Tag Archives: trauma

Journeying through betrayal trauma

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

Tero Vesalainen/Shutterstock.com

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

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

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

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

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

Answering the ‘why’ question

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

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

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

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

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

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

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

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

The root of addiction and the brain science

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

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

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

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

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

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

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

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

Let the healing begin

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

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

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

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

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

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

Reflection and reconstruction 

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

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

Forgiveness

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

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

Release and restoration

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

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

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

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

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

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

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

 

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

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

 

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

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

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

By James M. Smith March 9, 2022

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

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

Then the nightmares started.

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

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

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

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

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

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

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

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

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

Mindfulness in action

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

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

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

Yupa Watchanakit/Shutterstock.com

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

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

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

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

“Who’s going to hurt my children?”

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

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

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

Support and self-care

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Working through

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

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

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

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

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

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

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

 

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

 

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

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

Women and alcohol: Drinking to cope

By Bethany Bray November 2, 2021

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

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

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

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

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

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

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

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

Multiple factors at play

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

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

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

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

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

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

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

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

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

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

Intertwined with trauma

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

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

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

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

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

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

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

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

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

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

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

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

Lifting the shame

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Tailoring treatment

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

Vicky Gosselin/Shutterstock.com

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

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

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

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

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

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

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

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

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

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

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

Preparing for relapse

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

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

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

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

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

 

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How much is too much?

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

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

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

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

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

 

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Recommended titles

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

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

 

 

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

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

Tapping into the benefits of EMDR

By Lindsey Phillips September 27, 2021

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

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

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

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

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

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

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

How EMDR differs from other approaches

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

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

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

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

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

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

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

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

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

When to use (and not use) EMDR 

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

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

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

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

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

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

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

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

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

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

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

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

Case example with complex trauma

Larisa Lomaeva/Shutterstock.com

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Be fluid, not rigid

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

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

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

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

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

Don’t rush the process 

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

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

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

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

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

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

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

Adapting to the client’s needs  

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

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

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

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

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

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

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

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

 

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

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

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

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

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

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

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

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

(Information adapted from EMDRIA)

 

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

Trauma stabilization through polyvagal theory and DBT

By Kirby Reutter September 14, 2021

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

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

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

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

The two pedals

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

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

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

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

A breakdown in dialectics

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

  • Awareness
  • Thoughts 
  • Emotions 
  • Reactions 
  • Relationships 

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

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

bestber/Shutterstock.com

Restoring balance 

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

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

The RAIN dance: One path to mindfulness 

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

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

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

TIP the balance: One path to distress tolerance 

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

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

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

Sow your SEEDS: One path to emotion regulation

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

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

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

Working the TOM: One path to dialectical thinking  

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

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

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

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

DEAR Adult: One path to interpersonal effectiveness 

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

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

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

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

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

Summary 

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

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

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

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

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

 

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

 

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

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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.