share some observations with Jerry in the form of brief contact statements designed to enhance his awareness.

I also pose exploratory questions. “I’m noticing that as you talk about feeling incapacitated in the moment you were grabbed, your hands are balled into fists. Would it be all right to bring your attention to your hands for a moment?” Helping Jerry consciously connect with the most reactive part of his body invites his capacity to self-witness and be self-aware. This activates the prefrontal cortex that, according to body-centered trauma expert Bessel van der Kolk, is responsible for emotion regulation, cognitive and social behavior, and decision-making.

As Jerry accesses his past experience in the here and now from a nonreactive place, he is better able to observe it, recognize that it happened in the past, notice how it is manifesting in the present and identify new ways of understanding it. Next, we work to identify the emotions that arise with the declarative and implicit memories of the experience and any thoughts that accompany the physical and emotional manifestations.

“What are you sensing in your fists right now?” I ask. “Examples of sensation are tingling, tightness, cold, heat.”

“They’re stuck,” Jerry says. “I can’t do anything with them.”

I ask Jerry to name the feelings that accompany that sense of stuckness. “Examples of feelings are anger, sadness, guilt, fear. ‘I feel …’ Can you fill in the blank?”

Jerry stares at the ground. “I feel … angry.” He begins to weep inconsolably. “I’m so, so angry.” He drops to the floor and curls into a fetal position. I give him a few minutes to be where he needs to be, to experience being balled up and angry.

“I’m so mad at myself. I didn’t save myself. Who does that?” I recognize that I didn’t have to invite Jerry to reflect on any thoughts accompanying the emotion and the sensation; the thoughts are emerging on their own.

Minutes later, Jerry is still holding his fists, but his tears are subsiding. I grab a box of tissues and sit on the ground near him, close enough to offer the nonphysical support he may need. I pull out a tissue and drape it gently over his left fist. He flinches and opens his eyes, looking straight ahead.

I wonder if it might be helpful to invite some awareness around how he is organizing this experience. “What are you holding inside your fists, Jerry? And what is that doing for you?” Jerry continues to look out into the ether. “Your fists,” I prod gently. “If your fists had a voice and could speak, what would they say? ‘I …’ Can you fill in the blank?”

Jerry is silent for a few seconds. “I … I am …”

“Yes, Jerry. Keep going,” I encourage him.

“I am … very angry,” he offers meekly.

“Is that what the anger inside of your fists sounds like?” I nudge gently. Jerry shifts slightly in his fetal position and then stops. “What does your body need to do right now?” I ask. “Expand? Contract? Walk away? Move closer? Is it OK to explore that need?”

“I think I need to move,” Jerry says. Without further invitation, he sits up. His upper body is still collapsed, and he seems undecided. I invite him to attend, once again, to what his body needs. Jerry inhales a little more deeply, expands moderately with his intake of breath, tightens his fists further and bellows, “I AM SO ANGRY!”

“Say that again,” I urge. “Give your fists the voice they need.”

“I AM SO ANGRY!” he screams, over and over. Twenty times. Thirty times. “I WILL NEVER LET ANYONE DO THIS TO ME AGAIN!” Jerry says even louder, holding his fists chest high and shaking them like he has someone by the collar.

Once Jerry has experienced a full release of energy, his tight fists unfold, although with some reservation. “Would it be OK to let go of the rest of that?” I invite.

Jerry’s eyes close, and I realize he may be unwilling to let go. I offer a compromise. “You don’t have to let go of your anger forever,” I say. “Maybe you can leave it in a safe place so that you can have it back whenever you want it.”

Jerry seems open to this idea. After some deliberation, he looks at a print hanging on the wall behind me and says, “I think I’ll leave it behind that picture.”

Jerry and I have just worked through a process of using an implicit memory (balled-up fists) connected with his traumatic incident to initiate a recalibration of his nervous system. This process involved:

a) Creating a shared space facilitated by my presence

b) Helping Jerry identify different facets of memory (implicit and declarative)

c) Using contact statements to help Jerry recognize the orienting patterns he is using to organize his experience (“I’m noticing …”)

d) Inviting Jerry to name his sensory, emotional and cognitive experience (“What are you experiencing …?”)

e) Allowing Jerry’s body to tell its narrative (“If your fists had a voice and could speak …”)

f) Exploring modification of Jerry’s orienting patterns (“What does your body need right now?”) and experimenting with new ways of being

g) Restoring empowering actions (“Give your fists the voice they need.”)

The next step involves making sense of our process. The hope is that Jerry will use his new understanding of his experience to make new choices informed by the here and now.

Creating meaning and energizing change

“What was that like for you?” I ask.

“I don’t know,” Jerry says. “I feel like a heavy load has been lifted.” I nod. “From these,” he continues, raising his hands.

I acknowledge and affirm Jerry’s reflection. “Those fists were holding on pretty tight. What did it mean to hold tight?”

“I think … I felt in control.”

“Can you say more about that?”

“Yeah. Like I wasn’t going to lose it, I guess.”

I feel that Jerry and I are in a safe enough place for my next question. “What would happen if you allowed yourself to completely lose it?” Jerry clenches. “OK to exhale?” I invite.

Jerry releases his breath slowly. “I don’t know.”

“Jerry?” I invite him to make brief eye contact with me. “I’m not sure I buy that.” I smile gently. “What would happen?”

Jerry thinks but maintains eye contact. “I mean, I just lost it, right?”

I offer a perspective: “Seems like you trusted yourself with that too.”

“I did,” he says solemnly.

“What is it like for you to trust yourself?” I ask. “‘I …’ Can you fill in the blank?”

“I feel pretty big right now.”

“Hmm. What does big look like?” I invite. “Can you show me?” Jerry lifts his body and expands his chest. Although he does this slowly and with seeming caution, I am aware that he has given himself permission to explore a place beyond his wound. I open the door for a final inquiry that will help Jerry take what he has learned about resourcing himself outside of the therapy room: “What might you do with that bigness, Jerry?”

Working through roadblocks

Accessing and working with certain memories in the here and now is not always a straightforward process. In Jerry’s case, he sometimes exhibits an aversion to being in the present. For example, although Jerry shows relative ease connecting with his anger, in a later session he experiences great difficulty accepting his shame.

Jerry’s resistance manifests, initially, as indirect eye contact and fixation on the ground. Once we begin exploring this and Jerry identifies the emotions and thoughts connected with it, he manifests an outburst of physical agitation that is marked by twitching in his chair until he falls to the ground.

I invite Jerry to remain seated on the floor and connect with the ground (using a process we call grounding), which helps him feel connected to and supported by something outside of himself. Next I ask him to explore his center of gravity by way of a process called centering, which brings his attention back to his physical experience. Finally, I suggest containment, a self-holding exercise designed to facilitate self-regulation and awareness of one’s boundaries and overall physical presence.

Because of their focus on the physical, these exercises shift clients’ attention from the self-destructive emotional and cognitive narrative to their internal resources. With this, the counselor is tasked with pacing the session so that the client is not overwhelmed. Introducing these safety-enhancing exercises is often helpful as sexual trauma clients experience the need to recalibrate from the potentially overpowering experience of confronting their trauma.

Establishing a time frame for the therapeutic process

Clinicians working from a somatic approach are highly aware of the challenges of creating time parameters for their therapeutic work. On the other hand, it is not uncommon for clients to ask, “How long will I be in therapy?” My response is that it depends on a number of factors, including:

1) Whether the traumatic event was a single, first-time incident or is recurring

2) The client’s developmental history (i.e., milestones, attachment patterns)

3) The client’s current coping strategies

4) Systemic factors (i.e., family, community and broader social support)

5) Client openness to working with the body

6) Therapist consistency and the quality of the therapeutic alliance

That said, somatic therapy tends to be time intensive, unlike, say, brief solution-focused or cognitive-behavioral work. Jerry attended weekly 80-minute therapy sessions for approximately 10 months, followed by biweekly 50-minute sessions for three months. He is currently coming in for monthly 50-minute check-ins.

Although Jerry has not forgotten his traumatic incident, he has learned how not to be hijacked by memories, how to self-regulate when confronted with somatic, emotional or cognitive triggers and how to tap into internal resources (including his body) to address present-moment needs.

Closing reflections

Embracing a somatic approach in working with Jerry’s sexual trauma engages his verbal and nonverbal narratives, opening a door to reshaping his way of being in the world and catalyzing new intentions and experiences. It also helps us focus on what is versus what was or what might be.

Working in the present enhances Jerry’s awareness of who and how he is in the world, what he does and how he does it, and how remaining stuck in the past or allowing himself to be hijacked by the future are choices he can modify as he works to reconnect with his window of tolerance. Being aware brings present-moment possibilities and options center stage. The emphasis is no longer on irreversible past or anticipated future experiences but on what is happening in the here and now.

Thus, clients take responsibility for their needs, feelings, thoughts and actions. Taking responsibility and ownership of situations and experiences is, in itself, a holistic, anchoring and awareness-enhancing behavior. With it comes an increased ability for clients to push the boundaries that are stifling their self-expression, identify immediate needs and engage in self-mobilization, creative experimentation, somatic expression and self-regulation, all of which are at the heart of an existence that has made peace with its past and is grounded in the present. As clients’ awareness is ignited on a holistic level, they are empowered to decide whether their patterned behaviors still serve a purpose and how those behaviors can be modified to meet present needs.

How we inhabit our bodies reflects our way of being in the world. Through our bodies, we sense and experience, receive and perceive. Exploring the physical body and its manifestations of past sexual trauma helps clients integrate the physical, emotional and cognitive dimensions of their experience. Sensory-kinesthetic exploration brings history to life in the present and anchors it here, where it is more accessible.

Conscious engagement with the body’s innate knowledge permits clients to access their own strengths in the process of healing. How empowering and transforming for our clients who have suffered from sexual trauma to recognize that their well-being exists within their own bodies — the very site of their original wounding.

 

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

Nevine Sultan is an assistant professor of clinical mental health counseling at the University of St. Thomas in Houston and a licensed private practitioner specializing in trauma, dissociative disorders and grief. She embraces an embodied phenomenological approach to counseling and psychotherapy, research and teaching. Contact her at nevine.sultan@gmail.com.

Letters to the editor: ct@counseling.org

 

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

Informed by trauma

By Laurie Meyers September 22, 2017

In 1995, the Centers for Disease Control and Prevention and Kaiser Permanente began what would become a landmark study on the health effects of adverse childhood experiences. Over the course of two years, researchers collected detailed medical information from 17,000 patients at Kaiser’s Health Appraisal Clinic in San Diego. In addition to personal and family medical history, participants were asked about childhood experiences of abuse, neglect and family dysfunction, such as emotional and physical neglect, sexual and physical abuse, exposure to violence in the household and household members who had substance abuse problems or had been in prison.

Researchers found that the presence of these negative experiences in childhood was predictive of lifelong problems with health and well-being. The more negative experiences a participant had, the more likely — and numerous — these problems became. Another disquieting finding was that adverse childhood experiences were incredibly common. Almost two-thirds of participants had endured at least one adverse childhood experience, and more than 1 in 5 respondents had endured three or more such experiences.

In the decades that followed, this discovery of the prevalence and devastating effects of trauma spurred the development of practices such as trauma-informed counseling, which stresses the importance of recognizing and treating trauma and, most importantly, preventing additional trauma.

Drawing on basic counseling skills

According to the U.S. Substance Abuse and Mental Health Services Administration, programs, organizations or systems that are trauma informed:

  • Realize the widespread impact of trauma and understand potential paths for recovery
  • Recognize the signs and symptoms of trauma in clients, families, staff members and others involved with the system
  • Respond by fully integrating knowledge about trauma into policies, procedures and practices
  • Seek to actively resist retraumatization

In many ways, trauma-informed care involves using skills that every counselor should already possess. “Remain empathic, open, nonjudgmental and steady. Steadiness is particularly important,” says American Counseling Association member Cynthia Miller, a licensed professional counselor (LPC) in Charlottesville, Virginia, whose practice specializes in trauma. “You don’t want to overreact to things a client tells you. But you don’t want to underreact either. Screen for trauma at intake. Don’t just ask a client if they’ve ever been abused or neglected. Many clients won’t define themselves as victims of abuse or neglect, and if you ask it that way, you’ll miss it. Ask behaviorally instead.”

Miller suggests using questions such as, “Has anyone ever hit, punched, slapped or kicked you? Has anyone ever put you down, called you names or made you feel worthless? Has anyone ever touched you without your permission? Have you ever witnessed a violent or upsetting event that really troubled you?”

“If a client responds with a ‘yes’ to any of those questions, ask them if they’d like to share more about it now,” Miller continues. “Help them feel in control of what they disclose and when and how much. Don’t make the mistake of thinking you need all the details and then push to get them. You can retraumatize someone that way. Instead, ask them how they think the experience impacted them and if they think it is related in any way to their current struggles.

“At the opposite end, if they respond to everything with ‘no,’ don’t assume a trauma never happened. It may very well be that they’re just not telling you about it right now because they don’t yet feel comfortable. Stay open to the possibility and rescreen as appropriate.”

When specific questions about trauma don’t elicit answers, ACA member Rebecca Pender Baum, a licensed professional clinical counselor in Kentucky who has worked with survivors of sexual assault and interpersonal violence, often asks clients if there is anything they haven’t already told her that they think she needs to know. She has found that this approach often helps clients express concerns that they have been holding back.

Jane Webber, an ACA member and LPC in New Jersey who has written extensively about trauma and disaster, often mixes less threatening questions in with questions related to trauma. For example, in the midst of gathering basic background on family history, she will ask clients about events such as accidents or a history of falling. She then works up to questions about physical and sexual abuse. Webber emphasizes the importance of counselors using the same calm, steady tone of voice for all questions to prevent distressing the client.

Webber also finds it useful to tell her clients, particularly those on the younger end of the spectrum, that they can answer her questions via text during the session. She says that sometimes clients are more open to texting about things that they might struggle to express verbally.

Webber urges counselors to be intuitive with clients and look for signs of unexpressed trauma such as sweaty palms, restless movement in sessions and failure to make eye contact.

Miller says that she stays alert “for what I think of as disordered self-soothing,” which may include “substance use, self-injury or aggression. Individually, any one of them can be a clinical indicator. As a triad, they’re almost certainly covering up an untreated trauma.”

A different focus

At first, it may seem strange to treat every client as if he or she is a trauma survivor. However, clinicians who use trauma-informed counseling say that the practice is also about changing the overall focus of counseling by moving away from the “problem” approach. That approach demands, “What’s wrong with you? What did you do wrong? What’s making you act that way?” says Webber, a lecturer in the counselor education department at Kean University’s East Campus in Hillside, New Jersey. “[Trauma-informed counseling] is a paradigm shift from what is wrong with the client to what happened to the client.”

Julaine Field, an ACA member and LPC from Colorado Springs who works with traumatized children, agrees with Webber. Field explains that rather than focusing on changing a client’s thoughts or behaviors, trauma-informed care seeks to understand how people react and adapt to experiences.

A trauma-informed counselor helps clients understand where their behavior is coming from by explaining trauma’s effects on the brain and emotional regulation, says Field, a counseling professor and coordinator of the clinical mental health track in the Department of Counseling and Human Services at the University of Colorado Colorado Springs. “[Counselors] can also help [clients] understand the real importance of basic self-care, deep breathing, good eating, exercise and that a focus on wellness on a daily basis is the best way to fight the trauma impact and arousal,” says Field, who has also counseled veterans and survivors of interpersonal violence.

A recurrent — and perhaps predominant — theme when talking about trauma-informed counseling is safety. Making the client feel safe and welcome is paramount, say trauma experts. That sense of safety starts with the environment. Counselors should make sure their offices appear warm and inviting, considering everything from comfortable seating to appropriate lighting (neither too harsh nor too dim), says Pender Baum, an assistant professor of counselor education and practicum internship coordinator at Murray State University in Kentucky.

Clients should also feel that they have some control over the counseling process. “Even if you don’t know if a client has been through trauma, you can do things as a clinician that communicate to clients that they are safe and in control of what happens in the consulting room,” says Miller, an assistant professor of counseling at South University in Richmond, Virginia, who has also worked with incarcerated women.

“Let them determine where they want to sit. Ask if they are comfortable. Give them permission to decline to answer any question they are uncomfortable with and to take breaks at any time during the intake if they start to feel uncomfortable,” she suggests. “Pay attention to body language, tone of voice and other cues of emotional distress, and respond to them. Be willing to pause during a session and encourage clients to take a breath, ground themselves or stretch.”

Establishing safety

Both Miller and Webber stress that uncovering trauma is not an automatic green light for counselors and clients to start dissecting the past.

“Establishing safety is the most important and, often, the longest stage of treatment,” Miller says. “Don’t jump immediately into reprocessing, and don’t assume that everyone needs to reprocess. And remember that if you take away someone’s primary coping skill — however maladaptive it may be — you’re leaving them with nothing to soothe themselves when their emotions run high unless you teach them more productive skills.”

Webber spends substantial time helping clients build coping skills. She says that deep breathing is the fastest, easiest and most effective way to regulate emotion, but she cautions that there is no one-size-fits-all approach to this technique. Some people like to use counting — breathing in for three or four beats, holding the breath for another three or four beats, and then slowly breathing out, perhaps for six to eight beats.

However, some clients find it stressful to focus on counting, Webber says. In those cases, the counselor and client should just focus on breathing in and breathing out. She directs clients to inhale slowly and to exhale twice as slowly, noting that the slow exhale is what calms the nervous system and helps decrease a person’s level of physical agitation.

Another factor in breathing “style” is environment. Some people need to look at something specific such as a wall to focus on their deep breathing, whereas others prefer to close their eyes, Webber says. Counselors and clients should experiment with what works best. It can also be difficult to visualize what breathing from the diaphragm means, so counselors should practice their breathing in front of a mirror so they can better demonstrate it to clients, Webber advises. Because it is hard for people to learn when they feel overwhelmed, she also emphasizes the importance of teaching deep breathing and other grounding techniques to clients when they are calm.

Another grounding technique that Webber uses is anchoring in a safe place. Before asking a client to visualize a safe place, however, she says it is important for the counselor to know whether the client has experienced sexual or physical trauma. In those cases, “safety” for the client might mean hiding behind a locked door, which doesn’t provide a healthy, calm image.

“They may not have a happy place,” Webber says. “We might have to create a brand-new place [to visualize], such as a place with no people.” Counselors can help clients visualize their safe places by asking what environments are most comfortable for them.

Webber also uses tapping as a grounding technique. Tapping is a form of bilateral stimulation that helps clients desensitize feelings of trauma and stress. Webber leads clients through deep breathing and asks them to imagine something that is agitating but not overwhelmingly traumatic. Then, she instructs them to use their hands to tap their shoulders repeatedly, alternating between left and right. After about 40 taps, she asks clients to stop and smile.

Clients can also use tapping in public if they are feeling agitated or overwhelmed. Simple and inconspicuous techniques include tapping a foot on the ground three times, lifting a heel in and out of a shoe, or simply looking left and then right repeatedly, Webber says.

Even in the midst of teaching clients coping skills and grounding techniques, their safety is never far from Webber’s mind. To avoid retraumatizing clients, she monitors their level of distress in each session, giving them a scale on which 1 represents complete calm and 10 represents overwhelming agitation. Webber begins and ends sessions with the scale. She also pauses and does a quick check within the session if the client shows signs of agitation or arousal. If the client’s distress level is too high, Webber stops and does some grounding and deep breathing with the client.

All of the professionals interviewed for this article stressed the importance of counselors receiving supervision or working in tandem with a trauma specialist if needed. “When you start to feel in over your head, you’re probably in over your head,” Miller says. “That’s a good time to get supervision or to consult with someone who has more training and experience than you.”

However, there are basic principles of trauma-informed counseling that all counselors should know, Field says. These include:

  • Psychological first aid
  • Mindfulness techniques
  • Breathing techniques
  • Grounding strategies
  • Relaxation methods

“Psychoeducation about the brain and the impact of trauma on the brain is something that all practitioners can do,” adds Field, noting that simply normalizing the effects of trauma can be enormously helpful for many clients.

Helping the helper

Another tenet of trauma-informed counseling is self-care. Immersing themselves in others’ problems and pain can take a toll on counselors, and counselors who regularly engage in trauma work face an increased risk of vicarious or secondary traumatization. According to the second edition of the APA Dictionary of Psychology, burnout can be “particularly acute in therapists or counselors doing trauma work, who feel overwhelmed by the cumulative secondary trauma of witnessing the effects.”

To continue to treat clients affected by trauma with compassion, counselors must extend some of that same consideration toward themselves. A practice of good self-care can help trauma-informed counselors to safeguard their own mental and physical health.

That is a lesson Jessica Smith, an LPC with a private practice in the Denver area, learned early in her career. “My work used to define me,” says Smith, an ACA member who specializes in addictions and trauma. “If I did a pie chart of where I found meaning in my life, three-quarters of it would have been my work as a counselor when I first started out on this professional journey, but through my burnout and recovery, I’ve learned that I am so much more than this work. I care about my clients deeply, but I also love and care about myself deeply too.

“I used to view self-care as a burden — just one more thing to do. But now I see it as an opportunity to show up more fully in my life and the lives of those around me, including my clients.”

Smith now makes self-care a regular part of her day. “I start my day with meditation, journaling and movement in the form of walking, yoga or another form of exercise. I infuse self-care throughout my day through meals, writing, music, mantras, and connections and conversations with other colleagues. I have a mantra that I say before each session, which is, ‘Help me to be a conduit or reed to transmit … messages to this person in a way that they are able to receive them. Help me to remember that I cannot fix, change or save this person and that I am only one small part of their healing journey on this earth. Give me love, give me hope and give me light.’”

The creative interventions that Smith does with clients — including movement, art, visualizations, writing and breathwork — also serve as a kind of pressure valve, she says. “I’m constantly checking in with my body during sessions, especially when I’m working with [clients who have experienced] trauma, to notice, breathe into and release any areas of tightness and tension.” Smith finds that her body reflects the tension in clients’ bodies. “[I] check in with them about their sensations, then disclose mine as well in order to help model healthy body awareness and connection.”

At the end of the day, Smith clears the office by burning sage and consciously making a decision to let go of any residual trauma or distress. When she gets home, she physically “shakes off” the day before going into the house.

“I end each day with a meditation and gratitude practice where I write down three things I am thankful for that day,” Smith says. “I stretch and do heart-opening yoga poses, then go to sleep.”

Counselors need to have self-care strategies that allow them to gain distance from their work and give them the ability to check out mentally and physically from the responsibilities of being a counselor, Pender Baum says. She has learned to literally put self-care on her calendar.

“I live by my calendar, so if it is on there, it becomes just like another required staff meeting or counseling session,” she says. “It’s not negotiable. Admittedly, I can still struggle with this one at times, [but] it’s important not to let work get in the way of your me time. Get that self-care in whenever you can. It might be closing the door for five minutes and doing some deep breathing or taking a walk around the building. Something to break up the day and get you away from your office.”

It’s also important to engage in activities that don’t have a timeline or deadline and, most importantly, that are fun, Pender Baum says. “I like to kayak, watch movies with my husband [and] read to my daughter. Others might like going for a run, reading their own book [or] soaking in a bubble bath.”

Another self-care strategy that Pender Baum emphasizes for counselors is to avoid isolation. “Developing connections sometimes can involve seeking out professional development opportunities. This helps to keep you connected to the profession, learn new skills and be around other professional counselors without hearing the traumatizing stories from clients.

“For example, just this summer, my mother — a fellow counselor educator and counselor — and I attended a training on finding meaning with mandalas. We not only learned a fantastic clinical skill, but it was very therapeutic [for us] at the same time.”

Pender Baum also stresses the importance of peer support and supervision. “It’s … important to debrief after particularly difficult cases,” she says. “Have that peer support group, supervisor [or] consultant on hand that you can engage with. Have a mentor or be a mentor to someone.”

Smith participates in two therapist support groups that meet once a month. “Since I’m in private practice, isolation can be a risk, so I do these groups as well as go to lunch or coffee with at least one friend or colleague in the field each week,” she says. “I take time off each month and no longer feel guilty about doing so as I did early on in my career. I try to do a training or workshop quarterly for self-care, connection and to nurture my inner student.”

Pender Baum says counselors need to know themselves. “Give yourself permission to experience the emotions, but also set clear boundaries,” she says. “Know your limits, avoid overtime, commit to a schedule, and recognize and change negative coping skills.”

All counselors should also be aware of the signs and symptoms of vicarious trauma, Pender Baum stresses.

“Vicarious trauma can change one’s spirituality, and this can impact the way we see the world and how we make sense out of it,” she says. “Some counselors experience difficulty talking about their feelings, anger or irritation, an increased startle response and difficulty sleeping. Others might experience over- or undereating, an ever-present worry that they are not doing enough for their clients [or] possibly even dreaming about clients’ traumatic experiences. Still others might feel trapped in their jobs, lose interest in things they typically enjoy and even [experience] a loss of satisfaction and accomplishment. Some experience intrusive thoughts related to client stories and feeling hopeless.” These are all signs that counselors need to step back and focus on self-care, she says.

Other symptoms include:

  • Chronic lateness or absence from work
  • Low motivation and an increase in errors at work
  • Overworking
  • Avoidance of responsibilities
  • Conflict at work and in personal relationships
  • Low self-image

Pender Baum also urges practitioners to listen to their peers, family members, friends and loved ones if they say they are noticing a change in them. Counselors may be unaware that they are showing signs of burnout, and feedback from others can be helpful in preventing a crash from overwork and stress.

 

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Additional resources

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

Counseling Today (ct.counseling.org)

  • “Coming to grips with childhood adversity” by Oliver J. Morgan
  • “The toll of childhood trauma” by Laurie Meyers
  • “Traumatology: A widespread and growing need” by Bethany Bray
  • “The transformative power of trauma” by Jonathan Rollins
  • “A counselor’s journey back from burnout” by Jessica Smith
  • “Stumbling blocks to counselor self-care” by Laurie Meyers

Books (counseling.org/publications/bookstore)

  • Terrorism, Trauma and Tragedies: A Counselor’s Guide to Preparing and Responding, third edition, edited by Jane Webber & J. Barry Mascari (fourth edition being published in 2018)

Webinars (aca.digitellinc.com/aca)

  • “ABCs of trauma” with A. Stephen Lenz
  • “Children and trauma” with Kimberly N. Frazier
  • “Counseling students who have experienced trauma: Practical recommendations at the elementary, secondary and college levels” with Richard Joseph Behun
  • “Traumatic stress and marginalized groups” with Cirecie A. West-Olatunji

ACA interest networks

 

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

Letters to the editor: ct@counseling.org

 

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

Coming to grips with childhood adversity

By Oliver J. Morgan September 7, 2017

Counselors and mental health professionals of all stripes are coming to understand the prevalence of childhood adversity, toxic stress and trauma in our caseloads. Barely a day goes by that we do not see someone with a trauma history, whether we are aware of it or not. Some have even called for universal trauma screening of all clients and patients as an ethical responsibility, especially for those individuals who are more at risk, including first responders, military personnel, refugees, those with serious medical and chronic illness, and people struggling with addiction. It would help to know what we are dealing with upfront.

I became aware of a duty to inquire about trauma in 2007 when I began the Supportive Oncology Service (SOS), a psychosocial counseling practice colocated in a medical oncology setting. I had been teaching, practicing and publishing mostly in addiction studies at the time, but I was hungering for change in my own clinical work. When the opportunity to work alongside physicians and learn about serious medical illness came along, I jumped at it. Quickly, I discovered that what I was learning about the interface between addiction and trauma could just as easily be applied to the occurrence of trauma in a cancer-involved population. This cross-fertilization of ideas and their practical outcomes has been a rich source of learning for me.

The Adverse Childhood Experiences (ACE) studies, a collaborative project between Kaiser Permanente and the Centers for Disease Control and Prevention (CDC), instigated my interest. The ACE project was designed to study long-term relationships between adverse experiences in childhood and adult health and behavioral outcomes. I had begun looking into this as an offshoot of my addiction work but promptly came to realize its applications in the general population. The initial studies were conducted from 1995 to 1997 with 17,000 ordinary Americans in a large outpatient medical clinic and now have been replicated across a number of states and even internationally.

Since its inception in 1995, numerous papers have been published by the ACE project that present the evidence for consistently strong and graded relationships between adverse experiences in childhood, household dysfunction and a host of negative health outcomes later in life. Many of the most serious illnesses facing our country — heart disease, cancers, chronic lung and liver disease, a host of autoimmune disorders, obesity, substance-related and addictive disorders — as well as a variety of health-risk behaviors, including smoking, use of illicit drugs, high numbers of sexual partners and suicide attempts, are strongly related in a dose-response or graded fashion to childhood adverse experiences.

This suggests that the impact of adverse childhood experiences on adult health status and adult suffering more generally is powerful. Dose-response relationships indicate a change in outcome (e.g., harmful substance use or ischemic heart disease) that is associated with different levels of exposure to a stressor. Experiencing multiple categories of trauma in childhood increases the prospects for later illness. ACE studies measure the number of categories of exposure and not the number of instances; for example, one instance or multiple instances of sexual assault would count as one category. If anything, this underestimates a person’s exposure to adverse experiences.

Researchers are finding that the occurrence of adverse experiences is quite common in all populations. Relationships found in the original population are being replicated elsewhere. Fifty-two percent of those participating in the original study acknowledged at least one category of adversity in childhood. Eighty-seven percent of those who acknowledged one adverse childhood experience also experienced additional adversities. The study revealed that adverse experiences occur in clusters, with 40 percent of the original sample reporting two or more categories of adversity and 12.5 percent experiencing four or more categories of adversity.

The ACE categories are as follows:

  • Physical abuse
  • Sexual abuse
  • Emotional abuse
  • Physical neglect
  • Emotional neglect
  • Mother is treated violently
  • Loss of a parent for any reason
  • Mental illness in the home, including suicidal behavior or institutionalization
  • Substance abuse in the household
  • Criminal behavior in the household, including incarceration of a household member

‘Mild’ adversities?

What first strikes people when they review the categories above is how different the list seems from what we expect. It challenges our assumptions. Many of us are familiar with the standard understandings of trauma connected to natural or human-made disasters, battlefield experiences, violence or sexual assault. Clearly, these are life-altering events. Although these categories are on any list of traumatic events, so are forms of household dysfunction, neglect, and emotional abuse and humiliation. We are coming to understand that, when dealing specifically with children, a wider range of traumatic experiences can be equally devastating and produce debilitating outcomes years later. Further studies are also uncovering negative outcomes related to more “ordinary” adversities such as accidents, childhood hospitalizations or the loss of a sibling.

The ACE results had suggested that the different categories were essentially equal in their damage. This was startling. However, ongoing trauma science supports this conclusion. Although some categories of adversity stand out because of the social significance and stigma attached to them, we now know that more hidden or subtle adversities, such as neglect and experiences of recurrent humiliation by a parent, can both be detrimental in the present and carry long-term consequences for adult health and psychiatric illness. Scientists such as Martin Teicher and his colleagues at Harvard University have documented the potent negative effects of parental verbal aggression and emotional maltreatment.

More common adversities can have large impacts on children. The clinical and research focus on posttraumatic stress disorder may have slanted our expectations, giving us the impression that adversity comes only with high-profile suffering. If it doesn’t leave a mark, it can’t be all that damaging, right? In reality, nothing could be further from the truth.

In short, poor health and risk for illness — medical as well as psychiatric — can be rooted in childhood psychosocial experiences. They can also be hidden due to time, denial and social taboo. The ongoing ACE studies and allied research have given us a new lens for viewing health, wellness and disease. This is nothing short of revolutionary. It is instructive that this new vision has been picked up by the Center on the Developing Child at Harvard University and the American Academy of Pediatrics. Programs for medical education, intervention and prevention are being developed by these groups and others.

Looking at cancer

In 2010, one of the ACE papers made the dose-response link to risk for lung cancer. This got my attention. Adverse childhood experiences are obviously not the only causes of cancers — disease is often multicausal. However, the associations this paper made between having a history of adverse childhood experiences and those who were first hospitalized at younger ages with lung cancer and died prematurely at younger ages from lung cancer were striking. Smokers were much more likely to have a history of adverse childhood experiences than were nonsmokers. In addition, those with adverse childhood experiences were more likely to begin smoking at younger ages than were other smokers.

I was amazed until I went back and did a chart review for my small oncology service. At that time, we had seen about 100 patients. Admittedly, this was a potentially skewed population, but even so, 60-70 percent of our patients with a variety of cancers met the ACE criteria for adverse experiences, and a large proportion of them had multiple ACE categories in their past. Research had suggested that those with four or more categories of childhood adversity were likely to be diagnosed with cancer or some other serious illness. Those with six or more categories had a life expectancy shortened by up to 20 years. My patient population buttressed those numbers. In addition, several of my patients who were not smokers but nevertheless were diagnosed with lung cancer did have a history of trauma. That day I became a believer in universal screening for trauma in my population of cancer patients. My colleagues and interns have also become believers.

When I discussed these outcomes with several of my physician colleagues, they quickly came to the conclusion that because childhood adversity was strongly associated with the risk of early smoking — nicotine is a powerful anti-anxiety agent — that would likely explain the prevalence among patients with lung cancer. Case closed. If a cancer patient also had a traumatic childhood history, smoking was the likely pathway from trauma to lung cancer. Risky behavior led to later disease.

This did not sit well with me, however. First, it did not explain the high trauma numbers in my cancer patients more generally (a number of whom were nonsmokers) and, second, identifying only this pathway seemed too facile. I believed that more was involved.

Changes that make us vulnerable

At first blush, ascribing disease to risky behaviors and poor lifestyle choices seems reasonable. There is obviously some truth to it. Lots of scientific evidence points to smoking as a risk for cancer. Still, I wondered, could there be other pathways from childhood adversities to cancer? The connections seemed clear, but what were the explanations? As an addiction specialist, I was suspicious of the “poor choices” explanation. Were there other, hidden dynamics that were not so obvious?

This is where the intersection of childhood adversity and neurobiology becomes so important. As a counselor, I had focused my thinking on the social and psychological explanations. Childhood adversity short-circuited psychosocial development. Trauma created toxic stress in a person’s life. Negative experiences became part of a person’s sense of self and view of the world, which made living difficult. These negative experiences also placed emotional burdens on the person’s psyche and spirit, creating negative internal images, expectations and attachments at the core of the personality. People learned to be wary of others and became more guarded, isolated and distrustful. Fair enough. But how do we get to physical disease?

This move requires an alchemical kind of insight — namely that the footprints of our psychosocial experiences of attachment and caregiving are inscribed into our brains and bodies in what Allan N. Schore, Daniel J. Siegel and others call “psychobiological” experiences. Donna Jackson Nakazawa, in her 2015 book Childhood Disrupted, described it this way: Biography becomes biology.

We are continuing to learn about the depths of this process. From our earliest beginnings, experience shapes the development of our brains, bodies and critical survival systems. The formation of our neural architecture, emotional and cognitive networks, regulatory systems, coping and stress response, and immune systems depends on the kinds of caretaking we receive. Social networking is part of our DNA it seems; it is essential for our survival but can also create vulnerabilities.

In childhood, all the essential systems are forming and developing. When children are caught in cycles of abuse, neglect or humiliation, their stress response and coping mechanisms can be degraded and become stuck in the “on” position. Their bodies are continually bathed in inflammatory stress chemicals. This can lead to physiological changes, long-lasting inflammation, eventual breakdown and disease. The immune system can be weakened, even at the level of genes. Neuroscience is helping to document these enduring kinds of changes, large and small, that are the pathways to later illness.

Another form of negative development that can follow from childhood adversity affects the child’s regulatory coping mechanisms for stress. This can lead to difficulties such as substance use and addictive disorders. Emotional and behavioral regulation are essential skills, built upon the foundation of neurological development. Toxic stress, however, can alter and “miswire” the development of critical coping systems, resetting their baseline levels of activity and making them supersensitized, not only to stress but also to triggers that signal the approach of rewarding or stressful situations. In these instances, individuals may substitute chemical or behavioral forms of coping, reward, relieving stress or alleviating anxiety and pain. Regularly resorting to such substitutes can ingrain these choices into neural channels that are resistant to change once firmly set.

These ways of thinking have opened my eyes. Childhood maltreatment and adversity alter children’s brain development and create the underlying conditions for short-term coping and long-term medical and psychiatric problems, including cancers and addiction. The intersection of knowledge from developmental psychology, attachment theory, trauma and neuroscience is presenting us with many new ways to conceptualize the challenges that confront us. As counselors, it is imperative that we remain open to these new developments.

Recommendations

Based on my experience, I want to make some practical recommendations:

1) Counselors need to learn all we can about adverse childhood experiences and their impact on adult living.

2) We can all benefit from universal screening for adversity and trauma as a first step in clinical work. A few simple questions can be added to our standard history taking. Asking these questions on an abstract or computerized form, followed up with face-to-face conversation, has been found to be the best practice for obtaining accurate information. There may be direct health benefits to these conversations. As reported in Nakazawa’s book Childhood Disrupted, physicians who discussed adverse childhood experience questions with patients following completion of intake forms found a 35 percent reduction in office visits and an 11 percent reduction in emergency room visits for patients with chronic ailments over the ensuing year.

3) When we discover a history of adversity, we should remain curious, be empathic and be predisposed to believe. The primary consideration initially is creating a safe space.

4) Be prepared for pendulum swings in the conversations. It is normal to move forward in the story and then back off when the client shows anxiety.

5) Teach grounding techniques so that the client can retreat to safety when overwhelmed.

6) As is the case in much of our counseling work, self-knowledge is critical. Each of us can benefit from conducting our own self-assessment of adversity and trauma. Understanding our own issues and working with them may be the most important first step in recognizing the problem and then working with others.

Good luck. This work, I believe, is one of the greatest secrets and potential resources in clinical practice today. Trauma continues to be a hidden occurrence among our clients and patients for too many counselors, physicians and human service providers. We need to do better.

 

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Oliver J. Morgan is a professor of counseling and human services at the University of Scranton in Pennsylvania. He is beginning his 27th year at the university and is completing a book titled Hungry Hearts: Unlocking the Secrets of Addiction and Recovery. Contact him at oliver.morgan@scranton.edu.

Letters to the editor: ct@counseling.org

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

 

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

Through the child welfare kaleidoscope

By Sheri Pickover and Heather Brown June 27, 2017

The amazing feature about kaleidoscopes is the endless, ever-changing scenes and complex patterns they reveal to anyone who takes the time to look. The gentlest of rotations invites a new and oftentimes completely different perspective on the same set of colorful shapes.

Working with children, adults and families involved in the child welfare system is not so different. A vast array of interplaying events, reactions, concerns and characteristics make up a mosaic of factors that drive a counselor’s assessments and interventions. Any counselor who has worked with one or 100 cases involved in foster care understands how complex and overwhelming it can be to help this population. However, in using the metaphor of looking through a kaleidoscope, we are reminded of how one gentle turn of our focus can change our perspective of the case at hand in a way that will continuously drive more attuned, meaningful interventions. Knowing that the myriad shapes exist before, during and after our treatment with these clients, we can more easily remain open both to seeing and making sense of our clients, the child welfare system and its players, as well as our own experiences of these cases.

Given that each turn of the kaleidoscope brings a new feature into view, we have some idea of the shapes that are there: neglect or abuse, histories of mental illness and substance abuse, court involvement, grief and loss, trauma and attachment. One element might stand out from the others at different times during treatment, but all are present in the kaleidoscope, and we should always acknowledge them throughout the course of treatment even when they don’t dominate our view.

In this article, which is based on our book Therapeutic Interventions for Families and Children in the Child Welfare System, we will provide an overview of six perspectives, or “turns of the kaleidoscope,” to take with these cases. These perspectives focus on specific considerations and guided structure to drive effective intervention and counter burnout when working with this population.

First turn of the kaleidoscope: Client worldview

When a client is involved in the child welfare system, instead of beginning treatment with assessment, start with a curiosity about the client’s worldview (whether that client is a child or an adult) and a desire to understand that worldview better. This process builds empathy for the client and reminds counselors to evaluate possible motivations for the presenting behavior concerns. What is it like to be a child in foster care? What is it like to have your child removed from your care? What it is like to care for a child you don’t know in your home?

Many factors influence the worldviews of children in foster care:

  • Exposure to traumatic events such as being removed from their homes and the abuse or neglect that prompted removal
  • Shame and guilt related to blaming themselves for the removal
  • Their attachment style with their family members
  • Grief from multiple losses (home, school, friends, neighborhood)
  • A sense of constant chaos and a fear of what will happen next that is beyond their control

Children in foster care wonder if they will ever be safe, and if a child has experienced frequent foster home place disruptions, this fear only intensifies.

Birthparents’ worldviews begin with the helplessness and hopelessness that humans feel at losing their children. Grief and loss are compounded by judgment from family, friends, court personnel, therapists and case managers. The reason for removal, such as ongoing substance abuse, their own history of trauma or attachment issues, possible mental illness, poverty or a lack of educational opportunities, is further complicated when their family enters the child welfare system. Often viewed as resistant or unwilling to accept responsibility for their actions, these birthparents often feel alone and angry and use their energy to defend themselves against the onslaught of judgment.

Ironically, foster parents’ worldviews may also begin with helplessness. Although they receive training and support, sometimes it is not enough to counteract the effects of caring for a child in their home who is angry, traumatized, grieving and filled with anxiety. In fact, the experience of foster parents can be similar to that of the child’s birthparents in that they are quickly judged and required to abdicate control in their home to the child welfare rules and a series of child welfare workers. Foster parents are also asked to love a child and then let that child go, so they struggle with attachment, grief and loss issues on a constant basis.

Second turn: Counselor worldview

As counselors, what we see in others is often influenced by our own family histories, personal values and clinical experiences. These issues rise up early in the child welfare system, where counselors are often novice professionals just starting out, and they are given clients with chronic treatment issues who have often seen myriad other professionals.

Meanwhile, the pressure from the systems and individuals involved is often overwhelming. Counselors often feel responsible to “fix the kid” or “fix the family,” and this pressure can lead to countertransference, ethical violations and burnout. These children and families often exist in chaos, and counselors can easily be pulled into that chaos by a system that expects miracles but provides minimal support. The child welfare kaleidoscope can become a series of fast-approaching shapes, constantly spinning with what appears to be little direction, or it can become stuck, making it difficult to move or view another shape.

Counselors must always be on guard against the creeping sense of helplessness and the compassion fatigue that can occur when working with this population. Counselors must also combat the countertransference that can force the kaleidoscope to become stuck on one shape or color. Seeking qualified supervision with professionals who are experienced with this population can make a world of difference. Making self-care practices a necessity rather than a commodity will help protect counselors against compassion fatigue.

When working with this population, counselors can be pulled toward feeling pity or overwhelming sympathy for these clients. On the other side of the coin, they can find themselves judging or feeling angry with these clients, either for how the adults behave toward their children or how the children seem ungrateful toward the adults. These are all ineffective responses, both for the counselors and for their clients.

Using the metaphor of a bridge, remember that to stand in empathy is to stand on the rickety, scary bridge over raging waters to allow ourselves to feel what our clients feel. Either side of the bridge — pity or judgment — feels “safer,” but they both lead to ineffective therapy and further harm to the client. Closely evaluating your own personal values before beginning this work and knowing the child welfare laws in your state will provide necessary support to curate an empathic, realistic perspective on your cases.

Working with children in foster care also can be a minefield of ethical issues. Confidentiality can be complicated depending on the referral source and the child’s legal status. For example, the birthparent of a temporary ward of the court still possesses legal rights and must be consulted over treatment issues. At the same time, the child is placed in foster care, and foster parents need to be made aware of important issues that might impact the child in their home. The court might subpoena therapy files, and caseworkers also require treatment updates and recommendations. Each of these possible breaches is relevant to informed consent with this population.

The issue of mandated reporting can also become a prominent part of treatment. Children may disclose abuse in the birth home, foster home or both. Managing the ongoing relationships with birthparents and foster parents when required to report suspected abuse or neglect requires counselors to be honest, forthright and empathetic at all times.

Finally, facing clients with complicated trauma, grief and attachment histories can become demoralizing for counselors because they rarely see the type of progress that allows for professional satisfaction. The potential for experiencing vicarious or secondary trauma responses is also high. Counselors working with this population should engage emotional support from peers, supervisors and even their own counseling. These actions can help heal emotional wounds, keep the work in perspective and prevent the type of burnout that ends up hurting rather than helping clients and counselors alike.

Third turn: Assessment

Assessments with clients involved in child welfare must be understood as living documents of sorts. After all, anything captured at one particular time can be expected to shift because of the unstable nature of so much that influences the client’s life in profound ways. Counselors should obtain ongoing strategic updates on the child’s behavior, emotional status and the status of the relationship with the birthparent, then adjust goals accordingly. For example, try to find out when a placement transition or court-ordered change in permanency status takes place, when the client experiences an additional loss or traumatic exposure, or when the client newly acknowledges a past traumatic exposure.

Counter to the tendency of many counselors to see the concerns of each case first, this population greatly benefits from intentionally identifying their strengths during the assessment process. Children and adults who are involved in the child welfare system often possess amazing resilience, creative coping skills, abundant humor, deep love and extraordinary courage.

Beyond just accounting for strengths, effective assessment looks around the kaleidoscope, gaining information on all aspects of clients’ lives, not just the current presenting problem. Clients in the child welfare system often get viewed through one shape in the kaleidoscope — their behavior. As a result, trauma, grief and attachment concerns often get lost in the desire to stop the current behavior and the pressure felt to “fix the child” or “fix the parent.”

Assessment of the child begins by listening and watching: listening to a child’s stories, listening to the reports of both the foster parents and the birthparents, and watching how the child plays and interacts with you, other siblings and adults. Attachment style will be evident by whether the child seems angry or withdrawn from adults, or whether the child clings and appears fearful. The child’s response to trauma will be evident through sleeping patterns, the way the child eats and the level of fearfulness the child exhibits at home and at school. Educational information and potential medical concerns also may be highly relevant to interventions.

In addition, the amount and type of losses the child has endured and the child’s grieving process matter greatly. Taking session time to normalize the child’s reaction to removal from the home and any subsequent placements can have a significant impact on the child’s adjustment efforts. Finally, after examining and prioritizing behavior problems and building an understanding of what is driving them, work with the families to create a realistic and achievable plan that focuses on one or two concerns at a time. Using this approach, the counselor can keep the many parts of the client’s kaleidoscope in mind while knowing that trying to work on everything at once would be ineffective.

One common challenge in working with this population is the tendency to turn therapy into nonstop crisis intervention sessions, responding to the complaints of foster parents or case managers rather than holding steady to the set treatment plan. Although crisis management is necessary at times, learn to determine what is truly a crisis (e.g., suicidal ideations, homicidal ideations, an immediate risk of removal) and what qualifies as an ongoing complaint (e.g., trouble in school, acting out in the foster home). Holding focus on just two or three shapes at a time prevents therapy from turning into a nonstop process of confronting the child.

Fourth turn: Treatment

Beginning treatment for any primary concerns with this population must focus on giving the child and family space to feel safe and comfortable. For example, get on the child’s eye level, allow the child to move freely throughout the room, and be clear and open about what therapy is and is not. Because treatment is often specific to the needs of the child, be sure to research and seek training in specific interventions related to trauma, attachment, grief and loss, or behavior issues. The following brief case studies illustrate an intervention for each treatment issue listed above.

Trauma: A 15-year-old girl came into care for the second time in her life because of allegations of sexual abuse by multiple family members. She barely was eating or sleeping and kept her body and hair covered with multiple layers of clothing at all times. The counselor took time to connect with her in simple ways that she could handle — drawing, listening to a song she liked, smelling a favorite hand lotion, updating her on the status of her many siblings and naming how much had changed since she had come into care and how normal it would be to feel overwhelmed. Creating this routine of predictable, soothing interactions built a sense of psychological safety in the therapy space. From there, the counselor helped her learn how to lower her arousal enough to open up about her inner world. This allowed her to begin the long and life-changing intensive trauma treatment process that had previously been inaccessible to her.

Attachment: The counselor used a metal Slinky as a transitional object with a 7-year-old boy who refused to enter the counseling room. The counselor brought out the Slinky, and the boy played with it as he ran around the waiting room, not responding to verbal prompts or directions. When he stopped, he and the counselor would go and walk the Slinky up and down the stairs. After three sessions, the counselor stated that to play with the Slinky, the boy had to enter the counseling room. He was able to enter for a short time in the first week and stayed for the entire session from that point forward.

Grief and loss: An 11-year-old girl had witnessed her mother die of breast cancer in her home. The child had limited verbal skills and would draw pictures of herself jumping rope with her mother in the sky. Using her art, the counselor encouraged her to draw herself as she currently felt. She drew herself crying with her mother in the sky. As treatment progressed, she could draw herself smiling as she jumped rope, and this action was identified as showing her mother that she was coping. The counselor arranged to have the pictures sent to her mother in a balloon so that her mother could see she was starting to cope.

Behavior modification: A 10-year-old boy acted out constantly and did not respond to normal punishment. The counselor created a “caught being good” plan. The child received a star for every positive behavior and a check for every unwanted behavior. To earn his reinforcing reward — an allowance — he had to be good only one more time than he was bad. The counselor encouraged the foster parent to set the child up to win the reward, so he gained stars for stopping in the middle of acting out or for flushing the toilet. He received lots of verbal praise for the stars and no verbal response for the checks.

Fifth turn: Engaging adults

Perhaps the greatest challenge for counselors working with children in foster care is finding a way to also work with the myriad adults involved in the system. These adults include birthparents and any involved relatives, foster parents, caseworkers, casework supervisors, attorneys, educators and medical professionals, to name a few.

It’s easy to become stuck in silo thinking, focusing only on the therapeutic process in your sessions and becoming frustrated when others do not support or engage in the treatment. During this turn of the kaleidoscope, counselors can remember to picture the colors and shapes of all the other involved adults, including these adults’ own histories of trauma and their own feelings of helplessness and frustration. This will help counselors keep empathy at the forefront of all interactions, thereby avoiding blame and patterns of disempowering, ineffective interactions.

Reframe engagement as something the counselor is responsible for rather than it being the responsibility of the other adults in the child’s life. In other words, counselors need to take on the mindset that it’s our job to work with them, not their job to work with us. That way, if they don’t engage or respond to our efforts, it becomes our responsibility to try different engagement interventions. Trying different approaches might engage an adult who otherwise would not work with the counselor.

For example, focus on asking birthparents and foster parents for help with treatment. Identify the birthparent as the expert on her or his child. Even if you do not use the advice or data the parent gives you, the act of asking is often enough to engage the parent.

Another engagement technique involves remembering to praise something about the child and attribute the behavior to the parent. For example, “Your child has such good manners. It’s clear you spent time teaching him.”

Finally, remember to validate foster parents and birthparents whenever possible: “I wonder if you feel judged and belittled by having all these other adults tell you how to raise your child” or “People expect you to just deal with serious problems and don’t listen to your expertise.”

If collaboration with other professionals proves difficult, remember to empathize with their frustration over the many cases they have and the stress of their workload. Attempt to find compromises, such as shifting your schedule or using encrypted email to keep information flowing. Collaboration helps children in foster care in many ways. For example, it keeps these children from having to repeat stories over and over again. It also guards against having their needs fall through the cracks because everyone assumes that someone else is getting a task accomplished. Collaboration also sends a message to these children that they matter and that the adults in charge of their lives are making decisions together.

Final turn: Self-care

We already touched on this topic under the “counselor’s worldview,” but it bears repeating. Self-care cannot be viewed as a luxury when working with this population. It is a necessary set of supports and adaptive coping skills. Self-care is subjective, not prescriptive, so it should involve whatever works for the counselor.

At bare minimum, counselors should seek peer and professional supervision with others who have experience working within child welfare so that counselors can both vent and get validated. Remember that by nature, these cases are heavy with deep psychological wounding that will bring out countertransference one way or another. Building awareness and tending to your own reactions rather than trying to fight or minimize them will only make you a better counselor and person.

Professional development support, training and consultation around specific troubling cases or treatment concerns, such as sexual abuse reenactment, severe posttraumatic stress disorder or deep attachment insecurities, can make a significant difference in supporting feelings of competency and utilizing best practices for the challenges these cases will present. Give yourself permission to notice any signs of depression, anxiety, grief and secondary or vicarious trauma in yourself, and then seek professional support.

It’s also important and helpful to remember that working with clients with complicated trauma and attachment histories can become disheartening because the counselor rarely sees the type of progress that allows for professional satisfaction. Find ways to keep the work in perspective and balance work-life demands. Take time to seek joy and pleasure in life to prevent the type of burnout that ends up hurting rather than helping clients.

 

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

Sheri Pickover, a licensed professional counselor, is an associate professor and director of the counseling clinic in the University of Detroit Mercy’s counseling program. She has been a counselor educator for 13 years and worked in the child welfare system for 20 years as a therapist, case manager, foster home licenser and clinical supervisor. She currently teaches courses in trauma, human development, assessment and practicum. Contact her at pickovsa@udmercy.edu or childwelfaretherapy.net.

Heather Brown is a licensed professional counselor and art therapist in private practice in Detroit. She has more than 15 years of experience working with youth (both in and adopted out of the child welfare system), parents and professionals as a program developer, therapist, trainer and supervisor. Contact her at BrownCounselingLLC@gmail.com or BrownCounseling.com.

Letters to the editor: ct@counseling.org

 

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