Tag Archives: trauma

Healing attachment wounds by being cared for and caring for others

By Adele Baruch and Ashley Higgins October 29, 2020

Those who work with individuals who have been traumatized have noted the need for these clients to reestablish connection to their own internal worlds. In these cases, clients often become frozen or, depending on the depth of trauma and the immediate response to that trauma, have an outwardly focused, hypervigilant, fight-or-flight approach to their experiences.

Cases of troubled attachment are based in this kind of fight-or-flight response, whether it is rooted in large T trauma (i.e., catastrophic accident or abuse) or small t trauma (i.e., multiple experiences with neglect or mistreatment). This leads to an inability for these clients to securely attach to others.

Building safety via action-based attunement

In cases of troubled attachment, the first task in counseling is to build safety through a focus on empathic, attuned responses associated with the client’s primary pathway of learning (for more, see David Mars and the Center for Transformative Therapy Training Center).

In a chapter titled “The creative connection: A Holistic expressive arts process” in the book Foundations of Expressive Arts Therapy (1999), Natalie Rogers defined empathy as “perceiving the world through the other person’s eyes, ears, and heart.” She noted that this understanding is conveyed through both our words and body language: “The body language, although usually unconsciously given and received … offers a sense of safety and comfort.” As we offer this opportunity for empathic co-regulation, we concurrently engage grounding approaches to enable a return to safety if anxiety is too high.

Along with grounding approaches, it is often useful to initiate action-based responses that are shared by the counselor to promote collaboration and attunement. These can range from the very simple to the more complex.

The following are offered as examples:

  • Expressive arts: Both the client and counselor respond to a piece of music with line and color. Then each person can respond to the other person’s artwork through line and color. Notice that there is no interpreting of the art experience, only the sharing of a visual response to music, and then sharing one’s experience of that response.
  • Breathwork: The counselor may model and practice basic and simple breathwork alongside the client to help the client access more internal quiet and space.
  • Role-plays: Engaging in simple role-plays can offer alternative action-based responses to challenging interpersonal situations

The choice of action-based approaches will depend on the needs and inclinations of the client, but these approaches are all in the service of conveying empathy and expanding interpersonal resonance. As Allan Schore (2013), a neuroscientist who has looked at brain activity during attachment experiences, would describe it, these approaches create opportunities for right brain to right brain communication (the foundation of attachment experiences).

As the client and counselor create together with these practices, the client builds a repertoire of action-based responses. The client may then begin to engage some of these action-based responses when triggered by a reminder of a traumatic event. This increases the client’s sense of internal safety.

Building resilience via attachment rupture and repair

Once safety is developed along with basic attunement and the capacity to choose constructive action, there is an opportunity to build a more robust and mature attachment via the counseling relationship. This can be achieved through a process of both intentional and unintentional rupture and repair of that attachment bond developed in counseling.

In her book chapter “Dyadic Regulation and Experiential Work With Emotion and Relatedness in Trauma and Disorganized Attachment” (originally published in Healing Trauma: Attachment, Trauma, the Brain, and the Mind, 2003), Diana Fosha articulated the way that counselors may, with great care, begin to interpret and confront with the expectation that this may create temporary ruptures in empathy. This empathy can be carefully repaired and restored in session through the articulation of feeling and the expression of understanding. A hypothetical example:

Counselor: “I wonder if you returned to your medical books with such great fervor last week because your partner has been asking for increased intimacy, and that is scary for you.”

This confrontation may be experienced as a temporary break in empathy, but if the counselor and client can sense and articulate the client’s immediate experience during that break, it can lead to a deeper understanding of that experience. That deeper understanding may lead to a more mature connection and, potentially, to the experience of a return to empathic attunement. These experiences, over and over again, may become internalized, leading to a more empathic connection to the client’s internal self.

Client: “When you say that, I feel like you are trying to push me to experience things I am not ready to experience after my last horrible relationship. You don’t really care about me. … You just want to see me move on.”

Counselor: “I hear you saying that my view about using your studies to keep a distance feels as if I am pushing you, and that feels as if I don’t understand how scary that is. Do I have that right?”

Client: “Yes, that’s right. You don’t really understand how scary it is.”

Counselor: “Can you tell me more about how scary it is?”

The repair may not occur immediately, but with careful listening, engagement and articulation, the feelings of fear and vulnerability may become more accessible. That experience makes a repair of empathic breaks caused (both intentionally and unintentionally) in a mature relationship inevitable. As Fosha explained, the experience of repair, in the context of confrontation and deeper understanding, provides evidence that differences or misunderstandings may eventually result in deeper connection.

This experience can lay the groundwork for both a greater capacity and patience for real-world attachments, as well as greater internalized empathy. Through this, the client experiences more ruptures and the relational commitment necessary for repair. 

Building self-regulation via emotional flexibility

In addition to internalized empathy, resilience in attachment ruptures and repair also creates a sense of safety — safety to dwell near emotions and to work to translate vague sensations to words. This requires the development of a sense of “unconditional friendliness,” as John Welwood has described it (Toward a Psychology of Awakening), toward the emotions that come up during rupture and repair. As counselors, we model this friendliness to emotions when they come, both during periods of attunement and during experiences of rupture.

As clients become more experienced with the naming of feelings in both easy and difficult interpersonal situations, this encourages greater self-reflection. With practice, this leads to a “self” system capable of modulating a range of affects, with emotions that may be integrated into adaptive responses.

Schore noted in Affect Regulation and the Repair of Self (2003) that through this process of self-regulation, the client “develops the ability to flexibly regulate emotional states through interactions with other people.” It is through this increased flexibility in the expression of emotion that the client can productively practice emotional regulation in the real world.

Building agency via helping others

It is very useful for clients to see themselves not only as the one who is helped but also as one who helps others. George Vaillant reminds us that it is not so helpful to give into the understandable wish to “mother” or “father” our clients, as it is important for them to develop and internalize their own “parenting” capacities with others.

Often, clients who have been traumatized multiple times become frozen in the role of “helpee,” but by helping, they are developing an active response to others, often in the face of anxiety. Action in the face of triggered anxiety creates new neural pathways for responses to triggering events (as detailed in “A call to action” Overcoming anxiety through active coping” by Joseph LeDoux and Jack Gorman).

Additionally, as clients listen to and fashion adaptive responses to others, they further practice emotional flexibility and regulation. It is wonderful to exercise a developing sense of self with an empathic counselor; it can be even more rewarding to exercise these abilities with someone who may not have as much to give and who might challenge and stretch our adaptive responses — within reason. Early entry into the community as helpers and participants is often best done in a supportive environment, such as a peer support group or a well-structured community initiative or a learning environment.

Helping and prosocial behaviors foster more confidence in helping. Ervin Staub cites multiple studies that show that children and adults become more helpful once they start helping. This increased comfort with helping is generally positively received in peer milieus, and the person helping experiences a sense of being valued — and, if all goes well, a sense of community.

We suggest that the ability to practice responding, in a helpful, emotionally regulated way in the real world, is as important as counseling is on the path toward mature attachment.

Four examples of helping opportunities

The following are four brief examples of milieu settings that provide opportunities to help and observe others, as well as to articulate feelings that develop while participating. 

Example 1: Roots of Empathy

Schools in Canada and New Zealand have developed a program for young children called the Roots of Empathy. In this program, a group of children is selected to host a parent-baby dyad in their room each month. Before each visit, the class prepares for the new developmental stage of the baby and the dyad. During each visit, children are encouraged to closely observe the way that the baby communicates, almost always with an open-hearted curiosity to their surroundings, and how the parent reads their baby’s needs.

After the visit, the children participate in discussions, artwork, drama and journal writing about what was learned. The natural generosity of children is expressed when they use art, music and drama to present gifts to the baby and parent. The visits continue one time per month throughout the year.

In this context, difficult questions arise, such as, “What if you were once a bully?” and “If no one ever really loved you, can you still be a good father?” As the children discuss observations of the parent-child dyad, they gain insight into their own emotions and those of others, leading to greater empathy.

David was 9 years old and had a form of autism. His parents shared with the program leader that David had never been invited to a birthday party by any of his classmates until the year that Roots of Empathy came to his classroom. That year, he was invited to three birthday parties. (For more, read Roots of Empathy: Changing the World Child by Child by Mary Gordon.) 

Example 2: The Courage and Moral Choice Project

A program focused on the cultivation of empathy for older adolescents is the Courage and Moral Choice Project, developed in our Maine schools. With this project, students listened to stories of helping under catastrophic conditions, such as during Hurricane Katrina. They participated in group discussion after hearing these stories, where they were able to share their own stories of times when they, or someone in their neighborhood or family, took a risk to help someone.

Students were encouraged to express their own stories, and the stories of others, through art, song, essays and poetry. Those works were shared with the larger community at a school board meeting and a university conference. After presenting at a conference, one student approached a second student involved in the presentation and apologized for harassing and bullying her during her earlier years of school. The second student forgave the first student and expressed understanding that those years were rough ones for both of them.

Example 3: Active bystander training

Many student life programs have established active bystander training to support university students in preparing to step up when they see a peer harassed or bullied. Ervin Staub originally developed active bystander training for schools and government agencies to prevent a sense of isolation should an individual experience a violation.

The training promotes a sense of awareness on the part of community members, but more powerfully, it suggests a pathway to a sense of agency should a person experience the pain of knowing a friend or community member is being targeted.

Example 4: Transformative Couples Therapy

One final example of integrating attachment cultivated in counseling work and connection in natural support systems is David Mars’ transformative couples therapy (TCT). TCT is an approach to couples work in which partners may deepen their attachment to each other by providing empathic support as they work through the unexpressed feelings from experiences that may have left them in fight-or-flight mode. TCT offers examples of how prior individual counseling work may be augmented in a collaborative environment.

These opportunities are mentioned to provide examples of the kinds of programs that encourage empathic connections, self-expression, listening and a sense of agency. These integrated experiences support the work done in counseling toward the development of the capacity for mature attachment.

Conclusion

When working with individuals who have experienced either “small t” or “large T” trauma, it is essential to engage them in action-based responses that provide a healing alternative to the fight, flight or freeze reaction. Building agency in the form of fostering connections to their inner world (via safety developed through grounding and attunement) and outer world (via repaired ruptures in therapeutic alliance, and engaging as the “helper”) is critical.

For the client to establish connection to their inner world, safety is built in a therapeutic alliance focused on empathic, attuned responses and action-based grounding techniques. This allows for the clinician to challenge the client, creating mild ruptures in empathy that can be repaired to build a more mature attachment through the return to empathic attunement. These breaks and repairs provide practice for a greater capacity and patience in real-world situations. Greater patience increases clients’ empathy and connection to their internal world and an internalized safety to sit with uncomfortable sensations and experiences, thus increasing both internal and external resilience and agency.

In tandem to building internal resolve, balance provides the client the ability to further increase their agency. This is best accomplished by encouraging the client (the person originally helped) to help others in the context of a well-structured environment. With the balance of being “the one helped” and “the helper,” the client develops and internalizes their “parenting” ability, allowing individuation from being the “parented.”

Greater internal and external connection and competence heals attachment wounds both inside and outside of the clinician’s office.

 

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Adele Baruch chairs and is an associate professor in the University of Southern Maine’s counselor education department. She practiced couples and individual counseling for 15 years before starting to teach. She has focused her scholarship on healthy adaptation and has developed an action research project on courage and moral choice in Maine. Contact her at adele.baruchrunyon@maine.edu.

Ashley Higgins is a clinical counselor at the Glickman Family Center for Child and Adolescent Psychiatry at Spring Harbor Hospital in southern Maine. As a licensed professional counselor, her primary areas of clinical interest include integrative and strengths-based modalities for treating attachment trauma; family systems; and wilderness therapies. Contact her at amhiggins@mainebehavioralhealthcare.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.

Grappling with compassion fatigue

By Lindsey Phillips August 31, 2020

Compassion fatigue presents a paradox for counselors and others in the helping professions. As Alyson Carr, a licensed mental health counselor and supervisor in Florida, points out, it compromises their ability to do the very thing that motivated many of them to enter the field in the first place — empathically support those in pain.

Empathy and compassion are attributes those in the helping professions are particularly proud to possess and cultivate. Yet those same characteristics may leave some professionals more susceptible to becoming traumatized themselves as they regularly observe and work with those who are suffering.

Jennifer Blough provides counseling services to other helping professionals as owner of the private practice Deepwater Counseling in Ypsilanti, Michigan. She says many of her clients experience compassion fatigue. One of her former clients, an emergency room nurse, witnessed trauma daily. One day, the nurse treated a child who had suffered horrendous physical abuse, and the child died shortly after arriving at the hospital.

This incident haunted the nurse. She had nightmares and intrusive thoughts about the child’s death and abuse. She started to isolate to the point that she had to step away from her job because she refused to leave her house. She couldn’t even bring herself to call Blough. She just sent a text asking for help instead.

Blough, a licensed professional counselor (LPC) and certified compassion fatigue therapist, asked the nurse to come to her office, but the nurse said she was comfortable leaving her home only when accompanied by her dog. So, Blough told her to bring her dog with her to the session. That got the nurse in the door.

From there, Blough and the nurse worked together to help the client process her trauma. Blough also taught the client to recognize the warning signs of compassion fatigue so that she could use resiliency, grounding skills, relaxation, boundary setting, gratitude and self-compassion to help keep her empathy from becoming unmanageable again.

Defining compassion fatigue

“One of the most important ways to help clients who might be struggling with compassion or empathy fatigue is to provide psychoeducation,” Blough says. “A lot of people don’t even realize there’s a name for what they’re going through or that others are going through the same thing.”

Blough, author of To Save a Starfish: A Compassion-Fatigue Workbook for the Animal-Welfare Warrior, didn’t understand that she was experiencing compassion fatigue when she worked at an animal shelter and as an animal control officer before becoming a counselor. After she started feeling depressed, she decided that she was weak and unfit for her job and ultimately left the field entirely. It wasn’t until she was in graduate school for counseling that she learned there was a name for what she had experienced — compassion fatigue.

According to the American Institute of Stress, compassion fatigue is “the emotional residue or strain of exposure to working with those suffering from consequences of traumatic events.” This differs from burnout, which is a “cumulative process marked by emotional exhaustion and withdrawal associated with workload and institutional stress, not trauma-related.”

Although compassion fatigue is the more well-known and widely used term, there is some debate about whether it is the most accurate one. Some mental health professionals argue that people can never be too compassionate. Instead, they say, what people experience is empathy fatigue.

In an interview with CT Online in 2013, Mark Stebnicki described empathy fatigue as resulting from “a state of psychological, emotional, mental, physical, spiritual and occupational exhaustion that occurs as the counselors’ own wounds are continually revisited by their clients’ life stories of chronic illness, disability, trauma, grief and loss.”

April McAnally, an LPC in private practice in Austin, Texas, is among those who believe that people can’t have too much compassion. Compassion involves having empathy and feeling what the other person does, but we have a screen — an internal boundary — that protects us, McAnally says. “Empathy, however, can be boundaryless,” she continues. “We can find ourselves overwhelmed with what the other person is experiencing. … So, what we actually become fatigued by is empathy without the internal boundary that is present with compassion.”

As Blough puts it, “Empathy is the ability to identify with, or experience, another’s emotions, whereas compassion is the desire to help alleviate suffering. In other words, compassion is empathy in action.”

McAnally, a certified compassion fatigue professional, also suggests using the term secondary trauma. She finds that it more accurately describes the emotional stress and nervous system dysregulation that her clients experience when they are indirectly exposed to the trauma and suffering of another person or animal.

Symptoms and risk factors

Anyone can be susceptible to burnout, but compassion fatigue most often affects caregivers and those working in the helping professions, such as counselors, nurses, social workers, veterinarians, teachers and clergy.

Working in a job with a high frequency of trauma exposure may increase the likelihood of developing compassion fatigue, McAnally adds. For example, a nurse working in an OBGYN office may have a lower risk of developing compassion fatigue than would an emergency room nurse. Even though they both share the same job title, the impact and frequency of trauma is going to be higher in the ER, McAnally explains.

Counselors should also consider race/ethnicity and contextual factors when assessing for compassion fatigue. Racial injustices that members of marginalized populations regularly experience are sources of pervasive and ongoing trauma, McAnally notes. And unresolved trauma increases the likelihood of someone experiencing empathy fatigue, she adds.

Carr, an American Counseling Association member who specializes in complex trauma and anxiety, and Blough both believe the collective trauma resulting from the COVID-19 pandemic and exposure to repeated acts of racial violence and injustice could lead to collective compassion fatigue for all helping professionals (if it hasn’t already).

McAnally, a member of the Texas Counseling Association, a branch of ACA, says the current sociopolitical climate has also affected the types of clients she is seeing, with more individuals who identify as activists and concerned citizens seeking counseling of late. She has found that these clients are experiencing the same compassion fatigue symptoms that those in the helping professions do.

Blough and Victoria Camacho, an LPC and owner of Mind Menders Counseling in Lake Hopatcong, New Jersey, say symptoms of compassion fatigue can include the following:

  • Feelings of sadness or depression
  • Anxiety
  • Sleep problems
  • Changes in appetite
  • Anger or irritability
  • Nightmares or intrusive thoughts
  • Feelings of being isolated
  • Problems at work
  • A compulsion to work hard and long hours 
  • Relationship conflicts
  • Difficulty separating work from personal life
  • Reactivity and hypervigilance
  • Increased negative arousal
  • Lower frustration tolerance
  • Decreased feelings of confidence
  • A diminished sense of purpose or enjoyment
  • Lack of motivation
  • Issues with time management
  • Unhealthy coping skills such as substance use
  • Suicidal thoughts

There are also individual risk factors. According to Camacho, a certified compassion fatigue professional, individuals with large caseloads, those with limited or no support networks, those with personal histories of trauma or loss, and those working in unsupportive environments are at higher risk of developing compassion fatigue.

In fact, research shows a correlation between a lack of training and the likelihood of developing compassion fatigue. So, someone at the beginning of their career who feels overwhelmed by their job and lacks adequate training and support could be at higher risk for experiencing compassion fatigue, McAnally says.

One assessment tool that both Blough and Camacho use with clients is the Professional Quality of Life Scale, a free tool that measures the negative and positive effects of helping others who experience suffering and trauma. Blough says this assessment helps her better understand her clients’ levels of trauma exposure, burnout, compassion fatigue and job satisfaction.

Regulating the body and mind

“Having an awareness of our emotions and experiences, especially in a mindful way, can serve as a barometer to help protect us against developing full-blown compassion fatigue,” says Blough, a member of ACA and Counselors for Social Justice, a division of ACA.

Part of this awareness includes being mindful of one’s nervous system and the physical changes occurring within one’s body. When someone experiences compassion fatigue, their amygdala, the part of the brain involved in the fight-or-flight response, gets tripped a little too quickly, McAnally explains. So, their body may react as if they are in physical danger (e.g., heart racing, sweating, feeling panicky) even though they aren’t.

If clients get dysregulated, McAnally advises them to use grounding techniques to remind themselves that they are safe. She will often ask clients to look all over the room, including turning around in their chairs, so they can realize there is nothing to fear at that moment. She also uses the 5-4-3-2-1 technique, in which clients use their senses to notice things around them — five things they see, four things they hear, three things they feel, two things they taste and one thing they smell.

Research has shown that practicing mindfulness for even a few minutes a day can increase the size of the prefrontal cortex — the part of the brain responsible for emotional regulation, McAnally adds.

Blough often uses the square breathing technique to ground clients and get them to slow down. She will ask clients to breathe deeply while simultaneously adding a visual component of making a square with their eyes. They breathe in for four seconds while their eyes scan left to right. They hold their breath for four seconds while their eyes scan up to down. They breathe out for four seconds while their eyes scan right to left. And they hold their breath for four seconds while their eyes move down to up.

Counselors can also teach clients to do a full body scan to regulate themselves, Blough and Camacho suggest. This technique involves feeling for tension throughout the body while visualizing moving from the head down to the feet. If the person notices tension in any area, then they stop and slowly release it.

Camacho once had a client lean forward and grab the armrest of the chair they were sitting in while talking. She stopped the client and asked, “Do you notice you are gripping the armrest? Why do you think you are doing that?”

The client responded, “I wasn’t aware of it, but I find it comfortable. I feel like I’m grounding myself.”

Camacho, an ACA member who specializes in posttraumatic stress disorder, trauma, and compassion fatigue in professionals who serve others, used this as a teachable moment to show the client how to ground themselves while also having relaxed muscles. She asked the client to release their grip on the chair and instead to lightly run their fingers across it and focus on its texture.

Carr finds dancing to be another useful intervention. “Engaging in dancing and moving communicates to our brains that we are not in danger. [It] allows us to develop and strengthen affect regulation skills as well as have a nonverbal, integrated body-mind experience,” she explains.

Creating emotional boundaries

Setting boundaries can be another challenge for helping professionals. Blough says many of her clients report feeling guilty if they say “no” to a request. They often feel they have to take on one more client or take in one more animal. But she asks them, at whose expense?

Blough reminds clients that saying “no” or setting a boundary just means saying “yes” to another possibility. For example, if a client wants to schedule an appointment on Thursday night at the same time that the therapist’s child has a soccer game, then telling the client “no” just means that the therapist is saying “yes” to their family and to their own mental health.

Blough and McAnally recommend that people create routines to help themselves separate work from home. For example, clients and counselors alike could listen to an audiobook or podcast during their commute home, or they could meditate, take a walk or even take a shower to signify the end of the workday, Blough suggests. “Anything that helps them clear their head and allows them to be fully present for themselves or their families,” she adds.

People can also establish what Carr calls an “off switch” to help them realize that work is over. That action might involve simply shutting the office door, washing one’s hands or doing a stretch. At the end of the workday, Carr likes to put her computer in a different room or in a drawer so that it is out of sight and mind. Then, she takes 10 deep breaths and leaves work in that space.

Exercising self-compassion

“Because a lot of helping professionals are highly driven and dedicated, they tend to have unrealistic expectations and demand a lot from themselves, even to the point of depletion,” Blough says. “Having low levels of self-compassion can lead to compassion fatigue, particularly symptoms associated with depression, anxiety and posttraumatic stress disorder.”

In other words, self-compassion is integral to helping people manage compassion fatigue. “Self-criticism keeps our systems in a state of arousal that prevents our brains from optimal functioning,” Carr notes, “whereas self-compassion allows us to be in a state of loving, connected presence. Therefore, it is considered to be one of the most effective coping mechanisms. It can provide us with the emotional resources we need to care for others, help us maintain an optimal state of mind, and enhance immune function.”

According to Kristin Neff, an expert on self-compassion, caregivers should generate enough compassion for themselves and the person they are helping that they can remain in the presence of suffering without being overwhelmed. In fact, she claims that caregivers often need to focus the bulk of their attention on giving themselves compassion so that they will have enough emotional stability to be there for others.

People in the helping professions can become so focused on caring for others that they forget to give themselves compassion and neglect to engage in their own self-care. Blough often asks clients to tell her about activities that they enjoy — ones that take their mind off work, help them relax and allow them to feel a sense of accomplishment. Then she asks how often they engage in those activities. Clients often tell her, “I used to do it all the time before I became a professional caregiver.”

She reminds them that they can help others only if they are also taking care of themselves. That means they need to take time to engage in activities that relax and recharge them; it isn’t a choice they should feel guilty making.

Self-regulating in session

As helpers, counselors are likely to experience symptoms of compassion fatigue at some point. This is especially true for clinicians who frequently see clients who are dealing with trauma, loss and grief.

For McAnally, that experience came early in her career. During practicum, she had a client with a complex trauma history who couldn’t sleep at night. In turn, McAnally found herself waking up in the middle of the night, worrying about the client. She knew this was a warning sign, so she reached out to her supervisor, who helped her develop a plan to mitigate the risk of compassion fatigue.

It almost goes without saying that counselors should take the advice they give to their own clients: They should establish a self-care routine. They should seek their own counseling and support. They should set boundaries and find ways to recharge outside of work. And they should exercise self-compassion.

But counselors also need to find ways to self-regulate during sessions. “If you are tense and you’re hearing all of these heavy stories, you’re at a much greater risk of being vicariously traumatized,” Blough says. Self-regulation can provide a level of protection from that occurring, she notes.

Blough often uses the body scan technique while she is in session. Doing this, she can quietly relax her body without it drawing the attention of her clients. In addition, as she teaches relaxation skills to her clients, she does the skills with them. For example, she slows her own breathing while teaching clients guided breath work. That way, she is relaxing along with them.

Likewise, McAnally has learned to be self-aware and regulate her nervous system when she is in session. If she notices her heart rate accelerating and her stomach clinching when a client is describing a painful or traumatic event, then she grounds herself. She orients herself by wiggling her toes and noticing what it feels like for her feet to be touching the ground. She also looks around the room to remind her brain that she is safe.

McAnally also uses internal self-talk. She will think, “I’m OK right now.” As with the body scan, this is a subtle action that clinicians can take to ground themselves without the client even being aware that they are doing it.

Helping the helpers during COVID-19

Recently, Carr received a text from a counseling mentor who has been practicing for 40 years that said, “I am falling apart. I am lost. I don’t know what to do, but sending a text to someone I trust felt right. Write or call when you can.”

Carr quickly reached out, and her colleague said he was experiencing a sense of hopelessness that he hadn’t in many years. He worried about his clients and feared he wasn’t doing everything he could for them. He was also anxious about finances; several of his clients had become unemployed because of the COVID-19 pandemic, so he started seeing them pro bono. All of this was taking a toll on him personally and professionally.

Before the pandemic, McAnally managed her compassion fatigue symptoms in part by checking in with other therapists who worked down the hall from her office and by participating in in-person consultation groups. Now that she is working from home full time because of the pandemic, she says that she has to be more intentional about practicing self-care and accessing support. She calls her colleagues to check in, practices mindfulness, and schedules breaks to go outside and play with her dog.

Even when counselors recognize that they need help, they can encounter barriers similar to those their clients face. For instance, they may not be able to find in-network providers, and only a small portion of the hourly rate may be covered by their insurance. This problem made Carr pose some questions: “Who is helping the helpers right now? How can we take care of others if we aren’t able to more easily take care of ourselves?”

Then she decided to take action. She created Counseling for Counselors, a nonprofit organization dedicated to raising awareness about the emotional and psychological impact on mental health providers during a time of collective trauma. The organization’s aim is to generate funding that would allow self-employed licensed mental health professionals in need of treatment to more easily access those services.

“Although the heightened state of anxiety around the pandemic may have exposed this critical need, the demand for quality, affordable mental health care for counselors is ongoing,” Carr says. “Counselors are not immune to trauma and, now more than ever, licensed mental health professionals need access to mental health services in order to effectively treat the populations we serve and to continue to play an instrumental part in contributing to the well-being of society at large.”

Fostering compassion satisfaction

People in the helping professions often feel guilty or ashamed about struggling with compassion fatigue. They sometimes believe they should be immune or should be able to find a way to push through despite their symptoms. But that isn’t the case.

“I think the biggest takeaway when it comes to compassion fatigue is that it’s a normal, almost inevitable consequence of caring for and helping others. It’s not a character flaw or a sign of weakness. It’s not a mental illness. It affects the best and brightest and those who care the most,” Blough says.

For that matter, compassion fatigue isn’t something you “have” or “don’t have,” she adds. Instead, it operates on a spectrum, which is why it is so important for helping professionals to be aware of its warning signs and symptoms.

Blough acknowledges that compassion fatigue is always present in some form for her personally. She often manages it well, so it just simmers in the background. But sometimes it boils over. When that happens, she knows to regulate herself, to increase her self-care and to get support.

It is easy for a negative experience to overshadow a helping professional’s entire day and push aside any positive aspects. That’s why Blough and McAnally both recommend setting aside time daily to list three positive things that happened at work. A counselor or other helping professional could focus on the joy they felt when they witnessed an improvement in their client that day or when they witnessed the “aha!” moment on their client’s face.

Blough often advises clients to journal or otherwise reflect on these positive experiences before they go to bed because it can help prevent rumination and intrusive thoughts that may disrupt sleep. Celebrating these “little victories” will help renew their passion for their job, she adds.

As Blough points out, “Empathy can definitely lead to compassion fatigue, but if properly managed, it can also foster compassion satisfaction, which is the antithesis of compassion fatigue. It’s the joy you get from your work.”

 

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

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

The counselor’s role in community outreach and resiliency building

By Denise Takakjy April 15, 2020

Professional counselors do not practice in a vacuum. Counselors practice, regardless of the setting, in community with others. Counselors practice in neighborhoods, in schools, in mental health agencies, in inpatient mental health hospitals, in colleges, in homes, in homeless shelters, in assisted living homes, in prisons, and the list goes on. All of these areas of practice are in communities. Therefore, we must be aware as counselors of the issues that affect the communities where we practice.

Communities are often affected by traumatic events and experiences such as community violence, drug and sex trafficking, police shootings, crime, substance and alcohol abuse, and parental abuse and neglect toward children. As a licensed professional counselor, I work primarily with children and adolescents who have extensive trauma histories. I provide trauma therapy in the form of trauma-focused cognitive behavior therapy. I also work within my community to provide trauma education to organizations such as day care centers to help these educators understand trauma’s effects on young children. My goal is to provide more community outreach through education and training to enable communities to become more trauma informed and resilient.

In this article, I will discuss the pivotal role that professional counselors can play in developing resilient communities through outreach. Counselors possess the expertise, experience and training to help communities develop programs necessary for addressing and ending the adverse effects of events that have taken place within these communities.

Adverse childhood experiences

Adverse childhood experiences (ACEs) have been shown to have an impact on future health implications and violence victimization. These experiences can include:

  • Abuse
  • Neglect
  • Witnessing violence in the community
  • Witnessing domestic violence in the home
  • Having a caregiver or loved one experience a prolonged illness, mental health crisis or death
  • Having a loved one die by suicide
  • Being separated from biological parents
  • Being in the foster care system
  • Having a loved one engage in substance or alcohol abuse

Each of these experiences can lead a child to feel unsafe and to struggle with stability and attachment.

Early ACEs will have long-term impacts on children well into adulthood. ACEs have been linked to unsafe behaviors, chronic health problems, poor academic achievement, lower rates of graduation, more lost time at work, and early death. The original ACEs study was conducted by the Centers for Disease Control and Prevention (CDC) and Kaiser Permanente from 1995-1997 in Southern California. The conclusion of the study was that those who had experienced four or more ACEs were more likely to experience increased health risks for alcoholism, drug abuse, depression and suicide. These individuals were also more likely to experience poor physical health, have multiple sexual partners, contract sexually transmitted diseases, experience obesity, have limited physical activity, and engage in smoking. Among the physical problems noted among adults who had experienced four or more ACEs were ischemic heart disease, cancer, chronic lung disease, liver disease and skeletal fractures.

Another study, the Philadelphia Urban ACE Study, was conducted to determine how ACEs affected those in a large urban city with a socially and racially diverse population (the original ACEs study from the CDC and Kaiser Permanente involved mainly individuals who were white, middle class and highly educated). The Urban ACE Study found that 33% of adults in Philadelphia had experienced emotional abuse in childhood, while 35% had experienced physical abuse in childhood. Other findings included that 35% of adults in Philadelphia had grown up in homes with a family member who abused substances, whereas 24% had lived in homes with a family member who was mentally ill. About 13% of adults had childhood experiences of someone from their household being incarcerated.

These two studies demonstrate a need for a) early intervention trauma treatment and b) outreach to provide collaborative support to build more resilient communities. For communities to become resilient, there must be support for the well-being of children and their families. This is where professional counselors can become strong advocates for the clients they treat. Many of the children, adolescents, adults, families and couples that we treat are currently experiencing problems that may be related to ACEs. So, what can we do as counselors to build resiliency within our communities?

1) Understand the trauma response. Counselors should do what they can to become more trauma informed. This means understanding what trauma responses are and what these responses look like. In my own practice as a trauma-informed child and adolescent counselor, many children come to me with diagnoses of attention-deficit/hyperactive disorder, oppositional defiant disorder, depression, anxiety, conduct disorder, obsessive-compulsive disorder, developmental disorders, intermittent explosive disorder, and pervasive disorder. Many of these children have been seen by multiple mental health providers who have worked to extinguish the challenging behaviors that accompany these disorders. Parents are at their wits’ end because “nothing seems to work.”

What I often find is that no formal assessment of trauma symptoms has ever been performed to determine whether these children might be experiencing a trauma response. Understanding how trauma affects the brain can provide counselors with an awareness of where certain behaviors are originating. Traumatized children are not able to regulate emotions, tolerate distress or learn because the centers of the brain that control these functions have not developed appropriately. The body is in a constant state of stress, and the child is in the fight, flight or freeze state. So, the behaviors and emotional problems that we are seeing may actually be stress responses from trauma.

2) Screen for trauma symptoms. Trauma screening should be done on all clients whom counselors see. It should be a part of every intake. Not every client will screen for trauma symptoms, but when they do, counselors will have the information needed to begin trauma-focused therapy or to refer to other counselors who have that training.

Counselors can conduct outreach to their communities by providing trauma screening to organizations or by teaching those within organizations to screen for trauma. Trauma can be screened for in physicians’ and pediatricians’ offices, day care centers and schools. I conducted an in-service training in which I taught educators at a local day care how to recognize behaviors that might be a result of trauma and understand why these behaviors occur. The training was well received, and these educators are usually among the first to recognize when children are having behavioral or emotional difficulties. Once communities can conduct an initial screening, then an assessment for trauma symptoms can be made that will lead to recommendations for treatment.

3) Advocate for appropriate mental health services within schools and communities. Budget cuts in many organizations within the communities where counselors practice often target mental health services, resulting in the discontinuation of services. In my area of practice in Pennsylvania, when the educational budget needs to be trimmed, school counselors are usually cut. This leaves one or two counselors to serve a school with hundreds of students. Some schools do not have the benefit of having other mental health professionals in their buildings. There may be one or two school psychologists to serve a district of five to 10 schools. Thus, the ability to screen for trauma is nearly nonexistent due to the absence of personnel to conduct those screenings.

Professional counselors can reach out to collaborate with school districts in the areas where they practice. In my practice in both agencies and private practice, I enjoyed working with many school counselors who asked me to help support their students. I always reached out to coordinate with school counselors to plan how to best help my clients. This is very beneficial for clients because they then receive collaborative support within the school. Counselors may also have the opportunity to contract with schools to provide supportive mental health care to students.

4) Advocate to build more trauma-informed communities by reaching out to lawmakers. Counselors can reach out to legislators when issues of mental health come up. Counselors can advocate for more school counselors and for trauma-informed training of school personnel and personnel in other social services agencies, including children and youth agencies, foster care agencies and welfare services. Counselors can advocate for their clients by encouraging legislators to work within their districts to develop mental health programs that are more accessible. Many adults cannot afford mental health services. Counselors can be on the front lines advocating for affordable health care that includes mental health parity.

5) Support the integration of mental health care in pediatric medical offices and physicians’ offices and training for first responders. Counselors can reach out to pediatricians and medical providers to raise awareness of the need for trauma screenings. Some already conduct these screenings. Some may conduct these screenings but offer no referrals for help. Partnering with these medical services and working collaboratively with medical personnel will encourage greater screening of trauma among patients and allow medical personnel to provide their patients with referrals to mental health services. In addition, counselors can offer to provide trauma training to organizations that train medical workers. The more trauma training that medical professionals have, the more resilient the community is likely to become because referrals for mental health services will be made earlier.

One trend that is occurring is more first responders being trained to identify trauma symptoms. First responders are often the first to arrive when someone is in a mental health crisis. Unfortunately, the news is too often filled with stories about law enforcement personnel shooting and killing individuals who were having a mental health crisis. Teaching safer alternatives for first responders to engage with and de-escalate those in crisis is another area in which counselors can provide outreach to their communities. Creating more mental health crisis teams within communities can be effective in reducing the number of deaths that occur when individuals suffering from a mental health crisis meet untrained first responders.

6) Advocate for trauma-informed schools. Professional counselors can collaborate with schools to train all school staff on trauma-informed care. Helping school staff to recognize when a student might be exhibiting trauma responses will allow them to provide needed support until the student can be evaluated by the school counselor or a mental health professional.

Counselors can also collaborate with schools to develop anti-bullying programs and sexual assault awareness programs. Bullying and sexual assault cause trauma to many students and will result in emotional and behavioral problems in school. Traumatized students are unable to focus and learn and will tend to isolate themselves. Students may exhibit acting-out behaviors such as tantrums or oppositional behaviors. Some students may hold their trauma inside and exhibit depression and anxiety symptoms.

In my experience working with adolescents where anti-bullying and sexual assault awareness programs are already in place, I often hear reports that these programs are ineffective. I see this as an opportunity for professional counselors to develop evidence-based programs that are
truly effective.

Conclusion

Studies have demonstrated the long-term effects of ACEs, particularly in communities where poverty, substance abuse, alcoholism and violence are the norm. Counselors can provide outreach to their communities and advocate for their clients and communities to develop trauma-informed programs and early intervention.

The ACA Code of Ethics tells us that advocating for our clients is an important part of the work we do. My challenge to you, my colleagues, is to think about the many ways that you can advocate for your clients and your communities.

 

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Denise Takakjy is a licensed professional counselor, national certified counselor and licensed behavioral specialist working in private practice in Harleysville, Pennsylvania. She specializes in providing trauma-informed care to children and adolescents with extensive trauma histories. Contact her at dtakakjy@healingheartshealthyminds.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, go to ct.counseling.org/feedback.

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

Hearing voices: A human rights movement and developmental approach to voice hearing

By Laren Corrin March 12, 2020

In 2016, shortly after I entered a CACREP-accredited graduate program for clinical mental health counseling, I began hearing, outside of the class setting, about an international human rights movement centered around the “voice hearing” experience — what would be called auditory-verbal hallucinations in clinical mental health settings. The movement includes people with unusual perceptions that often get labeled as psychosis.

I slowly came to learn about the movement through an introductory workshop, a three-day group facilitator training, attendance in online and in-person groups for a year, and the reading of the literature on the topic. Most recently, I traveled to Montreal for the 11th World Hearing Voices Congress, where I was able to shake hands with and hear one of the movement founders, Dutch psychiatrist Marius Romme, speak.

With this article, I hope to familiarize counselors with the Hearing Voices Movement and related international networks of recovery groups. I believe the Hearing Voices Movement is in alignment with the values and ethical principles of the American Counseling Association.

History and current development of the movement

The Hearing Voices Movement started in the 1980s in Europe when a patient confronted Romme about the limitations of the psychiatric care being provided. Why, the patient asked, was it OK for Romme to believe in a God whom he could not see or hear but not OK for her, the patient, to believe in voices that she really did hear? To learn more about the voice-hearing experience and to try to help his patient, Romme had the woman’s story told on TV and asked for other voice hearers to contact him. Approximately 550 reached out.

Remarkably, many of the people who heard voices did not need clinical help. Writing in the Journal of Mental Health in 2011 after conducting a literature review, Vanessa Beavan, John Read and Claire Cartwright asserted that it was safe to say that 1 in 10 people in the general population will hear voices. Romme eventually compared psychiatric treatment to eliminate voice hearing to conversion therapy for sexual orientation.

How did he come to that conclusion? By accepting the reality of the voices rather than just checking them off as a symptom to be treated, Romme said, he could learn much more about their origin and meaning and identify ways to help his patients. He discovered that voices were often a reaction to problems in life, such as bullying or abuse, with which the person could not cope. In other words, there was a relationship between the voices and the person’s life story.

The Hearing Voices Networks (HVN) are the network of community groups that emerged from the Hearing Voices Movement. As of early March, the Hearing Voices Network USA had 119 groups listed on its national website. At the World Hearing Voices Congress that I attended, it was reported that Brazil has quickly grown over the past few years to have 35 groups, whereas the province of Quebec in Canada started with one group in 2007 and now also has 35 groups. The majority of groups are in Europe, where the Hearing Voices Movement started.

The groups developed when people with experiences of voice hearing got tired of not being listened to and of being labeled as having mental disorders. They were also frustrated by the coercive nature of the often ineffective treatments. Individuals with experiences that might be labeled as psychosis in clinical settings can meet in these groups and explore their experiences in spaces that are free of clinical judgment. If a clinician brings a person to attend a Hearing Voices group, the clinician will often be asked to wait outside or in another room while the voice hearer attends. Members of these networks believe in the freedom of voice hearers to interpret their experiences in any way they see fit. The key to this approach is for individuals to be listened to in a curious, nonjudgmental way as they describe their experiences.

People are discovering that when listened to in this way, profound healing can occur. Eleanor Longden’s TED Talk, titled “The voices in my head,” is a great introduction to this approach. Longden describes how changing her perspective on hearing voices — from a disorder to be treated to experiences with meaning if one could just open up their metaphorical wrapping — led to a huge developmental shift that allowed her to make peace with her experience.

Treatment alternatives

I firmly believe the Hearing Voices Movement is in alignment with ACA values. ACA has a rich tradition of promoting social justice, honoring diversity, and supporting the worth, dignity, potential and uniqueness of people. In clinical practice, counselors work to promote the ethical principle of client autonomy, fostering the right of clients to control the direction of their treatment and lives. This aspiration is realized with all range of mental health concerns, but experiences that could be labeled psychosis are generally approached differently in the U.S. mental health system, potentially indicating a blind spot in the field of mental health.

In contrast to the ACA values I learned in my first semester of graduate school, I began to have a growing concern when learning about counselor roles that stood in opposition to those values. Specifically related to psychosis were the two roles of providing psychoeducation and monitoring adherence to medications. This involves instructing the client in the medical model, explaining that hearing voices and other unusual experiences are symptoms of a brain disease process, asserting that symptoms have no personal value or meaning to be explored, and teaching that treatment should consist of attempting to arrest that disease process. In taking that approach, psychoeducation essentially serves to impose a particular value or framework on the client’s experience of hearing voices.

The American Psychiatric Association established the medical model upon its founding in 1844, writing in its journal at the time that “we consider insanity a chronic disease of the brain …” That is the lens and approach that the organization has taken and buttressed with evidence. Of course, the medical model framework is useful for some people, and many useful treatments have been derived from it. However, there are other people who prefer alternative social or developmental models and lenses that are more in alignment with ACA values.

A 2017 United Nations Human Rights Council report concluded that one of the barriers to mental health and wellness was a lack of free and informed consent. Specifically, “In order for consent to be valid, it should be given voluntarily and on the basis of complete information on the nature, consequences, benefits and risks of the treatment, on any harm associated with it, and on the availability of alternatives.”

The availability and awareness of alternatives and complementary approaches may be a key piece that needs some work. It is important for counselors to identify innovative approaches in line with the ACA ethical principles of client autonomy and nonmaleficence, or avoiding actions that cause harm. I believe the Hearing Voices Movement is one such promising innovative approach, with evidence building in academic journals and books, including Living With Voices: 50 Stories of Recovery, by Romme and colleagues (2009).

A developmental model

In contrast to the medical model, counselors rely heavily on a developmental model of client concerns. The Hearing Voices Movement comes very much from a developmental perspective and fully acknowledges that voices are often a reaction to problems in life. Having learned that with 70% of adults the onset of voices was related to trauma or conflicts, Romme and colleagues studied 80 children who heard voices and published the results in 2004 in the International Journal of Social Welfare. They found that 75% of children had an onset of voices in relation to circumstances they felt powerless over.

Although the Hearing Voices Movement acknowledges a trauma connection to the onset of hearing voices for the majority of people, a blanket causal explanation for all voice hearing is not declared. All explanations are given space to be heard in the Hearing Voices Networks groups, including the medical model, psychological models such as voices being subpersonalities of the voice hearer, spiritual beliefs that the voices are spirits, and other possibilities.

As a side note to the developmental perspective of hearing voices, there is a new culture emerging of tulpamancers — people who intentionally work to develop voices they call “tulpas” to interact with as friends, based on an ancient Buddhist practice. A researcher at McGill University, Samuel Veissière, has done phenomenological research on tulpamancers, and Tanya Luhrmann of Stanford University is working on a neuroimaging study of these individuals.

The book Living With Voices outlines a three-phase developmental recovery framework identified from people who recovered from the distress of hearing voices:

1) Startled phase: Anxiety and a feeling of being overwhelmed dominate. Sigmund Freud wrote about his experience of being a voice hearer while living alone in a strange city in The Psychopathology of Everyday Life. His description of his experience was translated into English as the voice suddenly pronouncing his name.

2) Organization phase: Interest in the experience is developed, and the voice hearer looks for more information.

3) Stabilization phase: Person recovers their own potential and capacity to live the life they choose.

Although this may appear to be a linear process, in actuality the process may be repeated each time that a new voice makes itself know to the voice hearer.

To clarify, in the Hearing Voices Movement, to “recover” does not mean that symptoms have been eliminated but rather that the person has recovered from the distress of hearing voices. As was the case in the not-too-distant past when homosexuality was termed a mental disorder, the solution is not to force people to be different than they are but rather to change society to allow people to accept themselves as they experience life and love. 

A role for the counselor

In the U.S. mental health system, clients who hear voices are most commonly acculturated into the perspective that their voices reflect a disease process with no inherent meaning. Frequently, once a mental health professional identifies voice hearing as a symptom, the voice hearer’s underlying traumas are systematically ignored and invalidated. The only history then asked about is family history of mental illness to confirm the diagnosis, even though the person’s trauma history could be addressed in counseling.

The Hearing Voices Movement allows many voice hearers to discover relationships between their voices and their life experiences. Some voices have the tone or use the language of a childhood bully or an abuser. Often, voices express difficult emotions that the voice hearers are not able to express themselves.

The Maastricht interview, named for the Netherlands university city in which it was created, was originally a research tool designed in collaboration with voice hearers to learn more about their experiences, but it was found to have clinical value in the beginning process for clients to explore their experiences. The Maastricht interview can be considered a voice-mapping process in which the interviewer asks the voice hearer questions about the voices. Through this process, voices are discovered to serve different purposes, such as representing unfelt emotion, protecting the voice hearer, or attempting to solve loneliness or social isolation.

Among the questions the Maastricht interview uses to accomplish this are:

  • Have you noticed whether the voices are present when you feel certain emotions?
  • Are you able to carry on a dialogue with the voices or communicate with them in any way?
  • Does the manner or tone of the voices remind you of someone you know or used to know?
  • Can you describe the circumstances when you first heard them (each voice)?
  • Please describe your own interpretation of what causes your experience and what your theory is for why you have this experience.

The Maastricht interview can be found on Intervoice, the International Hearing Voices Network website.

The Maastricht interview features eight specific questions that explore potential trauma experienced in childhood at home, in school or in the neighborhood. In addition to the counselor facilitating the organization phase of recovery for the client, these questions provide validation of the client’s life experience and raise awareness of unprocessed trauma that may be worked through more effectively with counseling than in the Hearing Voices groups.

Similarities with internal family systems

In Richard Schwartz’s internal family systems (IFS) model, a person is conceived as being born with several distinct parts (like subpersonalities), each of which can pick up burdens or traumas in life, and a core self that is not affected by traumas. The parts interact within the person, much in the way that different members of a family interact as a system.

I asked Schwartz if the IFS model could work with people who hear voices. He told me that it could. The voices can be worked with as parts in the IFS model, and Schwartz has done work with people with schizophrenia diagnoses.

In the Hearing Voices Movement, voices are seen as being very interactive within the individual who hears them. Likewise, in the IFS model, voices can be looked at as parts that interact as a family system. Additionally, in the Hearing Voices Movement, the goal is not to eliminate the voices (although that sometimes happens). Similarly, in IFS, the goal is not to eliminate the person’s distinct parts but rather to help the person discover and release unprocessed trauma burdens so that the system can live in a harmonized way. Much like in the Hearing Voices Movement, in which voices are acknowledged as real, IFS is best carried out from the understanding that a person’s distinct parts are real and can act within the internal family system.

In one last similarity of note, at the World Hearing Voices Congress, Romme said that most voice hearers know the age of their voices. At his workshop, Schwartz had some participants check in with their parts and find out what their ages were. 

Conclusion

Romme has drawn comparisons between using treatment to try to eliminate a person’s voice hearing with using treatment to try to change a person’s sexual preference. I was struck when I first read this comparison because I at the same time kept reading about ACA’s push to support bans on conversion therapy for sexual preference. Romme repeated this comparison at the World Hearing Voices Congress.

Initially, I kept thinking about the level of distress people must feel who hear voices that tell them to harm themselves or others. But I have since met, talked with and listened to so many people who hear voices — and who have really taken control of their lives by changing their relationship to those voices — that I am beginning to think that Romme is right. In my lifetime, homosexuality was included as a diagnosable mental disorder in the Diagnostic and Statistical Manual of Mental Disorders. It took a rights movement to change that. The Hearing Voices Movement — a human rights and social justice movement — is now well underway, with networks in 37 countries and counting.

 

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Laren Corrin is a counseling graduate student at the University of Southern Maine. Laren is an advocate for alternative frameworks for psychosis and complementary approaches to wellness. Contact Laren at larencorrin.com.

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

Helping clients grow from loss

By Sherry Cormier February 4, 2020

Loss is a universal experience and an underpinning of many therapeutic issues. The client who has just lost a job, the parents whose son is addicted to opioids, the client whose long-term relationship unraveled, and the client who received a devastating health diagnosis all have loss in common.

As a professional counselor and bereavement trauma specialist, I am sensitized to the ways that loss informs clients’ worldviews and emotional struggles. And as a grief survivor, I am aware of the unique ways in which loss can serve as a catalyst for growth. An African proverb captures this sentiment when it says, “Smooth seas do not make for skillful sailors.” But this raises questions: Is growth possible for everyone, and how do counselors help clients grow after a traumatic loss?

Posttraumatic growth: What is it?

Posttraumatic growth (PTG) is an approach that informs our practice as professional counselors. Richard Tedeschi and Lawrence Calhoun, who pioneered much of the research and theory on PTG, define it as positive change that follows the struggle after some kind of traumatic event. PTG represents change that occurs after a life crisis rather than during it. It usually involves longer-term change that occurs over an extended period of months to years as individuals cope with crisis by developing ways of thinking, feeling and behaving that are different from what they relied on prior to the life-changing event.

PTG is not the same as personal development or maturity. It may be thought of as something that occurs somewhat spontaneously as the result of trying to cope with a challenging life experience of seismic impact. Evidence of PTG does not imply that the loss or traumatic event was somehow desired.

Approximately 10% of loss survivors stay mired in grief, guilt and despair for an extended period of time following their loss. Clients who experience these emotions, coupled with an intense yearning for who or what was lost, might be suffering from complicated grief, which requires a particular kind of professional treatment (see complicatedgrief.columbia.edu). The majority of loss survivors do not get stuck in acute grief, however, and report some measure of growth during recovery from loss. For many of these survivors, growth may coexist with distress.

Research summary: What do we know?

In 1996, Tedeschi and Calhoun’s research resulted in the Posttraumatic Growth Inventory, a 21-item self-report measure that yielded five empirically derived markers of PTG:

1) Improved relationships with others

2) Greater appreciation for life

3) New possibilities for one’s life

4) Greater awareness of personal strengths

5) Changes in spirituality

These five markers of growth have been reported by a variety of survivors, including prisoners of war, veterans with posttraumatic stress disorder, people diagnosed with cancer or other life-threatening illnesses, people who became paralyzed from accidents, and those who have lost spouses or life partners. Although much of the research has been conducted with people living in the United States, other studies have explored PTG with individuals in other countries.

Among current findings on PTG, Tedeschi and his co-authors cited the following in their 2018 book Posttraumatic Growth: Theory, Research, and Applications:

  • About 30% to 60% of survivors report some experience of PTG following a difficult life event.
  • PTG is both a process and an outcome.
  • PTG is generally a stable phenomenon over time.
  • PTG is more evident in those individuals who score higher on measures of extraversion and openness to experience and is also related to optimism.
  • There are both universal aspects and culturally specific characteristics of PTG.

Critics of PTG point out that self-reported or perceived growth is not necessarily the same as actual growth. Some of the conflicting findings on PTG seem to be the result of differences in how growth is defined and measured across studies.

Growth-promoting practices with loss survivors

There has been less research about specific interventions and techniques that might facilitate PTG in survivors, although a predominant feature of a growth-oriented therapeutic approach involves working with client stories or narratives. The following practical strategies can be used to help facilitate growth with loss survivors.

Create a safe therapeutic environment. Traumatic loss erodes a sense of security and thrusts survivors into the middle of unfamiliar circumstances. Social support is crucial, yet many people in survivors’ social networks may be uncomfortable with grief or may offer well-intentioned comments that feel offensive to the survivor. Counselors’ first task is to provide a safe container that is comforting and companionable for loss survivors. Creating a therapeutic environment in which we listen closely and hold up a mirror to reflect these clients’ experiences will help loss survivors feel known.

Use self-care practices. Traumatic loss may disrupt the rhythm of survivors’ connections. One way to help loss survivors reestablish bonds with others is to encourage them to grow a new relationship with themselves. We can help clients do this by recommending effective self-care practices such as movement and exercise, adequate sleep, and the intake of nourishing food. In the 2012 book The Emotional Life of Your Brain, Richard Davidson points out that a lack of consistent self-care practices sabotages our ability to regulate our bodies and emotions. Mindfulness and self-compassion are additional self-care practices that can be used by loss survivors who feel emotionally flooded with anger, guilt or anxiety. Teaching self-compassion and mindful meditation to these clients can help them reestablish a connection with themselves and, ultimately, with others. These tools also enhance clients’ equilibrium, making further work toward growth possible.

Explore client narratives. An important part of therapy with loss survivors involves exploring their narratives or stories. PTG occurs most often with clients who create an adaptive narrative in which they are able to see themselves as survivors rather than victims. The following items play integral roles in exploring client narratives.

Timelines: Initially, clients can construct a timeline of their lives with significant events marked at various ages. Timelines provide critical clues about pre- and post-loss stressors as well as the loss event itself. Clients who have been subjected to many pre-loss stressors often have more difficulty discovering growth. Using strength-oriented queries when asking clients to review their timelines is useful. For example, “Juanita, I noticed you had a miscarriage when you were 20. How did you cope with that? What tools did you find that helped you through that loss?”

Clues of growth: Many clients are so affixed to the trauma of the event that it’s hard for them to detect anything positive about their story. Counselors can be most helpful by noting clues of growth and healing in clients.

For example, James, an African American in his mid-20s, is discouraged because he has been through multiple losses. The house he once lived in with his grandmother was recently obliterated by a tornado, and now she is in the hospital with multiple injuries. In addition, the business he started just folded. In recounting his narrative, James mentions that a local church has offered to help rebuild the home, and a nearby car dealership just offered him a job. He says having others reach out to him with offers of assistance feels so unfamiliar that it’s starting to change his opinions about the world and other people. Although he doesn’t identify this as an indicator of growth, his counselor does by pointing out ways in which James’ views of himself, other people and the world are shifting in a new direction.

Cultural context: Exploring client narratives within a cultural context is also crucial. Some clients may present narratives of cultural losses rather than individual losses in instances in which they have faced significant discrimination based on their race, ethnicity, gender, age, ability status or sexual orientation. It is important for counselors to be aware of the ways that clients’ cultural affiliations affect their lives and their views of traumatic loss and healing.

For example, James reveals that he has been working odd jobs since he was 14 to support himself and his grandmother, whose only source of income is a small Social Security check. James confides that this elevated level of financial stress and the recent losses he has experienced make him feel more vulnerable as a black man living in a predominantly white rural community.

Journaling: Counselors can also facilitate client narratives by encouraging the use of journaling as an adjunctive therapeutic intervention. Therapeutic journaling is a tool developed by James Pennebaker, who says that writing about traumatic events reduces stress and strengthens immune cells. Consistent journaling is most effective, but 15 to 30 minutes of journaling several days a week can be more productive than daily journaling, which may produce more rumination than growth, according to Pennebaker. When working with survivors of loss, counselors typically instruct these clients to write about their deepest thoughts and feelings regarding their loss.

Case example: Sharon

Sharon is a 62-year-old woman whose live-in partner of 40 years died of a sudden heart attack. Sharon resides in rural Appalachia, where she had lived with her now-deceased partner for many years. She has no children, and her one brother lives hundreds of miles away. Sharon stopped working in a dental office seven years ago to help take of her partner, who had uncontrolled diabetes. She has no real friends and reports that she has rarely been out of the house in the past seven years. She says that she has no neighborhood acquaintances or memberships in any social groups.

In the first several counseling sessions, Sharon sobs and indicates that she has no idea how she will go on after losing her partner. She has limited income but no real expenses other than rent and utilities. She insists that she does not want to return to work and has sufficient income to meet her monthly obligations. She presents herself as something of a loner and describes herself as isolated.

Sharon came to the community counseling center at the urging of her brother, but she is unsure that grief counseling can be helpful to her. Short of bringing her partner back to life, she doesn’t know how talking and crying about her loss will accomplish anything. She is not having trouble sleeping but feels compelled to get out of the house during the day. She drives around randomly and visits local discount stores just to have someplace to go.

Sharon becomes more interested in counseling when a grief support group is offered, and she attends several sessions. She returns to individual counseling in a much more animated state and is even able to laugh. Having made several friends in the grief support group, Sharon reports that the group has helped her feel less alone. She is able to construct a grief timeline in counseling and is amenable to doing occasional journaling when she has bursts of grief. Over time, she pursues recommendations for joining a local gym and a book club at the public library.

Four months into individual counseling, Sharon becomes interested in volunteering at a local animal shelter and starts doing so on a weekly basis. Several months later, she feels like a different person. She says she is ready to stop coming to individual counseling sessions but will continue attending the grief support group.

Not all grief survivors experience the kind of growth that Sharon experienced — or so quickly. Even though she continued to miss her partner terribly, her life as a caregiver for the past seven years had precluded her from developing much life satisfaction for herself. Her ability to make friends and develop social connections and her volunteering activities with the animal shelter gave her a great deal of self-efficacy and provided positive ways to deal with the absence of her partner.

Some people will not cope with loss as effectively as Sharon did. Those who experience losses associated with violence or who have coexisting diagnoses such as depression, anxiety or substance disorders are more likely to go through an extended recovery period for healing. In addition, many grief survivors feel guilty for experiencing any kind of satisfaction, as if it amounts to some kind of betrayal of the person who is no longer here.

At the same time, it is not uncommon for grief survivors to reevaluate and shift their priorities in life, in part because their life circumstances have changed. For example, Emilee lost her spouse Roberto, who was a retired military officer and active in veterans’ affairs. Roberto had spent his retirement years traveling internationally in support of this cause. Emilee had rarely accompanied him because of her fears of terrorism and plane crashes. After Roberto’s death, however, Emilee decided to engage with the same veterans’ foundation that Roberto had been active in and found herself traveling all over the globe. Emilee wanted to preserve her spouse’s legacy and share her own gifts with a larger number of people. Loss survivors such as Emilee and Sharon who find ways to give back or volunteer are more likely to report narratives of growth.

Being attuned to growth

Potential for growth exists when clients uncover meaning from their loss and construct narratives that fit into their worldview and sense of self. Skilled counselors can serve as guides to help survivors make sense of what has happened. No survivor should ever be pushed to grow, but having a counselor attuned to growth may be the missing piece that helps clients become more resilient in the face of traumatic loss.

In my own experience as a grief survivor following a series of personally devastating losses, awareness of my growth sneaked up on me. It was as if a dimmer switch got turned up again as my outlook and mood shifted in a positive direction. I include this because being attuned to indices of growth may be one of the best ways that we can help clients recognize growth possibilities and emerge from the darkness of a traumatic loss to find light again. As Jon Kabat-Zinn, founder of mindfulness-based stress reduction, has said, “You can’t stop the waves, but you can learn to surf.”

 

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Sherry Cormier is a licensed therapist, certified bereavement trauma specialist, and former faculty member at the University of Tennessee and West Virginia University, as well as being a public speaker, trainer and consultant. She is the author of Counseling Strategies and Interventions for Professional Helpers (ninth edition), senior author of Interviewing and Change Strategies for Helpers (eighth edition), and co-producer (with Cynthia J. Osborn) of more than 100 training videos for Cengage. Her newest book is Sweet Sorrow: Finding Enduring Wholeness After Loss and Grief. Contact her through her website, sherrycormierauthor.com.

 

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