Tag Archives: trauma

Effective ways to approach sexual assault response

By Hasmik Chakaryan July 10, 2018

The overwhelming number of women who have participated in the #MeToo movement has drawn renewed attention to issues of sexual violence, which remains pervasive in our culture. This newly risen wave has created a refreshed platform for addressing gaps in counselor training for sexual assault response.

Even though statistics from the National Sexual Violence Resource Center show that 1 in 5 women and 1 in 71 men in the U.S. will face sexual assault at some point in their lifetime, very few counseling programs have specific courses designed for training sexual assault response. Instead, counselors learn this “on the job”; we do our best to educate ourselves and to grow based on our experiences.

Those of us who have a special interest in working with this population seek additional training to acquire competence and to keep up with research in the field. Ongoing program evaluation at treatment sites is crucial so that we remain responsible for the outcome of our work and, at the same time, accountable to the public and to the third-party payers. We must constantly ask ourselves: Does what I do make a difference? Is my approach effective?”

The more common experience counselors have working with sexual assault survivors is in the traditional therapy setting, whether one-on-one or in groups, on campuses or within specialized agencies. Working with sexual assault survivors can be long and complicated, but it is often a rewarding journey of healing. Each of us tailors our own theoretical approach and framework to the needs of survivors with the techniques our profession has awarded us. So, we tend to approach sexual assault response from this end, engaging in short- or long-term therapy with survivors at some point on their journeys to heal.

Crisis intervention

An additional way to respond to sexual assault is at its onset, from a crisis intervention perspective. Traditionally, this is where victim advocates come in. Most counselors are not victim advocates, and most victim advocates are not counselors. Likewise, not all sexual assault survivors seek out victim advocate services, especially if they are already in counseling for other things. Regardless, counselors are often on the front lines of sexual assault reports and can be better prepared to handle such situations if they properly equip themselves.

To provide an adequate, timely and holistic response to sexual assault, it is essential that we learn about victim advocacy and incorporate some critical elements of this training into our counseling work when appropriate. Given the lack of specialized preparation during counseling training, I believe that counselors clearly need more tools to help them better respond to sexual assault, and I believe a need exists for an interdisciplinary approach regarding education, prevention and response efforts.

Based on the statistics, at some point during our practice as counselors, we will all encounter a client who reports sexual assault. I have worked in two campus-based counseling centers, and the number of students who reported sexual assault was startlingly high. According to 2016 statistics from the Rape, Abuse & Incest National Network (RAINN), young adults between the ages of 18 and 24 are at an elevated risk of sexual violence. In addition, based on statistics from the Centers for Disease Control and Prevention’s National Intimate Partner and Sexual Violence Survey published in 2011, it is estimated that 1.3 million women were raped in the past 12 months in the U.S. What I have learned over the course of the past 11 years in practice — as well as from my clients, students and colleagues — is that we, as counselors, need stronger training for providing a more timely and appropriate response to sexual assault.

In attempting to provide additional resources for my students who want to specialize in sexual assault response, I have found that the availability of trainings and educational programs varies widely from state to state. Information on these services and resources is scattered. We need to create education, training and workshops for those who want to specialize in this work. Perhaps what is called for is a nationwide network in which training and specialty certifications are streamlined and accessible in every state.

Meanwhile, I have attempted to put together a user-friendly diagram for counselors working with sexual assault survivors. In the remainder of this article, I will present a model that may help to organize sexual assault response into groupings for individuals who want to easily locate the appropriate next steps after a sexual assault or rape report. Allowing the survivor to have a voice and a choice in what comes next should serve as the most significant guiding element for counselors.

 

A chart of required or recommended action steps to take immediately after a report of sexual assault (courtesy of Hasmik Chakaryan).

 

Response to assault based on immediacy

One important recommendation is to always consider how the individual refers to herself (or himself) before using terms such as “victim” or “survivor.” The chart above walks readers through the required or recommended action steps immediately after a sexual assault report.

First, assess for safety. When working with victims of crime, it is critical to always consider their immediate needs first. It would be challenging and potentially damaging to the client to process any emotional responses without first addressing the physical or physiological needs, much like Abraham Maslow’s hierarchy directed.

Second, evaluate psychological needs. What are the individual’s most pressing psychological needs? This is where counselors apply their attending skills and provide the individual with empathy and respect.

From the tens of thousands of unprocessed rape kits (per a 2015 article in USA Today) to recent public rulings reducing sentences for college assaults (CNN, 2016) to new proposed laws that would permit a rapist parental rights (CNN, 2016), it appears that our society sometimes is confused about who the victim is and often participates in victim blaming. This widespread phenomenon often affects the ability of victims to recognize their experiences as assault and themselves as victims. It is imperative that counselors work against these societal/cultural norms by first questioning their own views.

Professionals need to check their assumptions and biases regarding sexual assault and who the victim is prior to sitting down with these individuals face-to-face. Counselors must become outspoken advocates for this population and ensure that the best psychological services are provided for survivors of this crime. This requires us to be nonjudgmental and to assert that a sexual assault is never the survivor’s fault. We should include assurances that the survivor is not responsible for either the crime or for the direct effects of that crime.

Third, lay out legal options. Does the survivor want to report the assault? Counselors do not provide legal counsel, but they do need to be informed about certain key elements when working with survivors who discuss legal actions. Most important, never make these individuals feel pressured to report; always allow them to make their own informed decisions.

If survivors decide that they do want to report the crime, inform them of the following:

  • Pursuing legal action requires collaboration with legal services, local police and forensic services. It is vital to process crime scenes immediately while there is still viable evidence and a better chance of locating witnesses to interview for accurate findings.
  • In some states, individuals can access treatment and counseling free of charge when they report the assault.
  • Reporting the assault can be empowering for some survivors and can help them regain some sense of agency. Reporting does not, however, guarantee that the perpetrator will be prosecuted. It is vital to avoid giving survivors false hope and expectations. In fact, a very small percentage of reported sexual assaults end up with the arrest of the perpetrator. According to a 2016 CNN report, of the nearly 300,000 average annual rape and sexual assault victimizations between 2005 and 2010, only about 12 percent resulted in arrests. Such statistics shouldn’t be shared to discourage individuals from pursuing legal actions. Rather, it is critical to process the expectations of sexual assault survivors in counseling.

Forensic exams

It is important to clarify the role of the forensic examiner (or the sexual assault nurse examiner) to sexual assault survivors. These medical professionals are very different from the nurses one might associate with a hospital emergency room. Instead, they are fulfilling a criminal justice role during the sexual assault exam, which is essentially a procedure to collect evidence. It is also imperative to explain the purpose of this forensic exam, the time sensitivity, the statute of limitations and the costs associated with the exam.

If survivors decide to pursue a forensic exam, notify them that they can terminate the exam at any time and can ask for a victim advocate or anyone else they want to be with them in the room. In most states, survivors of sexual assault incur no cost for the exam. The cost depends on what is included in the exam, what lab work and testing are performed, whether testing and prevention of sexually transmitted diseases are completed and whether any injuries incurred during the assault are treated. It is important to check any laws that may hinder the process in any way so that no unrealistic promises are made to survivors.

Counselors working with sexual assault survivors should know that many states process sexual assault forensic exams and related services under the Violence Against Women Act. One valuable resource for professionals and survivors is the RAINN website (rainn.org/articles/rape-kit), which offers a detailed rundown of what happens during the forensic exam. This information helps individuals grasp the importance of the forensic exam for evidence collection and assists them in making informed decisions. For all these reasons and more, independent advocacy is crucial for sexual assault survivors during the exam and throughout the entire process.

Immediate vs. delayed reporting

Providing survivors with information regarding the pros and cons of immediate versus delayed reporting can help them make educated decisions and aid the reporting process. Most of the information that follows in this section on the important elements of reporting and what reporting entails is based on the work of Andrea Sundberg and Dorene Whitworth at the Nevada Coalition Against Sexual Violence.

When a survivor of sexual assault arrives at the emergency room, the police are notified. Officers will interview the survivor for a thorough account of the assault. This helps them collect all of the crucial details while the person’s memory is fresh, giving them a better chance of collecting evidence to aid the legal process.

Providing a report of the assault to police is not the same thing as pressing charges against the perpetrator. Those are separate processes. It is vital for counselors to talk about this with sexual assault survivors and to prepare them as best they can. Not all police officers are trained to work with sexual assault survivors, and this interview may be triggering for these individuals.

Survivors may also choose to delay the reporting until they feel better prepared to handle it emotionally. The potential consequences of delayed reporting can include additional hurdles for thorough investigation, a lack of witnesses and a fading of the person’s memory regarding details of the assault. Delayed reporting may also affect the perceptions and responses of prosecutors and jurors and influence the prosecutor’s ability to obtain a conviction.

No report to law enforcement

Counselors working with sexual assault survivors may assume that the best direction for survivors to take is to immediately report the crime. There are many reasons why survivors may not want to report to law enforcement, however.

Most individuals hesitate to report immediately when there is fear of further danger to self, family or others. Others hesitate to report because of cultural beliefs or because of financial dependence on the perpetrator. Some individuals fear the investigation might reveal some kind of illegal activity related to underage drinking, prostitution, immigration status or other issues. Other individuals are simply terrified at the prospect of facing their perpetrators.

Some survivors will not report to law enforcement because of a sense of shame or embarrassment or because they worry about being blamed for the assault. There are also survivors who do not want to get their perpetrators in trouble because they are family members or are current or former intimate partners of the survivor. Some individuals may fear retaliation, especially if the perpetrator is their superior, employer or supervisor. If the perpetrator is a popular figure, survivors may fear social condemnation and disbelief if they report. Some survivors may lack trust in, or have had a prior negative experience with, law enforcement or the criminal justice system.

After obtaining 40 hours of intensive training in sexual assault response, I volunteered as a victim advocate, providing resources over a crisis hotline to individuals in central Ohio. Often, I would get calls from women saying they had been sexually assaulted by someone involved in law enforcement or the criminal justice system. These women feared more severe consequences if they chose to report. In some cases, these perpetrators were the survivors’ past or current partners; in other cases, they were not related to the survivor at all. In one particular case, the survivor told me over the phone that she feared going to the emergency room because the same police officer who had sexually assaulted her might respond to the call while he was on duty.

Regardless of whether individuals choose to report an assault, a forensic exam is available to them. The Violence Against Women Reauthorization Act of 2013 made it easier for all survivors to obtain a “Jane Doe rape kit,” through which they are given a code to identify themselves should they choose to report at a later date. Under this regulation, survivors must be offered a forensic exam and reimbursement for the cost of the exam without being required to participate in the criminal justice system or cooperate with law enforcement. This applies to all states in their applications for STOP Violence Against Women Formula Grants. In addition, survivors are not required to use their insurance benefits to pay for the forensic exams, which can offer them extra protection.

When educating sexual assault survivors about all of the possible options, it is critical not to make any promises that cannot subsequently be fulfilled. It is important to first find out how specific jurisdictions work and what procedures they follow. It is also imperative that counselors not pressure a survivor into any of these steps or decisions just because the counselor thinks it might be the best option. These individuals were already stripped of their choice and autonomy when they were coerced into nonconsensual sex, so it is vital that this agency be given back to them as part of the process that follows.

It is also important for counselors to know that sexual assault survivors are not limited to only one type of reporting. Indeed, there are various kinds of reporting, including:

  • No law enforcement involvement
  • Law enforcement involvement, storage only
  • Law enforcement involvement, anonymous/blind report (blind reporting is not the same as a third-party report; blind reporting means that the victim is involved but not identified)

For additional details on each of these options, refer to usmc-mccs.org/articles/restricted-vs-unrestricted-reports-know-your-options/.

Student/supervisee disclosure

When disclosure of a sexual assault is made by a student or supervisee, it is crucial to be trained in your institution’s Title IX regulations and requirements to respond adequately. The response will also depend on whether the individual is considered under the age of consent in your state.

I usually immediately connect students or supervisees with an on-campus victim advocate who then walks them through the entire process. I offer my expertise and answer their questions and concerns to ease some of their fears before referring them. If they request that I make the initial contact with the victim advocate and help facilitate the meeting, I offer to go to the first meeting with them.

The process of disclosing a sexual assault and deciding whether to report it understandably provokes anxiety in survivors. They are dealing with multiple effects that may include physical, psychological, spiritual and other issues. The most important piece for me is to make sure that I am present, available, attentive, caring, empathetic, responsive and nonjudgmental, and that I am able to provide a safe place for the survivor. I recommend that we all frequently assess our assumptions and biases regarding sexual assault and who the victims are because these are the nuances that can erect barriers between us and sexual assault survivors.

For more information about campus sexual assault prevention and services, see the White House Task Force to Protect Students from Sexual Assault 2014 fact sheet at justice.gov/ovw/page/file/910266/download.

Other considerations

Short-term crisis intervention vs. long-term counseling: Short-term services for sexual assault survivors include the initial crisis response and intervention immediately following the assault. Long-term mental health services might include a variety of therapeutic components such as assessments, goal setting, treatment planning and step-by-step work through each mental health concern and progress toward therapeutic goals.

A 2014 White House task force study of a community sample of rape survivors found that survivor outcomes were better in communities that had a greater number of post-assault resources. This also means that survivors report better outcomes when short-term crisis intervention is followed by long-term services such as a combination of individual counseling and group support work. Sometimes, it also may be beneficial to involve the family in the therapeutic process.

Trauma-informed care for treating sexual assault survivors: Trauma-informed care is a service delivery framework that considers the unique needs of trauma survivors by treatment providers. As part of this approach, important questions, such as how survivors should be treated by clinicians and what clinicians should be aware of when they are the first contact for mental health treatment, are addressed. Trauma-informed care simply adds a context of trauma to whatever theoretical approach and techniques clinicians find appropriate to use in their work with sexual assault survivors. It also brings up critical elements of neuroscience as a background to our clients’ trauma experiences.

Culturally competent counseling: Trauma looks different depending on the culture. In some cultures, women are blamed for being sexually assaulted. They are subsequently stigmatized, isolated and labeled as “damaged goods,” often resulting in them remaining alone for the rest of their lives. In other cultures, laws allow perpetrators of sexual assault to walk free while victims are either banned from the community or suffer severe punishments such as hanging or stoning.

To work effectively with sexual assault survivors in either short-term or long-term settings, it is imperative for counselors to possess strong contextual knowledge of the individual’s cultural, religious and ethnic backgrounds. Such knowledge helps us understand intricate nuances regarding the survivor’s self-perception, self-worth and perception of sexual acts, including those that were not consensual. It also allows for a more open conversation in a safe and nonjudgmental environment so that counselors can better guide survivors through their unique circumstance.

It is our ethical responsibility as counselors to continuously seek more education, awareness and self-growth in relation to culturally responsible and evidence-based counseling services.

Sexaual assault response training for counselors who desire to specialize: In most states, various sexual assault response teams carry out victim advocate trainings. These trainings are typically 40-hour, intensive educational experiences that include interdisciplinary input from experts in various specialty areas. Counselors who are not equipped to work with sexual assault survivors can always find a victim advocate to refer to in the area.

For more information on locating victim advocates in your area, see the National Organization for Victim Assistance website at trynova.org/crime-victim/advocacy/list/.

For more information on victim advocate roles and trainings, see the National Center for Victims of Crime website at victimsofcrime.org/help-for-crime-victims/get-help-bulletins-for-crime-victims/what-is-a-victim-advocate-.

For hotlines and other helpful links from the National Center for Victims of Crime, see victimsofcrime.org/help-for-crime-victims/national-hotlines-and-helpful-links.

 

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Hasmik Chakaryan is an assistant professor and director of clinical programs in the Department of Professional Counseling at Webster University. In addition, she is a licensed professional counselor, a clinical supervisor, a victim advocate and a trauma specialist. Her research also focuses on internationalizing the profession of counseling. Contact her at hchakaryan06@webster.edu.

Letters to the editor: ct@counseling.org

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

Past trauma in counselors-in-training: Help or hindrance?

By Bethany Bray May 20, 2018

Counselors are not immune to trauma — in fact, far from it. Many practitioners say that personal or familial experience with trauma or mental illness actually spurred them to become professional counselors.

The connection between personal experience and the pull to become a counselor is something that is hard to quantify, but “in my personal experience, I encounter it pretty frequently,” says Allison Pow, a licensed professional counselor in North Carolina and adjunct professor at both Wake Forest University and the University of North Carolina at Greensboro. “For a lot of people, past experience draws them into the counseling field, and trauma can play such a pivotal part in someone’s life. It’s a common thing that we see as supervisors and counselor educators.”

Past trauma can be either an impairment or a kind of “benefit” for counselors-in-training, depending on how much the person has worked through and processed the effects of trauma, say Pow and Amber Pope, a licensed mental health counselor and program chair of the clinical mental health counseling program at Hodges University in Fort Myers, Florida.

Counselor educators and other professionals in the field who have close contact with counselors-in-training should keep an eye out for red flags that may indicate that a person’s past trauma is interfering with their growth as a counselor or, in a worst-case scenario, has the potential to cause harm to clients.

“Just because you’ve been through trauma doesn’t mean you can’t become a counselor. You can become a great counselor if [your trauma] is processed correctly,” Pope says.

Pow and Pope co-presented a session, “Wounded healers: How to support counselors-in-training who have experienced trauma,” at the 2017 ACA Conference & Expo in San Francisco. The term “trauma” can encompass a wide variety of experiences, from an acute event to yearslong, developmental trauma, Pow explains.

People who have processed the effects of past trauma — often with the help of a therapist of their own — can become excellent counselors, Pow says. Posttraumatic growth and healing from the experience can foster empathy and strengthen coping skills.

“Going through trauma is a very unique experience [through which] you understand the way your brain works and your body reacts. That is hard for someone to understand who hasn’t gone through that,” Pow explains. “I have had some students who were very resilient because they have been forced to cope [in traumatic situations] in the past.”

“The reason a lot of people become very, very good counselors is their life experience,” Pow adds.

However, people who haven’t fully processed the trauma in their backgrounds can run into trouble as professional counselors. For example, in client sessions, they risk becoming triggered by topics that clients bring up and may be unable to regulate their own emotions or other behaviors in response. These reactions can harm the delicate balance of trust between practitioner and client.

“They may unwittingly be using their role as a counselor to work through their own unprocessed material or to recapitulate an unhealthy power dynamic to feel that they’re in control,” Pow says. “Control is often something that people seek after going through trauma. It may come from a lack of self-awareness.”

 

Red flags

Interactions with classmates and colleagues might be one of the best indicators of whether counselors-in-training have a trauma history that still needs to be worked through. During moments of vulnerability, do they become aggressive or reactive or express other strong emotions? In general, a lack of self-awareness, such as oversharing in class or being unaware of how the people around them are feeling, can be an indicator of unprocessed trauma, says Pow, who has a private practice in Greensboro, North Carolina.

Also watch for attachment issues or signs of avoidance, such as skipping classes or evading one-on-one contact with a professor or authority figures, Pow says. It can also be indicative of a trauma background if students do not generally have themselves together, including missing assignments or being late to class repeatedly, Pope says.

Other indicators can include:

  • Poor boundary keeping: This may manifest as oversharing, attention-seeking or disruptive behavior in the classroom, or an unhealthy preoccupation with relationships with classmates or colleagues.
  • Low self-confidence: Students with unresolved trauma may demonstrate low belief in themselves regardless of past successes. They may feel like they can “never do enough,” Pope explains. These students may lack motivation or even self-sabotage, such as missing a deadline even though they are capable of meeting it.
  • Rigidity in thinking: If students aren’t open to receiving feedback and unwilling to take constructive criticism, it can be a major indicator of past trauma that hasn’t been resolved. This attitude can stem from a black-and-white way of thinking in which the student categorizes things as “all good” or “all bad” with no in between, Pope says.

Everyone has bad days now and then that can set them off. However, if a student is repeatedly unable to regulate their emotions, such as becoming reactive or upset in class, it is a red flag, Pope says.

“When a student is so set in their values or way of thinking that they try and impose it on others, that can stem from trauma. If they can’t become more flexible in their thinking process or relationships with others, then they’re going to have a difficult time with clients,” she explains.

 

When it’s time to intervene

It is beneficial, for any number of reasons, for counselor educators to get to know and connect with the students in their program, Pope says. If a particular student seems to be struggling with challenges that could keep them from becoming a proficient counselor — such as issues related to unresolved trauma — it is better to intervene sooner rather than later.

Be prevention-focused instead of reactionary, Pope suggests. The longer a student continues in a graduate counseling program, the harder it will be to check their behavior or make decisions about their future.

“Don’t let students waste time and money if they’re not going to be a good fit,” she says.

Counselor educators who identify students raising red flags should pull them aside after class or ask them to stop by the counselor educator’s office, Pope advises. The first interaction with the student should be kept informal and light. Let them know that you have noticed some patterns and indicators in their behavior that require some attention, and ask them what supports they need to help them make improvements, she says. If appropriate, other professors or colleagues who know the student can sit in on this initial informal meeting to offer support, Pope says.

Check in with the student frequently during class breaks, supervision meetings and other opportunities. Ask how the student is doing and how they are practicing self-care. This conveys to the student that the professor wants them to succeed and grow, Pope says.

Pope emphasizes that this method should be applied only to counseling students who haven’t committed an egregious offense or intentionally gone against the ACA Code of Ethics. In those cases, a swifter and more formal response is necessary.

If a student does not begin to change their behavior after a first informal meeting, consider meeting with the counselor-in-training again to create a formal written behavior agreement. Spell out which behaviors aren’t acceptable, why those behaviors aren’t acceptable and what they need to do to continue in the counseling program. Be specific and include a timeline of when the expectations must be met, Pope advises.

If the student meets the requirements in the behavior agreement, they should be allowed to continue on with graduate school. If not, suggest that they take a semester or other time off to get the help they need, or leave the program entirely.

“When a student is given feedback and continues in their behavior patterns and doesn’t make any changes, that’s showing me that the student isn’t ready to change or do what they need to do to grow professionally,” Pope says.

Throughout the process, Pope says, she would recommend that the student attend counseling. There is some debate within counselor education as to whether it is ethical to require students to attend personal counseling . In the case of recommending a student to personal counseling, a counselor educator can request the student to provide proof, in the form of written letters from a provider, that they are attending therapy sessions and making progress to demonstrate their willingness to comply with their professors’ recommendation.

“We’re very open, telling students that we [their professors] have all attended or are attending counseling, and that it’s important to be as healthy as you can be, [to] take care of yourself mentally and emotionally,” Pope says.

Although sometimes uncomfortable, this process is also an opportunity for counselor educators to model what a healthy professional relationship should look like, Pope notes. It shows students that you can give critical feedback while caring and maintaining empathy.

“You can give suggestions and guidance while keeping professional boundaries. They may not have had that [example] in their life before,” Pope says.

“In my classes, I make a point of being very transparent with my expectations and predictable. I have a standard of which behaviors I respond to and which I don’t,” Pow agrees. “For a student who has gone through trauma, it’s not our job to be their counselor. But a lot of times their lives haven’t been predictable, and they haven’t had a safe base. We can be that predictable, safe base. We can talk openly about their struggles, getting help and that it’s not a bad thing that you’ve had some challenges in your life.”

 

Gatekeepers and guides

Counselor educators must strike a fine balance between acting as gatekeepers for the profession and serving as mentors and guides for those who need extra support, Pope says.

“When it comes to student trauma and challenges, for me, an ideal situation is when I can have enough conversations with a student so they can come to their own conclusions on whether the field is right for them or not,” Pow says. “Part of effective trauma treatment is creating choice and putting decision-making back into the person’s hands. That may be the choice to take some time off and return to the program. Emphasize where they have agency in things.”

It’s OK for a student to come into a graduate counseling program with unresolved trauma issues. They just have to be willing to work on it, self-process and accept help, Pow says. Students who are open to self-reflection and constructive feedback can experience a tremendous amount of growth, she says. “It’s unreasonable for us to expect, as educators, that people are going to come into these [graduate] programs having processed everything that has happened to them and be completely self-aware,” she affirms.

Processing and rising above trauma builds skills that are the hallmarks of a good counselor, including a strong sense of self-awareness, empathy and sensitivity. Counselors who have successfully processed their past trauma can become models for clients struggling with similar issues, Pope says.

“If you heal from a trauma, you really have to engage with the most vulnerable parts of yourself. It’s a depth that people who haven’t been through trauma may not fully understand,” Pope says. “That’s what creates really great counselors — [to be able to] engage with others at that level of vulnerability and intimacy. Knowing that going through something so challenging, you can become more whole, and in turn become a safe place for others. As a counselor, you’re better able to serve your clients.”

 

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Related reading

  • For more on supporting counselors-in-training through the supervision process, see the feature “Guiding lights” in the June issue of Counseling Today.

 

 

Suggested resources

Want to learn more on this topic? Pow and Pope suggest these titles:

 

 

 

 

 

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

 

 

Follow Counseling Today on Twitter @ACA_CTonline and on Facebook at facebook.com/CounselingToday.

 

 

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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.

 

 

Understanding and treating survivors of incest

By David M. Lawson March 6, 2018

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

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

Incest and its effects

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Betrayal trauma theory

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

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

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

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

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

Dissociation

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

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

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

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

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

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

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

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

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

Complex trauma

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

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

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

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

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

Treatment issues

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

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

1) Safety: Develop internal and environmental safety procedures.

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

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

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

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

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

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

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

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

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

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

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

 

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

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

Letters to the editorct@counseling.org

 

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

 

Beyond words

By Nevine Sultan September 28, 2017

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

A clinical vignette

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

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

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

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

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

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

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

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

Understanding dysregulation

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

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

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

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

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

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

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

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

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

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

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

Honoring the somatic narrative

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

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

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

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

Creating shared space

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

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

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

Organizing the client’s experience in the here and now

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

a) Creating a shared space facilitated by my presence

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

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

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

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

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

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

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

Creating meaning and energizing change

“What was that like for you?” I ask.

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

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

“I think … I felt in control.”

“Can you say more about that?”

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

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

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

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

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

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

“I did,” he says solemnly.

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

“I feel pretty big right now.”

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

Working through roadblocks

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

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

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

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

Establishing a time frame for the therapeutic process

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

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

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

3) The client’s current coping strategies

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

5) Client openness to working with the body

6) Therapist consistency and the quality of the therapeutic alliance

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

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

Closing reflections

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

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

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

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

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

 

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

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

Letters to the editor: ct@counseling.org

 

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

Informed by trauma

By Laurie Meyers September 22, 2017

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

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

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

Drawing on basic counseling skills

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

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

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

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

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

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

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

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

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

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

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

A different focus

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

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

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

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

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

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

Establishing safety

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Helping the helper

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Other symptoms include:

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

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

 

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Additional resources

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

Counseling Today (ct.counseling.org)

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

Books (counseling.org/publications/bookstore)

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

Webinars (aca.digitellinc.com/aca)

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

ACA interest networks

 

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

Letters to the editor: ct@counseling.org

 

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