Tag Archives: trauma

Generational trauma: Uncovering and interrupting the cycle

By Bethany Bray January 25, 2023

A young Black child sitting on a couch with her mother and father. The mother has her arm on the child's shoulder. A person sit across from them taking notes.

Prostock-studio/Shutterstock.com

Ashlei Petion, a licensed professional counselor (LPC) and assistant professor of clinical mental health counseling at Nova Southeastern University in Florida, noticed a common pattern in the counseling work she did with adolescents during her master’s internship. Her young clients would often talk in sessions about challenges and friction at home, but whenever Petion looped the clients’ parents into the discussion, they said they were simply parenting their child in the same ways their own parents had done with them.

Petion said she heard this over and over, and it made her realize that the challenges that her adolescent clients were facing were “bigger than the client who was sitting in front of me,” she says. “It’s part of their entire family and, in turn, their culture.”

This experience as a master’s intern sparked Petion’s interest in researching generational trauma, which eventually led to her doctoral dissertation and area of specialty as a counselor.

Generational trauma is complex, but counselors must remember that it doesn’t mean that there is “something inherently wrong with an individual [client],” Petion stresses. “It’s a collection of traumas that have been experienced by their ancestors, passed down, and it’s affecting them to this day. They are battling something bigger than them[selves].”

Taking a broader view of trauma

A common — and perhaps deserved — critique of the definition of trauma traditionally held by mental health practitioners and the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) is that it is too narrow and doesn’t acknowledge the many different types of trauma, says Rachael Goodman, an LPC and associate professor at George Mason University whose area of specialty is trauma.

Counselors and society at large, including clients, may conceptualize trauma as the result of a single event or events that an individual has experienced personally. Trauma, however, can take many forms; it can be ongoing, vicarious, complex, generational and systemic, notes Goodman, the academic program co-coordinator and the Council for Accreditation of Counseling and Related Educational Programs (CACREP) liaison for the counseling program at George Mason University.

Because of this narrow definition, other types of trauma, including generational trauma, can be overlooked and outside the awareness of both clients and counselors, especially during the client assessment, diagnosis and treatment planning process, Goodman says. Also complicating the issue is the disparity that exists for clients from minoritized cultures, who are more likely to experience generational trauma based on systemic oppression and related issues, she adds.

For some clients and counselors, societal oppression and historical/cultural erasure may keep them from linking presenting issues, such as trouble in relationships or problematic coping, to challenges or trauma that clients haven’t experienced themselves, but which affects their family and community, Goodman notes. Counselors’ role “is to bring that [trauma] into consciousness and work with the client to address it,” she says. “It can be very powerful for the client to have their experience acknowledged and framed as a ‘legitimate’ source of trauma, when often systemic or ‘nontraditional’ forms of trauma are ignored or excluded from mainstream assessment and practice.”

“Clients often report that it feels like [a weight] sitting on their shoulders,” Petion agrees, “and they feel like they need to interrupt this and not pass it on.”

Like Goodman, Petion feels there is sometimes a knowledge gap among counselors regarding generational trauma. There’s just no way a counseling program can cover everything fully, including the complexities of trauma, in a two-year master’s program, she says. In addition, many of the textbooks and materials counselor education programs use to teach students about trauma have a Western viewpoint and do not cover historical and generational trauma, she adds.

This means that it’s essential for counselors to seek out additional training and information on generational trauma and best practices for treating it if it’s coming up within their client population, stresses Petion, a member of the American Counseling Association and co-author of the recent Journal of Counseling & Development article, “‘Battling something bigger than me’: A phenomenological investigation of generational trauma in African American women.”

Petion admits that it can be hard for those who haven’t experienced generational trauma to grasp just how challenging it can be to live with — or overcome — this type of trauma. “Changing just ourselves [in counseling] is really difficult, but then adding in other people and your whole family — it’s really difficult to ignite change,” she says, “but we know it’s possible.”

Identifying generational trauma

The first step to identify generational trauma is to ask the client to talk about their family history, including their relationship dynamics and how their family interacts with each other and the world around them, says Jordan Mike, an urgent care counselor at the counseling center at Vanderbilt University who is working on earning a professional counselor license in Tennessee. However, the most important thing a counselor can do during this process is to simply sit with and support them and “truly listen” as the client tells their story, he notes.

Generational trauma is an area of research for Mike, a third-year doctoral candidate in counselor education and supervision at the University of Florida, but it’s also something he personally witnessed growing up as a Black man. He says he also sees its effects in the concerns of the students, faculty and staff he counsels at Vanderbilt.

It can be an aha moment when a client realizes that an issue they are struggling with is actually something all of their family has suffered with as well, Mike says. And now as counseling becomes more available and accepted, he hears more clients are saying, “Hey, this is not a ‘me’ issue; it’s something that has been trending in my family for decades and hasn’t been addressed or helped.”

Clients who are affected by generational trauma may exhibit some of the same behaviors and symptoms as people who have experienced a traumatic event directly, including strong emotions such as anger, sadness or anxiety, notes Mike, an ACA member. Fear, including irrational fears, and distrust are common emotions among clients who are affected by generational trauma, he notes, particularly intense fear, anxiety, avoidance or distrust of places, communities, situations or systems that they’ve never experienced or have been to or through themselves.

The crux is to uncover where these feelings originate; if it’s something that they’ve internalized from their family or community, then it can indicate they have generational trauma that needs to be addressed, Mike says. For example, a client who expresses fear or distrust of law enforcement or medical care may not have a personal experience that prompts that fear. When asked where they think the fear originates, they may answer, “I’m not sure but this is what I’ve always heard; this is what my parents say and my community says,” he explains.

Desiree Guyton, an LPC with a private practice in New Jersey, says that generational trauma can also cause clients to harbor feelings of shame and negative self-worth. She guides these clients to talk about their family of origin, and where their feelings of shame might have originated. Clients who are affected by generational trauma often find that they stem from cultural messages they have internalized, Guyton says.

Generational trauma can also become apparent if a client talks about what isn’t addressed, acknowledged, processed or talked about in their family, culture or community, Mike adds. Cultures of silence are often adopted as a protective or coping measure, he says, but this can also mean that “there are so many things that can go untalked about, unsolved and unresolved.”

Because this trauma often goes unacknowledged, coupled with the fact that clients may struggle to pinpoint or name their generational trauma, Mike finds that it can be helpful to prompt clients to think of major events in their family or community, including things that were “hard to get through,” such as violence or loss, in addition to asking about family dynamics. He often asks clients, “What are some things that you have come together for as a community or family?” or “What is something that left a lasting impression?”

The counselors interviewed for this article agree that delving into a client’s family dynamics and history, including the use of timeline exploration activities and genograms, is helpful to uncover and distinguish clients’ generational trauma from other trauma experiences or mental health challenges.

Goodman developed a genogram tool that counselors can use to screen for intergenerational trauma in clients, which she wrote about in an article published in Counselling Psychology Quarterly in 2013. It can be particularly helpful for clients to write out aspects of their history or express them visually (e.g., making a collage out of images) to help them “get it out of their head,” look at it, and find patterns of trauma as well as resilience and persistence, she says.

Go slow

Guyton and Goodman both stress that counseling work with clients who have been affected by generational trauma needs to be client led and only go as far and as deep as the client is comfortable.

“Give the client time to build trust with you. They may not be willing to share and talk about [this topic] right off the bat. They may need you to demonstrate that you are someone who can be trusted, someone who will believe them,” says Goodman, an ACA member and representative on the ACA Governing Council.

Goodman notes that some clients may want to do a deep dive into processing the historical origins of their trauma while others may simply want to acknowledge it and focus on other work, such as learning coping tools for everyday life. For some, healing and meaning making can also involve engaging in social action, supporting their own family members or embracing a helping role within their community, she adds.

“The goal is for our clients to be able to live the life they want to live,” Goodman continues. “It’s not up to me to tell them they have to revisit their entire family history. … I’m interested in finding out what ‘living a meaningful life’ means for each client and helping them get there.”

Similarly, Guyton, an ACA member and co-author of the workbook Healing the Wounds of Generational Trauma: The Black and White American Experience, has had clients who traveled to speak with extended family members to learn more about the trauma, context and life stories of their ancestors, whereas others are not comfortable doing so. She herself has found it healing to trace her own family history to its enslavement and connection to the descent of slave owners.

Counselors must also be sensitive to the ways generational trauma can dovetail with systemic issues such as racial trauma and oppression. For example, a counselor can help a Black client who is activated by news coverage, such as when George Floyd was killed by police in Minneapolis in May 2020, to process how they feel — including grief and loss — and how it connects to their trauma history, Guyton says.

“Not all grief is traumatic, but all trauma has some feelings of loss,” she adds.

Guyton, who also leads groups and does trainings on racial conflict, trauma and healing through the nonprofit Quest Trauma Healing Institute in partnership with Trauma Healing Institute, advises counselors to listen when clients talk about their family unit or abuse history “because for people of color there is often more to it,” she says. “There is usually a connection to what it is to be an American and how they feel as an American.” Also, the field of epigenetics, she adds, teaches us that the historical trauma reactions can be passed down to next generations.

Counselors may also need to work on multiple challenges with these clients at once, Guyton says. “For those whose [generational trauma] comes out in session, we need to take it very slow, because often they are struggling with another presenting issue or other trauma. Once it surfaces, I focus on it as much as the client leads and wait until they’re ready to process it. I want to also be sensitive to the other types of trauma” they’re dealing with, she explains.

Both/and approach

Guyton has developed an approach that uses a combination of cognitive behavior therapy, narrative therapy, genogram and some guided imagery work to help clients identify the generational trauma being passed down to them and gain the skills to interrupt transmission to the next generation. She also starts by offering psychoeducation on trauma (and generational trauma) and asks questions about how and where the client may be experiencing the effects of trauma physically in their body.

Goodman agrees that counselors may need to vary their counseling approaches to address the interrelated concerns and challenges these clients are facing. She encourages counselors to take a “both/and” approach to address clients’ immediate needs (i.e., coping mechanisms to calm down when activated or social services to address stressors of daily living) as well as deeper work to address their trauma from a culturally sensitive, intersectional perspective.

“There are a lot of different ways of approaching this, but I tend to believe that ‘one size fits all’ is not going to do it,” says Goodman, a past president of Counselors for Social Justice, an ACA division. “Instead, [counselors should] think broadly of a both/and intersectional model that addresses the underlying and systemic causes of trauma.”

Goodman has past experience doing community engagement and support work on a Native American reservation. Some parents that she worked with often expressed feeling like they did not have enough tools or knowledge on how to parent, which placed stress and strain on family relationships, she recalls. Some of these parents had been removed from their family home as children and sent to boarding schools where they experienced trauma, so they never had the experience of growing up in a supportive, loving family. The situation left many of the parents with intense feelings of shame, fear and generational trauma, Goodman says.

In turn, these parents and their children were living with generational trauma as they struggled to maintain family bonds, she adds.

She found that these parents wanted to learn parenting skills in counseling to meet their immediate needs and support their children, but they also needed deeper work to process the trauma of their experience at boarding school, where they weren’t allowed to speak their native language or wear their native dress and, in some cases, suffered abuse.

In addition to cultural sensitivity, Goodman urges counselors to keep a focus on hope with clients who are living with generational trauma. At intake, explore not only their trauma history and challenges but also their strengths, resources and things that give them hope, she advises.

“Hope and having connection [in relationships] is so important” for these clients, Goodman stresses. “These problems are huge and have huge impacts, so helping our clients persist in spite of these barriers is really important.”

Supporting clients

Counseling to help clients acknowledge and unpack their generational trauma must be culturally sensitive and tailored to each client’s different combination of needs. The counselors interviewed for this article offer the following insights to support clients in this process.

The miracle question. Mike finds that it can be helpful to start discussions by prompting clients to consider the “miracle question” and imagine or visualize a world where their challenge or problem (in this case, generational trauma) is completely removed. He suggests asking the client, “What would it be like if you didn’t hold on to these feelings, or this pressure wasn’t there?” to spark thought and discussion about the big picture and larger issues connected to their challenges.

A client, for example, may be the first person in their family to attend college and feel intense pressure about choosing the “right” major. Mike says he would support the client in their decision-making process and help them gain perspective and clarity by asking, “What would be different for you if everyone in your family had gone to college or if there was no pressure and you could do whatever you want?”

“This [miracle question] gives them permission to not have to consider all the things that weigh on them, for once,” he explains.

Communication and boundary setting. Petion led a support group for Black women who had experienced generational trauma as part of the research for her doctoral dissertation. One of the things the group members found helpful, she recalls, was building communication and boundary-setting skills that they could use with their family members. The group talked a lot about how to remain calm, manage their body language and keep a problem-solving (rather than blaming) focus when having “brave dialogues” with family members about behaviors and patterns that had been adopted because of generational trauma, she says.

Petion also equipped them with ways to use “I” statements to voice their feelings. Instead of saying, “You really hurt me when you did this” to a family member, a client could say “I was really hurt when you did this” or “I felt this way,” she says. The purpose of shifting from “you” language to “I” language is to minimize or eliminate feelings the other person may have of being attacked or blamed, Petion explains. “I statements help us to take accountability for our own actions and feelings, speaking for ourselves instead of projecting onto the other person,” she says.

One group member grew up with a mother who didn’t believe children should express their feelings, Petion recalls. Having her feelings dismissed throughout her entire childhood was chronically traumatic for her. In group, this participant was able to practice having an assertive yet productive conversation with her mother to explain that she was using a different method to parent her own child because she had been hurt by her mother’s approach during her childhood, Petion says.

Guided imagery techniques. When a client is processing their generational trauma, guided imagery, including the “empty chair” technique from the Gestalt method, can be a way to ask questions and speak to family members or ancestors who are no longer alive, Guyton says. This technique was beneficial for one of Guyton’s clients who described “harsh” treatment by her grandmother growing up, and now as an adult, she was struggling with feelings of shame and negative self-worth, poor choices of intimate male partners and parenting stressors. This client’s desire not to pass on her trauma reactions to her children, as well as her anxiety about being poor and abusive, is what led her to seek counseling, Guyton adds.

When the client began to explore her family history, including the pressures her grandmother faced as she emigrated from her Caribbean homeland to the United States, she realized “I need to talk to her,” Guyton recalls. (The client had recently traveled to her grandmother’s home island and spoken to extended relatives to learn more about her grandmother’s life story and context.)

Guyton used guided imagery with this client and began by asking her to picture her grandmother and describe what she was seeing. Guyton then prompted the client to talk to her grandmother and share how she was feeling. The client responded by saying, “I see you, Grandma. I see you in this context. I’m understanding more now, and I wonder what it was like for you to raise all of us through poverty, sexism, racism and physical abuse. I want to know what it was like.”

These types of conversations can help a client process their connections to trauma and find closure. For this client, “being able to close her eyes, breathe, remember and picture her [grandmother] in a different way” and think of her difficulties in context moved her toward forgiveness and healing, Guyton says.

Case management. Counselors sometimes shy away from conversations or tasks that feel like case management, such as helping a client enroll their child in school or navigate the bus system to commute to work, Goodman notes. However, this type of support can be particularly helpful and needed by clients who are affected by generational trauma, especially those with refugee or immigrant experiences, she says.

“You may get pushback from a supervisor because it’s outside of counseling,” Goodman says, “but what I’ve found is that these experiences are really important.”

Do your own work. Processing a clients’ generational trauma in counseling involves inviting them to talk about their experience, but the onus should never be on the client to teach the counselor about their culture and history, Goodman stresses. It’s vital for counselors to seek out consultation with peers or do research on best practices to treat a client who comes from a specific community or cultural group, she says. There are treatment methods that are tailored to meet the specific needs and trauma experiences of different cultures and that use culture-centered, decolonial and liberatory approaches, she notes. Counselors just need to seek them out.

Similarly, practitioners must do their own work to become comfortable broaching the subject and discussing cultural issues and generational trauma with clients who come from different — and possibly less privileged — backgrounds than their own, Goodman continues. She encourages counselors to gently name any differences that exist in the counseling room, using questions such as “When counselors and clients are different in their identities, it can be helpful to name that and to think through how we might work together. Since we have some differences in our identities, what challenges might we have in working together?”

Goodman urges counselors to broach this subject not only at the start of counseling work with a client but also with regular check-ins throughout the relationship. “We [counselors] each have to figure out for ourselves language that is genuine for us” to foster these conversations, she says. And counselors need to “be willing to say, ‘I’m hearing some hesitancy, and I wonder if you have any concerns about talking to me about this.’”

Don’t make assumptions. Counselors should be listening for the signs of generational trauma in each client, regardless of their cultural background, Petion adds. “Privileged groups can still have generational trauma, even though it’s not talked about as much,” she says. “Anyone who has experienced trauma can pass it down. … Don’t make assumptions. This affects us all in some way, shape or form.”

Healing in connection

In her book All About Love: New Visions, the late bell hooks wrote, “Rarely, if ever, are any of us healed in isolation. Healing is an act of communion.”

Petion says she shares this quote often when talking about generational trauma with clients and colleagues. The truth is that clients do not live in a vacuum; they can work toward healing individually in counseling but will ultimately return to live within their culture and family system, she notes.

“Generational trauma is just that — an individual whose trauma is perpetuated within family and culture,” Petion adds. So, with this client population, practitioners must “think beyond the individual sitting in front of us” in counseling, she stresses, and focus on how they are healing in connection to their family and community. “That’s really where we interrupt the transmission of trauma,” she says.

At the same time, counselors should remember that it may not be the client’s role to “fix” or heal their family or community, Mike cautions. “They may need to make peace with healing themselves without taking on entire systems,” he says.

Generational trauma “can be a biological thing, an emotional thing, a social thing. … Trauma changes our chemistry; it can change how we interact with other people, … who we are and even our gene expressions,” Petion says. But “counseling offers the space to relearn that [and] a space where clients are heard and validated.”

Bethany Bray is a former senior writer and social media coordinator for Counseling Today.

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.

Regulating the autonomic nervous system via sensory stimulation

By Samantha A. Hindman July 6, 2022

It is estimated that around 70% of the global population has been exposed to a traumatic event at some point during their lifetime. This is a staggering approximation when we consider that beginning counselors are often woefully unprepared to support clients from a trauma-informed perspective. Although the annual rates of diagnosable posttraumatic stress disorder (PTSD) are comparably low, symptoms such as hyperarousal, a frequently negative emotional state, and negative mood alterations can be far more common than clinicians may recognize when initially assessing clients.

A significant number of my very first clients were survivors of trauma or clients who had moderate to severe symptom presentations, which is not uncommon for a community mental health agency. As I waded my way through the tide of intakes and assessments and diagnoses as a green counselor, I naturally defaulted to a top-down approach to treatment. I confidently stepped into the field thinking that if I focused on coping skills, faulty thinking patterns and behavior modification, then I would help clients get to a place where they could choose to embrace a new way of living.

This was occasionally reinforced, but for maybe about 10% of my caseload. Regularly, clients would say that the skills didn’t work. They couldn’t find the words to journal or untwist their thoughts. Going on a walk only made them think about their distress more. Squeezing a stress ball when they were angry was fine, but it didn’t really do much to change their emotional state. In some cases, they couldn’t even remember that the skills existed until far after their distress had passed.

What I began to see was that most clients had significant difficulty getting to a place where their logical brain could be accessed. Clearly, there was something else going on. The more I explored different approaches for answers as to why these skills weren’t working, the more I realized that this top-down approach wasn’t meeting my clients where they had control.

Ignoring the body experience and the nervous system were almost certainly the barriers I had inadvertently fortified for these initial clients. What if regulating the nervous system could help clients quickly regain control and resolve distress? The possibilities were endless.

The autonomic nervous system

The autonomic nervous system (ANS) consists of two main processes: the sympathetic nervous system (SNS) and the parasympathetic nervous system (PNS). These processes typically work in tandem, cyclically activating the SNS and the PNS as the usual up and down experiences of life occur.

The SNS is the mobilization system often referred to as the fight-or-flight response. Activation of the SNS in the wake of perceived danger typically results in an increased heart rate, increased blood flow, increased body temperature and increased respiration rate. The PNS is the homeostasis system often referred to as the rest-and-digest response.

When stressors occur and danger is sensed, the body automatically moves from the rest-and-digest state into the fight-or-flight response of the SNS. Once the threat passes, the PNS will reengage, but it can be helped along by distraction and self-soothing, such as grounding or sensory techniques.

Grounding techniques include activities such as:

Cuddling a soft blanket, stuffed toy or piece of fabric
Rubbing fingers across a textured surface
Using a weighted blanket
Drinking a warm or cold beverage
Mindfully eating an orange
Experiencing soothing or relaxation-inducing smells
Listening to enjoyable music
Looking around and naming all of the items of a specific color that are in the vicinity
Looking at a picture of someone or something that is important to you
Accessing religious/spiritual tokens
Accessing other items of sentimental value

Polyvagal theory and somatic experiencing

Considering that approximately 70% of the global population has experienced a traumatic event during their lifetime, difficulty regulating the nervous system would appear to be more common than we may have realized. Furthermore, what do we do when the typical grounding techniques fall short of said regulation?

Stephen Porges, the researcher who posited polyvagal theory, suggested that the vagus cranial nerve plays a significant role in how information is communicated to the systems of the ANS. Rather than having two systems, Porges indicated that the ANS actually involves a three-system hierarchy that divides the PNS into two branches: the ventral vagus complex responsible for sensing safety and social connectedness, and the dorsal vagus complex responsible for sensing danger.

Activation of the PNS typically results in decreased heart rate, increase in digestive function, decreased muscle tension, regulated body temperature and regulated rate of respiration. However, perception of extreme danger may further immobilize an individual beyond the rest-and-digest response to experience what is known as the freeze-or-collapse response.

Peter Levine conceptualized in his book Waking the Tiger: Healing Trauma that individuals who do not perceive having access to safety during hyperarousal will shut down, their SNS seemingly suspended in time as the dorsal branch of the PNS takes over. Levine indicated that individuals could wake from this freeze response by bringing mindful awareness to the bodily experience, thus bridging compartmentalized aspects of previous trauma stored in the body. This would allow individuals to detach from trauma reminders and move that suspended energy from one system to another.

Sensory integration

The 1960s work of A. Jean Ayres with sensory processing issues theorized that such impairment would result in various functional problems. This theory was expanded by later researchers and referred to as sensory integration theory. Sensory integration theory refers to the processes of the brain that regulate the impact of sensory experiences on motor, behavior, emotion and attention responses. The research of Stacey Reynolds and colleagues published in The American Journal of Occupational Therapy in 2015 postulated that delivering alerting or calming sensations to an individual could change the function of the ANS. They hypothesized that sensations that were alerting would increase SNS activity, whereas activities that were considered calming would activate the PNS.

Although these theories have largely been applied to sensory disorders and trauma responses, it is reasonable to believe that even for individuals experiencing chronic stress or intense symptoms of anxiety and depression, engagement in sensations recognized as alerting would serve to arouse the SNS and decrease the activity of the dorsal vagus complex of the PNS, effectively rousing the individual from immobility or dissociation. Once the stressor passed and the individual recognized that they did have access to safety, they would have the ability to move from SNS activation to the social engagement state of the PNS.

Building a sensory kit

By incorporating the ideas of polyvagal theory and sensory integration theory, we can surmise that the use of intense sensory experiences could wake an individual from immobility and reset the suspension of energy being held by the ANS.

The old frozen orange trick is an excellent example of this sensory distraction skill in action. The idea is that the cold temperature of the orange will cause an immediate distraction, thus slowing down the release of cortisol and adrenaline and releasing endorphins that help the body cope with the sensation of pain. Unfortunately, most of us don’t have access to a frozen orange in the middle of a stressful meeting, at the courthouse or while driving on the highway, which happened to be some of the exact moments when clients I was working with mentioned needing such an intervention.

In search of an accessible way to actively distract clients from the overwhelming physiological and emotional shutdown, I considered how sensory tools might look if they were portable. After all, having immediate and reliable access to these alerting sensory tools when the PNS dorsal vagus complex response is engaged is key to habituating the idea that we can be in control of regulating our own ANS.

carole smile/Unsplash.com

I started making small to-go bags for my clients to take with them, which I now refer to as a trigger kit. The bags contained sour candy, a raw crystal that was jagged to the touch, and a sample of peppermint essential oil.

You might be wondering why those things? Although we do have five external senses (i.e., sight, smell, taste, touch, hear), building a kit that effectively arouses the SNS involves selecting accessible tools that quickly and powerfully activate taste, touch and smell. Intensely distracting sounds or sights are likely to intensify dysregulation and are not advised, but of course, the kit is completely customizable. Whatever works for the client, works for the client!

I introduced the kit by providing psychoeducation about the ANS. I would have clients experiment with the sensations during session so they could have a reasonable expectation of what they were trying to replicate on their own. Maintaining a small sensory kit that can be easily transferred between locations — in a purse, in a jacket pocket or in a backpack — allows for immediate access as needed. I initially used small sandwich bags but have since moved on to small drawstring bags that can both conceal and contain the items. My clients have consistently cited the trigger kit as one of the most effective grounding tools they have attempted to use in the midst of distress.

TLDR

Grounding techniques are commonly used to create a mindful awareness of the present moment and can be quite effective for bringing the client back to their body. However, when clients experience intense dysregulation, it is likely that typical grounding techniques will not be enough to pull an individual from hyperarousal or immobility. A more intense grounding experience, such as a powerful, portable sensory experience, may be useful. Empowering individuals with psychoeducation surrounding the functions of the ANS and the use of a trigger kit can assist clients who might benefit from regulating from the bottom-up.

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Samantha A. Hindman is a licensed mental health counselor, national certified counselor and certified clinical mental health counselor. She is an educator for the Community Care program for AdventHealth in the central Florida region. She has experience working as a trauma therapist for a community domestic and sexual violence agency and is a therapist in private practice. Samantha has taught mental health courses at the graduate level and enjoys providing in-person and virtual trainings on research methodology, program evaluation, basic and advanced counseling skills, neurobiology, and therapeutic considerations for working with survivors of trauma. She is currently in the dissertation phase of her Ph.D. journey in a counselor education and supervision program. Contact her through her LinkedIn page at linkedin.com/in/samanthahindman.

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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.

Journeying through betrayal trauma

By Allan J. Katz and Michele Saffier June 6, 2022

Tero Vesalainen/Shutterstock.com

“Cathy’s” life has just been turned upside down. She picked up her husband’s cellphone only to discover a loving message from his affair partner. Cathy’s brain is spinning, and her emotions are all over the map. She feels embarrassed and alone, disconnected and detached from reality. She questions whether her entire relationship has been an enormous lie. She questions her attractiveness, her sexuality and her ability to ever trust anyone again. She feels as if she were just pushed out of an airplane and fell with no parachute.

As a certified sex addiction therapist and a member of the American Counseling Association, I (Allan) have seen firsthand that betrayal trauma is real. The shock is debilitating for betrayed partners and can last for years. Their lives are broken to pieces, and they are overwhelmed with shame, often thinking, “How could I be so stupid not to realize what was happening right under my nose? I’m such a fool for trusting him/her.” They feel they are going crazy.

But these feelings are all normal because in all likelihood, this is the most shocking and confounding crisis they have ever experienced. After all, they thought they knew their partner and never thought their partner would cheat. The reality of the situation rocks the foundational values they have believed in and based their lives on. What is perhaps most disturbing is that they were going about their daily routine in the safety of their own home, and, in an instant, a discovery upends their world. It happens through answering a knock at the door, reading a random text, picking up a ringing telephone or — the most common form of discovery — turning on the computer to check email.

The shock for the betrayed partner is so profound in the first moment, the first hour and the first day that it is hard to comprehend. It feels surreal, as if it can’t be happening. It feels as if you are suddenly outside of yourself watching a movie, seeing yourself react and not feeling connected to your own body.

International trauma expert Peter Levine explains that when we are confronted by a situation that our brain experiences as frightening, we automatically go into a freeze response. We are thrust into a primal survival strategy commonly referred to as being “like a deer in headlights.” It is the state of being “beside yourself.” Betrayed partners describe it as being frozen, numb or in an altered state. Being lied to in such a profound manner by your partner, lover, sweetheart and beloved feels wholly abnormal. For many betrayed partners, there is no precedent for the experience.

Answering the ‘why’ question

The “why” question is what betrayed partners find themselves coming back to over and over again. Why did you engage in this behavior? Why did you lie … repeatedly?

Betrayed partners often feel that they can’t move on and find closure without knowing the answer to the “why” question. The painful truth is that there is no good reason and, for the betrayed partner, no right answer. The “explanation” can be challenging for betrayed partners to hear and can take time to process fully. Although they may not understand the “why” behind the behavior, betrayed partners can gain answers that help provide clarity and make healing possible for them and the relationship.

“Daphne,” a heartbroken partner, described her “why” questions as follows: “What were you thinking? Was I the only one longing to share my life with you? What makes you think you can take a stripper and her child to Disneyland, tell me and then expect me to stand for it? How could you use my faith and religion against me by saying, ‘Aren’t you supposed to forgive? Judge not lest you be judged,’ and, most offensive, ‘I think you were put on this earth to save me.’ Why did you even marry me? Why did you stay married to me? What does love mean to you? You obviously have no heart. How could you look me in the eyes and see how much pain I was in and how unloved I felt and continue giving our money to your girlfriend? Why did you promise me that you would never cheat on me as my father did to my mother? How can you say, ‘It’s not about you’? You admitted to me that you never considered my feelings. Why? You acknowledged that you lied to your family about me, portraying me as a horrible spouse so that you would feel justified to continue your affair. Why did you need to go that far?”

These are the types of questions that every betrayed partner asks. Betrayed partners believe that they cannot heal unless they know why their beloved cheated on them. But in the case of chronic betrayers, their reasons lie deep below the surface, much like the iceberg that sank the Titanic. The question becomes, “Why would someone who appears to be functioning well act against their morals and values?” Are these folks actually addicted to sex, or is sex addiction an excuse for bad behavior?

In her “What Your Therapist Really Thinks” column for New York magazine on May 11, 2017, Lori Gottlieb responded to a letter from a reader wondering whether their husband might be having an affair. Gottlieb mentioned that whenever someone comes into her office to discuss infidelity, she wonders what other infidelities might be going on — not necessarily other affairs but the more subtle ways that partners can stray that also threaten a marriage.

In his book Contrary to Love, Patrick Carnes said his research indicated that 97% of individuals who were addicted to sex had been emotionally abused as children. These individuals were raised in unhealthy or dysfunctional homes with parents who did not give them the care essential to their healthy growth and development. Poverty, mental illness, alcoholism, drug addiction, violence and crime are among the many reasons that individuals turn to sexually compulsive behavior as adults. As a result, people who are sexually addicted have negative core beliefs about themselves. They feel alone and afraid and believe they are unworthy of love; they believe that no one can truly love them because they are unlovable. Therefore, they learn from a very young age that intimacy is dangerous in real life and that they can trust themselves only to meet their needs.

In an article titled “Can serial cheaters change?” at PsychCentral.com, psychologist and certified sex addiction therapist Linda Hatch discussed two reasons that people cheat, both due to deep insecurities. Some who cheat feel intimidated by their spouse in the same way that they felt threatened in their childhood homes. A real-life connection is terrifying to someone who was not shown love as a child. In response, they seek affair partners, watch pornography or pay for sex to avoid these real-life connections.

Carnes’ second book, Don’t Call It Love, is aptly titled. Acting out is not about love or sex; instead, acting out numbs the overwhelming agony of being loved by a real-life partner.

The root of addiction and the brain science

At the root of addiction is trauma. Trauma is the problem, and for some, sexual acting out is the solution — until the solution fails. And when it fails, it results in more trauma.

Deep wounds suffered when young cause a level of pain that overwhelms the child. Because human beings are built to stay alive, the brain banishes the ordeal’s worst feelings and memory. It locks them away to keep the child alive.

Understanding the brain science of trauma and addiction enables the betrayed partner to see the big picture. The acting out had very little to do with the relationship or the partner.

Many mental health professionals do not believe that sex addiction is a legitimate disorder. Therapists often think that the betrayed partner is the problem because they’re “not enough” — not attentive enough, not available enough, not sexual enough, not thin enough, not voluptuous enough. Sex therapists (not to be confused with sex addiction therapists) believe that sexual expression is healthy — regardless of the behavior. Understanding the science that drives the addictive process is vital for the betrayed partner’s wellness, lest they take responsibility for their betrayer’s acting out. Knowing the brain science that causes a process addiction is essential to understanding how something that isn’t a chemical substance can be addictive.

In his book In the Realm of Hungry Ghosts: Close Encounters With Addiction, Dr. Gabor Maté described childhood adversity and addiction, noting that early experiences play a crucial role in shaping perceptions of the world and others. A 1998 article by Vincent J. Felitti and colleagues in the American Journal of Preventive Medicine explained that “adverse childhood experiences, or ACEs (e.g., a child being abused, violence in the family, a jailed parent, extreme stress of poverty, a rancorous divorce, an addicted parent, etc.), have a significant impact on how people live their lives and their risk of addiction and mental and physical illnesses.”

There are two types of addictions: substance and process (or behavioral) addictions. Process addictions refer to a maladaptive relationship with an activity, sensation or behavior that the person continues despite the negative impact on the person’s ability to maintain mental health and function at work, at home and in the community. Surprisingly, an otherwise pleasurable experience can become compulsive. When used to escape stress, it becomes a way of coping that never fails. Typical behaviors include gambling, spending, pornography, masturbation, sex, gaming, binge-watching television, and other high-risk experiences.

Process addictions increase dopamine. Dopamine is a naturally occurring and powerful pleasure-seeking chemical in the brain. When activities are used habitually to escape pain, more dopamine is released in the brain. The brain rapidly adjusts to a higher level of dopamine. The “user” quickly finds themselves on a hamster wheel, seeking more exciting, more dangerous, more erotic or more taboo material to maintain the dopamine rush. The brain has adapted to the “new normal.” The brain depends on a higher level of dopamine to regulate the central nervous system. It quickly becomes the only way to reduce stressors; the person struggling with addiction ends up doing and saying things they will soon regret but cannot seem to stop on their own. Carnes aptly refers to this as the hijacked brain.

Once the brain is hijacked, the downward spiral of craving more and more dopamine affects higher-level thinking and reasoning.

Let the healing begin

Healing for the betrayed partner begins with a formal disclosure process, ideally guided by certified sex addiction therapists. Betrayed partners often have difficulty making sense of their reality on their own. There are so many unanswered questions, and each question has 10 questions behind it.

Betrayers are reluctant to answer questions because they fear the answers will cause the betrayed partner more harm and therefore will cause them harm. However, withholding information is what causes harm. Betrayed partners report difficulty getting the whole truth on their own. Even if their betrayer does break down and answer questions, they will not get the entire story because the betrayer is in denial — they are in denial that they are in denial!

A formal disclosure process led by a certified sex addiction therapist is the best way to get the information necessary so that the betrayed partner can make the most important decision of their life: Will they stay in the relationship or leave?

Partners who continue to be consumed with seeking information are tortured — not by the behavior but by their unrelenting quest to uncover all of the lies. Initially, information-seeking helps decrease panic and the horrible loss of power experienced after discovery of the betrayal. However, searching for information or signs of acting out quickly becomes all-consuming. Without intervention, intense emotions lead to faulty thinking, which becomes a force from within that fuels anger, rage and revenge. The powerful energy inside can be like a runaway train gaining speed until it crashes.

Betrayed partners learn that betrayers live in a state of secret destructive entitlement. Education about the conditions that led to the betrayer’s choices and deception is essential for the betrayed partner’s healing. Still, it is in no way a justification or vindication of the betrayer’s egregious behavior.

It is complicated to understand that there are two truths for people who struggle with sex addiction: they love their partner (in the way they know love) and act out sexually with themselves or others. Betrayed partners come to understand that addiction is a division of the self.

Reflection and reconstruction

Betrayal trauma causes a fracture in the foundation of a relationship and the foundation of the self. The secrets, lies, gaslighting and deception throughout the relationship are a silent cancer that consumes the infrastructure. The most devastating aspect of discovery is that the entire system that holds the relationship together begins to collapse into itself.

For the betrayed partner, healing involves self-reflection. Although they didn’t create the problem, their mental health requires them to face aspects of themselves that have been affected by infidelity and deception. During therapy, both partners face reality and let go of the illusion that theirs was a healthy marriage/relationship. They grieve what was lost and learn to let go of anger. Letting go creates space to build inner strength and accept love back into their hearts.

Forgiveness

Healing of the mind, heart and soul can happen regardless of the magnitude of the deception. But in the absence of a healing/recovery process, the betrayed partner’s anger intensifies and can cause them to be further traumatized by sifting through emails, texts and conversations, asking for every minute detail of the affair. As anger ferments, it can lead to rage. Rage can wreak havoc on the body, leading to health problems.

The solution is forgiveness. Many partners worry that they will be expected to forgive their betrayer. But forgiveness is not about forgetting nor is it about condoning bad behavior. Instead, forgiveness is a process of opting out of anger and the need for revenge — forgiving the human qualities that lead people to act in terrible ways. To be clear, forgiveness frees one’s heart from the prison of anger. Forgiveness is a decision that is made daily.

Release and restoration

After discovering a beloved’s infidelity and deception, and after accepting their own call to action, the betrayed partner turns inward and begins their own hero’s journey. This journey requires courage, loyalty and temperance. Each phase of the journey involves purifying, grinding down, shedding and brushing away unhealthy attitudes, beliefs and behaviors. The hero’s journey brings the betrayed to a state of purity and clarity.

Eckhart Tolle described the “dark night of the soul” as a collapse of the perceived meaning that the individual gave to their life. The discovery of infidelity, deception and trickery causes a shattering of all that defined the betrayed partner’s life. Their accomplishments, activities and everything they considered important feels like they have been invalidated.

At the bottom of the abyss, however, is salvation. The blackest moment is the moment where transformation begins. It is always darkest before the dawn. The only way to heal is to head straight into the fire toward restoration.

The restoration phase is all about finding meaning in life again. This doesn’t mean the betrayed partner will no longer have any feelings of sadness or longing. But they will also have moments of happiness again.

There are two tasks in this last phase of the hero’s journey: reclaiming their life with a new story that includes the bruises and scars bound together with integrity and pride, and restoring one’s self to wholeness. Before putting it all back together, partners must find their meaning in their own personal hero’s journey. To accomplish this, partners must discover how to make meaning out of suffering.

In his book Man’s Search for Meaning, Viktor Frankl, a Holocaust survivor, asserted that even in the worst suffering, having a sense of purpose provides strength. He contended there is no hope to survive if suffering is perceived as useless. Finding purpose transforms suffering into a challenge.

Frankl believed that in the worst of circumstances, there are two choices: 1) to assume that we cannot change what happens to us, leaving our only option to be a prisoner of our circumstance or 2) to accept that we cannot change what happened to us but that we can change our attitude toward it. A more potent, resilient, and positive attitude allows us to realize our life’s meaning. Through their hero’s journey, betrayed partners learn that their brokenness can lead to wisdom and deeper meaning in their lives.

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Allan J. Katz is a licensed professional counselor and certified sex addiction therapist. He is products co-chair at the Association for Specialists in Group Work and has written five books, including Experiential Group Therapy Interventions With DBT. Allan is the co-author, with Michele Saffier, of Ambushed by Betrayal: The Survival Guide for Betrayed Partners on Their Heroes’ Journey to Healthy Intimacy. He can be reached on his website, AllanJKatz.com.

Michele Saffier is a licensed marriage and family therapist and a certified sex addiction therapist and supervisor. As clinical director and founder of Michele Saffier & Associates, she and her clinical team have worked with couples, families, betrayed partners and people recovering from sexually compulsive behavior for 24 years. As co-founder of the Center for Healing Self and Relationships, she facilitates outpatient treatment intensives for individuals, couples and families healing from the impact of betrayal trauma. She can be reached at her website, TraumaHealingPa.com.

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

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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.

Other people’s monsters: A personal account of vicarious traumatization

By James M. Smith March 9, 2022

Last year, I was fortunate to have a piece published in Counseling Today with my co-author, Adrian Warren. The article, which appeared in the June 2021 issue, encapsulated our research on adult male survivors’ lived experiences of disclosing child sexual abuse.

Necessary to this research was the interview process in which I listened to the stories of men who had experienced horrific child sexual abuse, some by multiple perpetrators. These interviews took place over the course of about six weeks. I was bombarded with horror stories of emotional betrayal and sexual violence.

Then the nightmares started.

I can’t recall the exact date of my first nightmare, but I remember waking up angry and in a cold sweat after having dreamed that my youngest, 8 years old at the time, had been molested by a friend’s father. A few nights later, I dreamed I was beside my oldest son’s hospital bed after he was found beaten on a playground at school. In my dream, he was too ashamed to tell us who the perpetrator was or what exactly had happened. I woke up again in a cold sweat with a deep feeling of guilt that my son had been victimized. It took a minute for me to realize it was just a dream.

A few weeks after the nightmares started, my daughter, our middle child, announced she was planning to go to a sleepover at a friend’s house that weekend. “No, you’re not,” I blurted out without thinking.

My wife gave me an inquisitive look and asked, “Why not? We don’t have anything planned this weekend, do we?”

I couldn’t respond. I honestly didn’t know why I had suddenly become defensive, maybe even a little angry, about the thought of my daughter spending the night at a friend’s house. She had done it before many times, and we knew the family she would be staying with. My wife and I had been friends with this family since before our children were born. Why did I suddenly feel sick to my stomach at the thought of our daughter going to their home?

My wife made the arrangements. My daughter would go straight from school on Friday to her friend’s house with her friend’s parents, and we would pick her up around lunchtime on Saturday.

Friday loomed. The knot in the pit of my stomach grew heavier. Friday morning, I woke up in a cold sweat. Before getting in the car to take our daughter to school, I made sure she had her cell phone, a portable charger and her charging cable. I went over with her what numbers to call “if anything happened” and she needed us. I harped on it.

“Dad, chill out,” she said that morning. “You’re freaking me out a little.”

I was freaking myself out a lot. I checked my phone about every two minutes to see if she had called. When 9:30 p.m. rolled around, I called her. She didn’t answer. I was over the edge. I texted her and asked what she was doing. “Hanging out,” came the reply. She had just finished watching a movie, and they were getting ready to play some games. I spent that night in a state of near panic. I slept for maybe an hour and made sure my phone was on full volume and by my side the whole time.

Saturday morning came, and I couldn’t wait to go get our daughter. I was crawling out of my skin waiting. I almost called her at 6:30 a.m. to make sure she was OK. I sat that morning in a state of uncontrolled fear until we picked her up and she was safe with me again.

Mindfulness in action

The next day, as I nursed my cup of coffee, I realized I had not spent time in my mindfulness exercises all week. I have practiced mindfulness for more than 20 years. It was first introduced to me by Benedictine monks at a college I attended. Mindfulness exercises helped me manage depression and anxiety. When I became a counselor, I started integrating mindfulness into my own work with clients.

I put my coffee aside and went to my meditation chair. I have a specific place where I practice mindfulness exercises. The chair is comfortable but not so much that I fall asleep. It helps me sit up straight. I can put my feet on the floor or cross them underneath me depending on what is most comfortable on any given day. I went to my chair and began a mindfulness body scan.

I could feel how my feet rested on the floor with my ankles crossed. I could feel the bend of my knees and how my legs felt as I focused on each part of them. I could feel the pressure of my forearms resting on my thighs as my hands were placed in my lap, cupped in each other.

Yupa Watchanakit/Shutterstock.com

My attention moved up my hips and to my abdomen. Fear. There it was. Intense fear. The fear filled my stomach and rose up my chest like I was gagging on it. As I got in touch with that fear, I could feel my heart pounding and the tension in my shoulders, arms and neck. I noticed for the first time the stutter of my breath as I exhaled. I sat with this fear, recognizing the emotion of it. I accepted that I was afraid of something. I noted the physical sensations of fear and moved on with my body scan.

I spent the rest of the day paying attention to those physical cues of fear. I noticed how they intensified as my children talked about their activities. Every time my children mentioned their experiences of spending the night at a friend’s house or participating in some extracurricular activity, my stomach would knot up and my breath would quicken.

As I reflected on that fear in the coming days, I kept coming back to the same question: “What am I afraid of?”

“They’re going to hurt your children.” The voice was clear inside of me, although it felt a little alien.

“Who’s going to hurt my children?”

“Your friends. Your family. The abusers and manipulators. And you won’t know who they are until it’s too late.”

I had heard of vicarious traumatization in my academic studies, and it had always been an academic exercise: Identify the symptoms, prescribe intervention, promote prevention. I thought my academic understanding would be enough to insulate me from the threat.

Here I was though — nightmares, hypervigilance, intrusive thoughts, all underneath an anger that I didn’t understand. The worst part was the constant suspicion of everyone, even family members. As a counselor, I knew what these symptoms indicated. As a person, I wasn’t ready for the emotional toll they would take.

Support and self-care

I have always made it a point in my professional career to maintain a close-knit support group with other clinicians. Sometimes, I’ve been able to do this with co-workers in the same treatment organization. Other times, I’ve worked diligently to create my own professional support network. The iteration of my professional support network during this season of my life was a small group of three other counselors who met about every other week to talk and drink coffee. They were mindfulness practitioners too.

We visited with each other, and I let them know what was going on with me. Their response was more of a “Well, duh!” support than the kind of empathy that Brené Brown has spoken elegantly about, but that’s the kind of relationship we have. I told them I was kind of at a loss, and they helped me put together a plan and a series of exercises. They reminded me of the fundamental mindfulness concepts: radical acceptance, nonjudgment, compassion, patience, here-and-now focus. They reminded me to remain attuned to what I was paying attention to in my thoughts, to my emotions and to my body. They reminded me that the time to practice mindfulness is not when I’m in the grip of a vicarious trauma reaction or panic episode and most need to be mindful, but rather when I’m more relaxed.

Together, my support network and I worked out a plan of practice to address the experiences I was having. The first step was acceptance. I worked on accepting that the fears I was experiencing were not from my own lived experiences.

I found an image once of a woman walking down a darkened street. Her shadow was visible from a nearby street lamp, but behind her were the shadows of monsters clearly coming from a different source. This image summed up my understanding of vicarious trauma. Those of us in the helping professions can be haunted by the monsters that other people have faced.

We as counselors have many protective factors, including our knowledge, a developed self-awareness and strong support networks. While these protective factors may help us gain insight, they do not insulate us entirely from the vulnerabilities of our profession. Sometimes, we must accept the truth that we are not doing very well ourselves. The fear, nightmares, hypervigilance, suspicion and anger followed me but did not originate from my own experiences. Accepting that I was having these experiences was key to dismantling them.

The second step was to make sure I was engaging in my daily mindfulness practices. It has always been very easy for me to get busy and forget about the things that keep me well. I mentioned that I had not engaged in mindfulness practices the week prior to my daughter’s sleepover. That wasn’t because I deliberately chose to put these things on the back burner or to ignore my own needs. I just got busy.

Our practices for self-care are training for a marathon — training that needs to happen before the day of the race. We learn coping skills, just as our clients do, to make sure that we can manage our experiences as helpers. So many of the clients I have worked with through the years believe that they need to use the coping skills we review only when they are in the midst of dysregulation, be it panic, anger or addiction. We as counselors know that if a coping skill is not practiced before it is needed, it is not as effective as it could be when the time comes to use it.

The same is true of our own self-care. If the only time we engage in self-care is when we are on the edge of burnout, compassion fatigue or vicarious trauma, our self-care might stave off a crisis, but it won’t be very effective at keeping us well. So, I pledged to my support group that I would return to the daily practices that had helped me in the past. I made a commitment to them to practice mindfulness skills in meditation at least 30 minutes every morning, to exercise several times a week and to spend more time with my spouse and children. I committed to being mindful.

Finally, I used my support network. I have been to counseling in the past. It helped me immeasurably and put me on the path of becoming one myself. I am not opposed to seeing a counselor for my own individual therapy. Just as I encourage my clients, however, I decided to use my natural support network first.

These are friends in the profession with whom I have bonded. We meet regularly and speak openly to one another about our personal challenges. Sometimes we complain about our employers. Sometimes we complain about our employees. Most of the time we challenge one another to make sure we are taking care of ourselves, our families and our clients. I knew that I could sit down with them and say, “I think I’m having a vicarious trauma reaction.” I knew that they would hear me and help me recenter and get through it. Each time that we met afterward, I shared with them how I was doing on my plan to address these experiences.

Having this professional support is invaluable to me. We gather often to challenge, support and educate one another. This small group of clinicians is an important element of my self-care and ongoing professional competence.

Along with this professional network of support, I have natural supports in my life. I belong to a group of men that meets every Saturday morning for breakfast to share our stories of personal faith and to hold one another accountable as spouses and fathers. I shared with this group what was happening. They expressed understanding.

I also told my wife what was going on. She asked me if I wanted to stop letting our kids spend the night with friends for a while. I said just the opposite. I felt we needed to proceed as normal with our children’s activities, and I needed her to remind me that it would be OK.

This sharing of my experiences with my natural supports helped in the acceptance process. Talking about it with them and having to explain it at times helped me accept that it was happening.

Working through

I wish I could say that the nightmares, discomfort and anxiety stopped after a period of time. Word spread through my professional network that I had expertise in working with men who were survivors of child sexual abuse. This led to me getting more referrals of this particular client population than I had before. I have heard many more stories of abuse and betrayal since then. So, I continue with the regimen I established:

Regular meetings with my professional support network
Daily training in mindfulness practices that prepare me for the moments of panic I sometimes feel
Honesty with my natural supports in life, which helps with the acceptance that I have this vulnerability

The symptoms of vicarious trauma have not gone away, but I am managing better. I still wake up occasionally from a nightmare, but the nightmares are less intense. I still experience bouts of anxiety when my children attend sleepovers and other activities. I was out of my mind this past summer when my kids went to a swim party at a friend’s house. I practice deliberately shifting my attention to other things until they are home and remind myself constantly that my wife and I have done our due diligence regarding who our children are spending time with.

I caution counselors-in-training against acting as their own counselors. In this spirit, I continue contact with my support network of other counselors. I am radically honest with them about my self-care. These supportive colleagues helped me create a list of things I need to watch for as indicators that I should seek individual counseling myself.

In the final analysis, my experience of vicarious trauma did not affect my work with clients. Based on the feedback I receive from them, they continue to feel that I am present and empathic, compassionate and helpful.

No, this experience primarily affected my life at home and my relationship with my children. It wasn’t just that I wanted to crawl into a hole but rather that I also wanted to put my kids in a hole where I thought they would be safe. My fear was closing in around my children, making me want to shrink their world and experiences. It threatened their well-being as they continue developing into their outstanding selves.

Through this experience, I have learned that self-care for me means that I wrestle with other people’s monsters so that my children, wife and friends don’t have to wrestle with mine.

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James M. Smith is a licensed professional counselor, national certified counselor, approved clinical supervisor and board certified telemental health provider. In addition, he is a contributing faculty member with Walden University, a husband, a father, and a friend to a golden retriever. To contact him, email james.smith@mail.waldenu.edu.

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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.

Women and alcohol: Drinking to cope

By Bethany Bray November 2, 2021

Holly Wilson, a licensed professional counselor (LPC) candidate in Colorado, knows firsthand that women can feel disconnected or overlooked in addiction recovery programs. When she decided to seek help for alcohol dependency through 12-step and other treatment programs, Wilson kept hearing staff in these facilities talk about addiction in terms of “hitting rock bottom” and “failure” and make blanket statements such as “all addicts are liars.”

These types of statements didn’t fit Wilson’s experience, but they did add to the self-criticism she was already feeling. A self-described “high-functioning drinker,” Wilson had always been able to hold down a job and had never been cited for drunken driving. She didn’t fit the messy, drunken stereotype that many people associate with those who need treatment for addiction.

“I kept drinking for a long time because I was able to show up and look good, but I was really dying inside,” says Wilson, a member of the American Counseling Association. “I just got sick of myself and saw that I wasn’t achieving what I could.”

Declaring in treatment that “failure” had brought her to this point didn’t feel accurate or helpful, Wilson recalls. “I had to subscribe to calling myself an alcoholic and [agree to] ‘your best thinking got you here.’ It reinforced a lot of the shame that I was already feeling about myself,” she says. “I was actively seeking help and wanted to get better, and the system I experienced felt like it was forcing me into this box that I was a rock-bottom failure. … I kept hearing the message that you have to hit rock bottom before you can get well, and I thought that was really dangerous.”

The focus that some treatment programs place on admitting failure or a sense of powerlessness over a substance can alienate or even drive away female clients because many women already carry intense feelings of shame about their alcohol use, Wilson notes.

Despite Wilson’s difficult initial experience with treatment, she stuck with it and eventually found outpatient group therapy and individual therapy that felt welcoming and helped her learn more about the reasons why she drank. During her time in a women-only sober living house, she and her housemates were able to have deep and honest conversations about the trauma they had experienced — much more so than in the dialogue she’d experienced in coed groups, Wilson says.

Wilson’s recovery journey inspired her to help other women with similar experiences. After becoming a counselor and working in numerous positions in different substance use programs, she founded Women’s Recovery, an outpatient addiction treatment center for women with locations in Denver and Dillon, Colorado. Wilson serves as chief empowerment officer of the treatment center, which combines trauma-informed care with clinical treatment. The organization has a client-focused model that begins with asking clients what they want to get out of life, rather than prescribing what they should or have to do, Wilson says.

Treatment for alcoholism “doesn’t have to be through the lens of [a] power struggle over [a] substance,” Wilson says. “There is a misnomer that people have to get to rock bottom before getting help. … I would love to see a psychic shift [away from] that. It’s a problem whenever alcohol is getting in the way of things they want out of life. … The best thing we can do as counselors is shift our focus from that kind of rock-bottom-drunk perspective to an early intervention approach. We don’t have to wait until our clients lose everything and burn their life down to help.”

Multiple factors at play

Alcohol consumption and rates of alcohol use disorder among American women have been rising steadily in recent decades. Data compiled by the National Institute on Alcohol Abuse and Alcoholism indicates that although men consume more alcohol overall than women do, the gender gap is closing. In the nearly nine decades since Prohibition ended, the male-to-female ratio for measures of alcohol consumption — including prevalence and frequency, binge drinking and early onset drinking — has gradually narrowed from 3-to-1 to close to 1-to-1.

Rates of alcohol-related hospitalizations and health concerns, such as liver problems and cardiovascular disease, are also increasing for women. In an article published last year in Alcohol Research: Current Reviews, researcher Aaron White noted that “although women tend to drink less than men, a risk-severity paradox occurs wherein women suffer greater harms than men at lower levels of alcohol exposure. … Because women reach higher blood alcohol levels than do men of comparable weight, their body tissues are exposed to more alcohol and acetaldehyde, a toxic metabolite of alcohol, with each drink.”

The stress of the COVID-19 pandemic, of which women are bearing the brunt with job loss and child care and caretaking pressures, is exacerbating these trends, says Todd Lewis, an LPC who authored chapters on alcohol addiction and prescription drug addiction in the ACA-published book Treatment Strategies for Substance and Process Addictions. Alcohol is often used as a fast-acting way to temporarily ease or ignore one’s emotions or psychological pain, notes Lewis, a professor of counselor education at North Dakota State University who also sees clients at a private practice one day per week. The immense stress that many women have faced throughout the pandemic, coupled with increased isolation and the extra strain on relationships, has played a role in furthering the rise in alcohol use among women, he says.

Although many factors are at play, Sarah Moore, an LPC with a private practice in Arlington, Virginia, points to the intersection of alcohol being readily used as a coping mechanism and alcohol being widely available and interwoven into social norms and expectations. The expectation to drink can also dovetail with the pressure to be thin and other issues related to body image that women face, including disordered eating, she adds.

It’s more challenging than counselors may realize, Moore says, for emerging adults to foster and maintain social relationships through activities that don’t involve alcohol. “For a lot of 20- and 30-somethings, that [drinking alcohol] is their entire social life. Older generations may not be aware of how hard it would be to skip out, how integral that is to social situations,” she notes.

Moore, an ACA member, specializes in counseling for women, including issues related to alcohol dependency. She co-moderates a therapeutic group for women — Me, My Body and Alcohol — with Jyotika Vazirani, a psychiatric nurse practitioner and psychotherapist.

Alcohol is easily accessible and seemingly everywhere, Moore notes. It is often a part of sporting events and professional networking events, in which participation can be seen as a way to further one’s career, especially in high-pressure fields such as technology and law. The popularity of touring craft breweries and wineries also continues to grow. In many areas, alcohol can be purchased via delivery or curbside pickup at grocery or liquor stores.

One ironic aspect of American culture is that it frowns on both alcoholism and sobriety, Moore and Lewis note. “If you lose weight or quit smoking, everyone wants to know your secret,” Moore says, “but if you say you’re not drinking, they don’t know how to respond” in social settings.

And if individuals choose not to drink in social situations, they can face stigmatizing comments such as “you’re not having any fun,” Lewis adds.

In counseling, Moore role-plays and talks through scenarios with clients who have anxiety about declining alcohol at work events and in social situations because drinking has become so ingrained in these settings. She works with clients to plan and practice ways to artfully dodge questions and comments about their beverage choice.

Intertwined with trauma

All of the counselors interviewed for this article note that women who have an unhealthy relationship with alcohol often have experienced trauma in their past, are currently experiencing trauma or, in some cases, both. It is imperative that counselors are sensitive to this potential connection; use trauma-informed methods; are able to screen for posttraumatic stress disorder, intimate partner violence and abuse (physical, emotional, sexual, etc.); and know when and how to refer clients for specialized care when appropriate.

Sophie Hipke, an LPC in training at Women’s Recovery Journey, a women’s-only outpatient recovery program within the counseling clinic at Family Services of Northeast Wisconsin, says a vast majority of clients there have experienced (or are experiencing) “significant” trauma and turned to alcohol to cover up or numb painful emotions. Clients are often aware that alcohol won’t fix their problems, but they feel that it holds the promise of offering temporary relief, notes Hipke, who is training to be fully certified as a substance abuse counselor.

Many of the clients that Hipke and the counselors at Women’s Recovery Journey treat started drinking alcohol at an early age, sometimes as young as 11 or 12. For these clients, alcohol was often a way to escape an abusive household or deal with a loss or trauma, Hipke says.

“Substance use is often just a symptom, and the client has been self-medicating [to cope with] trauma or mental illness or both,” Wilson says. “We find that the majority of people who are seeking substance use disorder counseling have a reported history of trauma. There’s been a shift [among mental health practitioners] in the recent decade to recognize that it’s intertwined. … In order to really help people recover, we have to help them dig out of that trauma that has built up over time.”

For Wilson, the trauma of her brother’s death was what “pushed her over the edge” with her drinking, she says.

Clients who have a substance use disorder and a trauma history need a two-pronged approach in counseling, Wilson notes. They need to process and heal from past trauma and develop skills that allow them to deal with new traumas as they (inevitably) happen. “With both ‘big T’ trauma and ‘little t’ trauma, every person has a threshold and level of internal resiliency, and they can only take so much,” Wilson says. “If they don’t have the ability to cope as new trauma comes in, they are overwhelmed. [That’s when] we find ourselves continuing to turn to that substance over and over.”

Building rapport with clients is always an important aspect of counseling, but that is especially true with this population, Moore says. Women often feel intense amounts of pain and shame related to their trauma and alcohol dependency or addiction, so it’s vital that counselors focus on fostering a nonjudgmental and trusting relationship with these clients before delving into the hard stuff. Practitioners should also be patient, understanding that it may take these clients a long time before they feel stable enough to process their trauma, Moore advises.

Because trauma commonly dovetails with alcoholism and problem drinking in women, counselors should carefully choose treatment methods that are appropriate for this population, Moore stresses. Supports that are commonly used with male clients may not be helpful for female clients, especially if they have experienced sexual abuse or domestic violence.

Moore and the other counselors interviewed emphasize that recovery treatments that involve mixed-gender groups may not be appropriate — and could even be harmful — for female clients who have a substance use disorder. The vulnerability involved in talking about deeply personal issues that tie into their alcohol use can be triggering in coed settings for this client population, especially if they have experienced past trauma involving a man.

Counselors should thoroughly vet their local Alcoholics Anonymous (AA) chapter and other coed support groups before recommending them to female clients, Moore cautions, because these groups could exacerbate clients’ feelings of shame and possibly even retraumatize them. “AA can feel disempowering to women clients,” she says. “A lot of these women have a history of sexual trauma, and being around men is not therapeutic [for them] necessarily.” On the other hand, female-only group counseling or support groups can be powerful settings for female clients to feel supported and understood.

Lewis notes that although mutual aid groups such as AA can be a helpful supplement to counseling for some clients, practitioners should be mindful that AA’s 12-step method has a Western, patriarchal and masculine bias. The organization’s founding roots also have ties to Christianity, which can further alienate some clients, he adds.

Women for Sobriety (womenforsobriety.org) can be a helpful alternative, Lewis says. The organization’s model is based on a series of steps, like AA, but with an empowering focus, he explains.

Lifting the shame

Feelings of shame are common with women who have an unhealthy relationship with alcohol. Because of this, these clients often harbor denial or strong urges to hide their problem even from their therapist, which can affect the dynamic in counseling sessions, Moore notes. It can also cause these clients to cancel sessions or stop counseling altogether.

Moore urges counselors to be prepared for — and patient with — the resistant behaviors that this population may exhibit. “This is a challenging population to treat,” Moore acknowledges. “It [alcohol use] is something that can be a very closely guarded part of their life.”

Resistance and secrecy can be especially prevalent among female clients who are successful in their careers or who work in helping professions such as medicine or counseling, Moore says. Throughout her career in the mental health field, she says, she has witnessed many peers “quietly struggle” with alcohol misuse.

Women are often socialized to be concerned with how others might judge them, which can cause perfectionist tendencies and feelings of shame, Wilson points out. “One of the things that keeps women from getting help is that they can show up, put their best foot forward and play the part of someone who is well when they’re suffering inside. That can be really hard to break through as a counselor,” Wilson says. “Women also have an incredibly high pain threshold. We can take a lot before we break down.”

Hipke finds that women’s shame around drinking often dovetails with parenting issues and feelings of failure as a mother. Many of the clients in the recovery program where Hipke works have had child protective services involved with their family or children removed from the home because of alcohol- or substance-related offenses. These women often feel ashamed for being a burden to family or others who care for their children when they are unable to. The feeling of being a bad mother “really cuts deep for them,” Hipke says.

“Society’s expectation is that women are supposed to naturally be a good mother,” Hipke points out. “Society sees them as doing this [being addicted to alcohol] to their kids rather than doing it to themselves.”

Clients always need an atmosphere of nonjudgment in counseling, but that need is magnified exponentially for this client population because of the associated shame, Hipke says. Practitioners should be hyperaware of the language they use with these clients to ensure they are not reinforcing feelings of shame, she stresses. Counselors must also be careful not to frame a client’s situation as something that they brought on themselves. Statements that assign blame, such as “you’re choosing alcohol over your children,” are not only hurtful for these clients, Hipke says, but also carry the false message that substance use disorder is a choice.

“Be aware of how you’re talking about addiction [and] reiterate that addiction is not a choice,” Hipke urges. “We don’t see any other mental illness as a choice, but people often see addiction that way.”

Part of fostering a welcoming and nonjudgmental atmosphere in counseling is being sensitive to the needs and stressors that women might be juggling outside of counseling, such as child care or transportation. This might call for clinicians to exercise greater flexibility by offering to use telebehavioral health with these clients or allowing them to bring an infant or small child into counseling sessions when child care is unavailable.

Wilson’s facility offers group counseling both in the mornings and the evenings to accommodate clients’ schedules. “We [counselors] need to accommodate women who have a lot of balls in the air already,” she says. “There can be a lot of pressure for women to be the anchor of their family, the scheduler, and that can be something we need to be cognizant of.”

Practitioners may also need to think of creative ways to broach the subject of alcohol use with female clients in counseling sessions without being too direct or aggressive. Otherwise, these clients may stop attending. One method Moore likes is asking clients detailed questions about their sleep habits, including whether they use alcohol as a sleep aid.

“Find ways to get the conversation started early. Don’t wait for it to come up,” Moore says. “It can be hard to get an authentic answer from women regarding alcohol because of the [associated] shame. Sleep can be a good way to ask and bring it up because alcohol use can really mess up sleep.”

Lewis also urges counselors to weave assessment questions regarding alcohol use into conversation with clients rather than firing one question after another at them. This approach intersperses questions about what is happening in the client’s life beyond drinking, such as in their home and family life and relationships, he says.

Instead of asking direct questions about the quantity and frequency of their alcohol consumption, using prompts such as “What does a typical week look like for you in terms of drinking?” can offer a gentler way to query clients about their alcohol use, Lewis says.

For his doctoral dissertation, Lewis researched binge drinking among college students through the lens of Adlerian theory. He found that unhealthy relationships, including problems forming and maintaining relationships, were more often a predictor of women’s drinking behaviors than of men’s. As he points out, dependence on alcohol can cultivate an unhealthy cycle: Poor or absent relationships can contribute to alcohol use, which in turn can hinder an individual’s ability to maintain or build new relationships. So, asking female clients about their relationships and social supports can help counselors understand when further questioning about alcohol use might be needed, Lewis says.

(See the Counseling Today article “Becoming shameless” for an in-depth look at helping clients with feelings of shame.)

Tailoring treatment

Equipping clients with coping mechanisms, including ways to quell critical self-talk, is another important part of working with this population. Clients will need robust, healthy coping skills as they work to eliminate alcohol consumption — the quick, accessible coping tool they have come to rely on.

Vicky Gosselin/Shutterstock.com

Providing psychoeducation that addiction is a disease and that recovery involves rewiring one’s neural pathways for decision-making is helpful, Wilson says. Her initial work with clients includes a focus on coping mechanisms that will help them regulate their emotions. She also works to build up clients’ communication and social skills, which may be underdeveloped because of the individual’s history of trauma, mental illness and substance use.

“The only thing they’ve known to use to cope is the substance, so we need to replace that right away,” Wilson says. “We [the staff at Women’s Recovery] are big believers in skill building. We start with loading clients up with all sorts of coping and grounding skills [as well as] the message that this is going to be a lifelong journey. Clients are recovering, and it will take constant work.”

One nice thing about outpatient treatment is that clients learn to live without substance use in everyday life during treatment, Wilson notes. Clients can see what triggers come up and learn how to address them as they navigate work, family life and relationships while living at home.

Hipke notes that group counseling can also be a rich setting for female clients to learn coping mechanisms, both because they are exposed to the lessons that other women have learned during their recovery journeys and because they are provided with a safe place to strengthen their social and relationship skills.

“Group [counseling] is the most powerful part of our program. It resonates with them to hear others’ stories, helps them build bonds and also holds them accountable,” Hipke says. “It’s powerful [for clients] to know they can share stories and talk about whatever they need to, and it won’t leave the room. As a therapist, we can point things out to them all day long, but it’s so much more powerful to hear it from a peer.” Hipke has noticed that she can say something repeatedly to a client in an individual session, but it often won’t “click” until the client hears the same message in the group.

Lewis and Hipke note that in individual counseling, motivational interviewing is a useful method for building rapport and helping clients who may be resistant or ambivalent to behavioral change. This approach can also be beneficial when counseling female clients who are in denial or who have complicated feelings that are exacerbated by the stigma and shame associated with their alcohol use.

The counselors interviewed for this article also mentioned cognitive behavior therapy (CBT), Gestalt techniques and trauma-informed modalities, including eye movement desensitization and reprocessing, as being particularly helpful with this client population. Hipke says that using a strengths-based approach can also be useful, as can including a client’s partner or family in sessions, when appropriate.

Including clients’ family members or others in counseling sessions can help clear up misunderstandings and hurtful feelings that linger regarding a client’s addiction and past behavior, Hipke explains. In these cases, a counselor can act as moderator to support and guide conversations toward healing. “Having kids, parents or siblings join in on sessions for the therapist and client to be able to talk more about addiction and provide a safe and neutral space to have discussions can be very healing for both the client and their family,” she says.

These clients may also need to spend significant time working on self-talk and intrusive thoughts and learning how to deal with difficult feelings in a healthy way. With self-talk, part of the work involves helping female clients hold themselves accountable while resisting the urge to be overly critical and beat themselves up, Hipke says. Mindfulness and CBT can be particularly helpful in these areas, she adds.

Many clients, especially those with abuse histories, must unlearn behaviors they adopted over time to block out powerful emotions such as anger, sadness and happiness, Hipke says. These women often struggle to find the words to explain what they are feeling. Hipke uses an emotion wheel to help clients name their emotion, recognize how it manifests in their body and identify why it’s a difficult feeling for them to experience.

“For many clients, they were either punished or wouldn’t get their needs met if they showed emotion. … They often need to rediscover sadness or anger and realize that it’s OK to feel those emotions, or even that it’s OK to be happy. They often don’t know what to do with being happy,” Hipke says. “From there, we identify why it’s so difficult. What has led to the place where feeling sad or angry isn’t OK? And then we begin to dismantle that. Just labeling it, identifying it, is helpful — and then they can match coping skills to the emotion they are feeling.”

Preparing for relapse

When doing counseling work with women who are addicted to or dependent on alcohol, it is important to be prepared for the possibility of relapse.

It can be helpful to talk frequently about relapse prevention skills, both in group and individual counseling, Hipke says. This includes being able to recognize the signs that an individual might be headed toward relapse. She also listens for instances when clients mention going through a stressor. This presents an opportunity to offer extra support and check on how the client is coping, including asking gentle questions about the possibility of the client feeling an urge to return to substance use.

Once again, it is important for counselors to provide nonjudgmental responses, Hipke stresses. If a client relapses, counselors should normalize the experience and celebrate that the client recognized it and shared it with the therapist, she says. Women are often afraid to tell their counselor about a relapse. So, when they do, Hipke recommends that clinicians assure them that it’s not a sign of “failure,” either on the part of the client or the counselor.

Hipke also emphasizes that counselors should not take client relapses personally. “For a lot of the women [in our program], they struggle with balance in different areas of their lives. They’re not just stopping drinking, they’re making a lot of behavioral changes in their lives,” Hipke explains.

She often talks with clients about how it’s normal for relapses to occur during any kind of behavioral change. “It’s not the relapse that we want to focus on but what to do after,” Hipke says. “What can we do differently to make sure it doesn’t continue happening, [and how can we] keep [clients] from beating themselves up, because that can lead to more relapses.”

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How much is too much?

Counselors shouldn’t take a one-size-fits-all approach to assessment questions about a client’s alcohol use because women form dependency on alcohol for different reasons — and in different ways — than men. Practitioners should focus more on the context and reasons why a female client drinks alcohol rather than on the quantity, says Holly Wilson, the founder and chief empowerment officer of Women’s Recovery, an outpatient substance abuse treatment program for women in Denver.

Questions about the number of drinks a client consumes also have the potential to spark countertransference issues, notes Wilson, a licensed professional counselor candidate. Counselors will have personal feelings about how many drinks are acceptable, and they must be careful not to project those assumptions onto clients.

“It doesn’t matter if you would have a problem doing what they’re doing … or [if] the quantity or frequency of the client’s drinking may be something you’re fine with, but they’re not,” Wilson says. “It doesn’t have to be according to your own personal standards of drinking or substance use.”

Instead, she advises counselors to focus on exploring the client’s relationship with alcohol. The CAGE questionnaire can be a helpful tool to use with female clients, Wilson says, because it focuses on how a person feels about their drinking. CAGE poses four questions that can prompt further dialogue with the client:

Have you ever felt you needed to Cut down on your drinking?
Have people Annoyed you by criticizing your drinking?
Have you ever felt Guilty about drinking?
Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover?

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Recommended titles

Here are some books that Sarah Moore uses with individual and group clients:

“Can I Keep Drinking?: How You Can Decide When Enough is Enough” by Cyndi Turner
“Between Breaths: A Memoir of Panic and Addiction” by Elizabeth Vargas
“The Sober Diaries: How one woman stopped drinking and started living” by Claire Pooley
“This Naked Mind: Control Alcohol, Find Freedom, Discover Happiness & Change Your Life” by Annie Grace
“Quit Like a Woman: The Radical Choice to Not Drink in a Culture Obsessed with Alcohol” by Elizabeth Whitaker

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