Tag Archives: trauma

A hero/heroine’s journey: A road map to trauma healing

By Federico Carmona July 8, 2021

American mythologist Joseph Campbell dedicated decades to studying ancient texts and oral stories told in different cultures around the world. Campbell realized that most mythological quests in every culture followed a pattern he called the “monomyth.” 

This thematic tool was conceived with the notion that all of humanity, in all its diversity, reflects similar existential pursuits and living experiences. They are all part of an unknown larger universe or state of existence. In this pattern, a hero embarks on a journey to slay a monster, recover a precious artifact or rescue someone — the main objective always being to save the world from the end of times or from a great evil. 

This journey is full of challenges that threaten both the hero’s known inner world and the present mission, whatever that may be. Each obstacle the hero overcomes thematically shows a different lesson from which one can learn. The hero thus grows in skills and self-awareness as the journey continues. By the time the hero confronts the problem, or whatever serves as the primary antagonist of the story, they have evolved into a more superior version of themselves, a progression that doesn’t stop as the hero returns with the prize. This evolution holds the hero in an enlightened state of grace, able to understand and deal with the mundane and transcendent way of life.

Campbell described this idea in the book that made him renowned in the literary and artistic communities, The Hero With A Thousand Faces. Published in 1949, Campbell’s three-part presentation of the hero’s journey encompasses departure (embracing the journey), initiation (confronting and accepting change) and the return (maturing and moving forward). This echoes the stages of development of the human psyche, which involves transitioning from childhood to adulthood to the individuation or full realization of Carl Jung’s vision of the human psyche’s developmental climax — emotional maturation and connection with the transcendent.

In her book The Post-Traumatic Growth Guidebook: Practical Mind-Body Tools to Heal Trauma, Foster Resilience and Awaken Your Potential, Arielle Schwartz introduces the idea of looking at trauma recovery as a hero/heroine’s journey. Schwartz describes Campbell’s hero’s journey as a classic plot structure that has inspired a variety of literary and cinematographic works for generations. Schwartz contends that Campbell’s hero’s journey can also be applied to trauma healing. People can relate to this journey as they find themselves triggered into a crisis due to a traumatic event, the accumulation of stress or memories of abuse or neglect. 

Emotional crises usually take us into dark and painful places. The hero’s journey, Schwartz argues, encourages people to transform that pain and fear into a guiding wisdom toward self-awareness and emotional growth.

Healing is a journey

We tend to perceive and pursue healing, happiness, meaning and self-fulfillment as a linear and clear destination. However, these quests are meant to be experienced as a journey and not as one’s end goal. In the progression of the journey, one can experience healing and continue to pursue it. That is because there will always be something to heal in our physical, emotional and spiritual selves. Life never stops giving us challenges that provide us with valuable experiences.

Overcoming psychological trauma, while growing emotionally, intellectually and spiritually, is a journey that can be viewed as both challenging and rewarding. I would go so far to say that healing from trauma is a sacred journey. It requires venturing into the deep self to plant the seeds of healing, ultimately bringing forth a better version of one’s self. However, this journey requires a hero. The person affected by trauma is the one who embarks on this journey, and there is no vicarious substitution for the journey.

Venturing into the unknown is scary. Worse, becoming a hero is a terrifying task and a huge responsibility. Thus, many people would prefer to decline the invitation or call to healing because there is something comparatively cozy about that state of trauma. People who have lived parts of their lives in trauma are used to that state because it provides familiarity. Therefore, some will embark on the hero’s journey on their own, others will do so at a time when they have more support, and others will never respond to the call.

Therapeutically speaking, counselors walk along with clients who decide to take the journey of healing from trauma. Counselors also patiently prepare and encourage those clients who are doubtful about embarking on the journey because of its tremendous responsibility. Likewise, counselors understand and comfort those clients who refuse the journey because they are terrified of the pain and paralyzed by fear of the unknown.

Trauma-informed counselors understand that trauma is a neurobiological and emotional response to a frightening and upsetting experience. Trauma can be either a one-time or prolonged experience that affects a person’s outlook, beliefs, emotions and behaviors in their day-to-day life. Treatment plans include goals that deal with the most distinctive consequences of trauma:

  • Sense of powerlessness
  • Nervous system dysregulation
  • Self-devaluation
  • Disconnection from self

Clients who make the adventurous yet painful decision to embark on this journey will notice that they are building resources and improving their self-awareness with every step. This emergent growth is critical when confronting inner and outer obstacles while embracing change. As clients grow in resources and self-awareness along the way, they will also notice a developing improvement in the way they see themselves, others and the world. People living in trauma are reactive to life’s circumstances, whereas people living beyond trauma are proactive to life’s circumstances.

What kind of hero is needed?

Campbell set the record straight for doubters. The hero archetype is for anyone who finds the strength to embrace the call to the journey and perseveres in it, despite the overwhelming circumstances that may be facing them. This is because they believe in the healing purpose of the journey or are looking for something that is more significant than themselves. 

The hero is expected to learn an important lesson from the journey — that life is a constant and contradicting experience of good and bad things, all of which must be lived through willingly. Campbell also depicted the archetypal hero in different roles: as a warrior, lover, emperor/tyrant, redeemer and saint. Each of these roles represents a stage of the cosmogonic cycle, a mystical realm in a pure spiritual form transitioning to a physical manifestation and returning to the beginning.

The hero-warrior slays the monsters and tyrants of the hero’s past and present, ushering the hero’s community into the future. This hero-type promotes the renewal of life as the living God does. The hero-lover represents the connection with the transcendent, the relationship of humanity and the divine. The hero-emperor rules the earth as the living manifestation of the mystic realm. Human after all, the emperor becomes a tyrant as he learns to love flattery more than the relationship with the divine. The new hero-tyrant then is no longer the mediator between the human and the divine. The hero-redeemer bears more than a likeness to the divine, as they are one. In this oneness and incarnation with the divine, the redeemer is above the typical temptations of the flesh and ego. This hero’s mission is to save the world by confronting the divine tyranny that the hero-tyrant imposed on the world. After teaching “a new way of being in the world,” the hero-redeemer confronts such tyranny by sacrificing themself. The saint is a spiritual role and is the highest calling of a hero. This hero’s story is the beginning and end of the cosmogonic cycle — the spiritual creating the physical, which in time returns to its source.

The journey of trauma healing is a mixed bag of the mythic (fighting the beasts in the unconscious), the spiritual (believing and trusting in something bigger than oneself), the emotional (knowing and loving oneself), the intellectual (understanding and embracing change) and the practical (living beyond trauma). Every hero’s role is an aspect of the archetypal hero in Campbell’s monomyth. But do we need them all to achieve enlightenment?

This healing journey requires slaying the monsters and tyrants (one’s ill attachments) of the past and present so that one can move forward with renewed life. Love is also needed to connect with the self and the transcendent. This connection brings wisdom, order and redemption to the chaos of the unconscious. Whatever the task may be — e.g., healing from the wrongness of others or the self, rescuing the child-self frozen in time, healing from intergenerational trauma — the journey of trauma healing requires specific qualities and steps. These are:

1) Determination to let go of insecure attachments and tendencies.

2) Love to connect with oneself in the emotional and transcendent.

3) Wisdom to understand and integrate the self.

4) Pragmatism to live sensibly yet realistically beyond trauma.

A road map to healing

Living in trauma is living in emotional extremes, which is an impairment to one’s self-regulation. Thus, overcoming trauma requires two basic things: 

1) Regaining nervous/emotional self-regulation, which is the ability to face and make sense of one’s feelings and emotions rather than avoid them or shut them down.

2) Understanding and accepting one’s inner self rather than ignoring it. 

One-third of trauma work is teaching clients what trauma does and how the human body responds to it. The second third is reconstructing clients’ lost sense of safety, even in the face of uncertainty, and fostering reconnection with the self to reclaim control over it. As this process develops, clients grow in trust and self-compassion, which are key elements in overcoming self-imposed isolation due to the negative perception of self, others and the world around them. The final third of trauma work is integrating the traumatic experience by changing the narrative of the adverse experience in the here and now.

The proposed road map to trauma healing works well in 12-week psychoeducational groups of 90-minute sessions. The idea is to empower qualified participants with a concrete structure and strategies to do the work on their own. Each session is designed to introduce group members to new coping skills and life strategies to help them:

  • Establish a sense of safety
  • Achieve emotional regulation
  • Integrate traumatic experiences
  • Move beyond trauma

In his book Modern Man in Search of a Soul, Jung wrote, “The shoe that fits one person pinches another; there is no recipe for living that suits all cases.” The same holds true for various trauma treatments. Thus, this road map to trauma healing is adaptable. It is based on a variety of experts’ work in the interdisciplinary field of interpersonal neurobiology, which seeks to heal trauma by stimulating the brain’s neuroplasticity with positive persuasion and support.

Stage I: Establishing safety and competence

>> Step 1: Understanding oneself and one’s world. Clients are introduced to a short self-assessment and the art of journaling. The six-domain self-assessment is to be filled out with short phrases or single words to provoke enthusiasm for journaling. Clients are encouraged to revisit it as needed throughout the journey. Find the assessment at https://tinyurl.com/3yumcynf.

>> Step 2: Understanding the journey of healing. Clients learn about what trauma is and does and how the body responds to it. The Adverse Childhood Experiences (ACEs) study is introduced so that clients can find their ACEs score. The positive power of resilience is introduced to bring hope and direction to such a complex topic.

>> Step 3: Changing one’s story. Clients are introduced to the unhelpful thinking styles that prevent them from envisioning a better version of themselves and to the ABC model (adversity or activating event, beliefs about the event, consequences) in order to challenge and modify their cognitive distortions. Clients are also introduced to setting meaningful goals based on healthy personal values and beliefs. They learn that it is better to depend on new healthy habits than on motivation alone.

Stage II: Establishing self-regulation

>> Step 4: Learning to relate to others healthily. Clients are introduced to the topic and practice of healthy boundaries. They learn the degree to which setting healthy boundaries can ease their inner conflict in saying “no” while boosting their self-esteem and improving their relationships.

>> Step 5: Improving self-reflection and introspection. Attachment theory is introduced to foster self-reflection on patterns of thinking, behaving and relating to others and self. Identification with a dominant attachment style is critical to understanding what is needed to move toward a more secure attachment adaptation. Dan Siegel’s concept of “mindsight” is also introduced.

>> Step 6: Learning self-regulation (body and emotions). Clients are introduced to the skills of tracking, resourcing, grounding and others from the Community Resiliency Model to become familiar with their bodies, emotions and resources. Clients are also introduced to the practice of mindfulness. This step requires two group sessions.

Stage III: Integration of the traumatic experience

>> Step 7: Composing the narrative of trauma. Clients are introduced to the process of creating a coherent narrative. Techniques from narrative therapy, narrative exposure therapy or trauma narratives can be tailored to the group’s need (type of trauma) in this step.

>> Step 8: Reframing the trauma narrative. Clients are guided to see their narratives from the vantage point they have in the here and now. At this point in the journey, clients have grown enough in knowledge, self-awareness, skills and coping strategies to make favorable comparisons and lower the intensity of their fears and other negative emotions.

>> Step 9: Building self-acceptance. Clients learn to accept and integrate their reframed adverse experiences while facing the emotional consequences of trauma (e.g., shame, guilt, self-loathing). Strategies from acceptance and commitment therapy, cognitive processing therapy, transactional analysis or internal family systems can be helpful depending on the group’s need. In individual counseling, consider referring clients who feel stuck processing their negative emotions to a therapist trained in eye movement desensitization and reprocessing. This step requires two sessions.

Stage IV: Consolidation

>> Step 10: Transcending trauma. Clients learn that helping others is self-care. Love and connection with oneself and the transcendent facilitate acceptance and integration. Clients are invited to reflect on their journey from victim to survivor. Siegel’s mindsight levels of integration are lightly introduced to motivate clients to persevere in their healing journey to thrive in life.

Conclusion

Everyone faces and grieves their adverse circumstances in their own way. Some people become more resilient and wiser the more hardships they face. Other people become trapped in trauma and the victimizing sequel of their adverse circumstances, even after those circumstances have passed. 

People who overcome trauma grow emotionally, intellectually and spiritually from their adverse experiences. They are better prepared to face life circumstances and make better choices. They understand that helping others is critical to their own healing and well-being. People trapped in trauma remain focused on surviving their recurring adverse circumstances and their ensuing cycles of emotional turmoil. 

Applying this road map to healing also works well in individual counseling, although it takes much longer because clients’ current circumstances tend to dominate the sessions. In any case, therapy is an art. Counselors can help clients link their current and past experiences and do the work suggested in the steps that target their needs. Thus, individual counseling can use the road map as it fits clients’ needs and expectations. Consider that Stage I is the foundation of the work ahead and that trust, not rush, is the foundation of a successful therapeutic relationship.

 

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Federico Carmona is a certified clinical trauma professional working as a trauma therapist at Peace Over Violence in Los Angeles. Federico works with survivors of domestic and sexual violence and child abuse who are experiencing the devastating effects of posttraumatic stress disorder, complex trauma, trauma bonding and related psychological afflictions. Contact Federico at fcarmona@mac.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.

There’s nothing small about trauma

By Bethany Bray June 24, 2021

When talking about trauma, Hillary Cook, a licensed clinical professional counselor (LCPC) with a solo private practice in Boise, Idaho, has a saying that she often imparts to clients: It’s as possible to drown in a puddle as in the depths of the ocean.

Trauma is often lumped — some would even say oversimplified — into “big T” or “little t” categories. Big T trauma encompasses what many people think of when they hear the word trauma: large-scale, life-shattering events such as living through a war or natural disaster. Little t trauma includes more common events such as pet loss, work stress, parenting struggles or racial microaggressions, which on the surface may seem smaller. However, trauma is a complex issue, and all traumatic events — no matter how big or how small they may appear to others on the “outside” — have the potential to negatively affect clients’ mental health.

Cook, like many counselors who specialize in trauma, has seen clients who minimized their little t, everyday traumatic experiences or failed to even recognize them as traumatic. Even when clients seek counseling because they recognize that something is causing them distress and disrupting their life, they sometimes are unable to pinpoint or verbalize why, she says. Others may harbor feelings of shame or insecurity about how they feel. Cook has often heard clients, unsure of whether their experience warrants counseling, preface their stories by saying, “I don’t want to waste your time.” 

Cook, a member of the American Counseling Association, has also worked with clients who dismissed their traumatic experiences by stating, “I didn’t go to war,” “It wasn’t violent” or “I don’t know why this is bothering me.” She explains to these clients that the sticking point is not the traumatic incident itself but rather how it is stored in their brain. Counseling won’t take that traumatic memory away, but it can change how it is stored, enabling the client to carry it in a less painful way, Cook explains.

Providing psychoeducation is a critical first step when working with clients who have experienced little t traumas, says Debbie Millman, a licensed professional counselor and director of a trauma therapy practice in Madison, Wisconsin. It is helpful to explain to clients the depth and breadth of trauma, which can range from something catastrophic or systemic, she says, to “someone who didn’t get picked for the kickball team [in childhood] and it cut deep, and they still dwell on it today.”

“I see trauma as anything that affects how you see yourself or feel now. No matter how big or small it seems, it’s worth revisiting that [in counseling],” notes Millman, an ACA member.

She helps clients understand the importance of recognizing and addressing trauma — even everyday ones — with the following illustration: Trauma is like pushing a ball under the surface of the water in a swimming pool. You don’t know where it’s going to resurface, but it always will. The same rule applies to trauma: You can’t keep it buried; it will always resurface. The key is to process it.

Jessica Tyler, a professional counselor licensed in Alabama and Georgia, considers trauma to be “any experience that shifts your perspective on self, others or the world.” For one person, that experience might be tied to surviving a horrific car accident. For another person, it might trace back to feeling humiliated when they were called on by their first-grade teacher to read something aloud in class. The important point to communicate is that all of these experiences are valid, she says.

“I am very adamant [with] my clients that it serves no one to compare suffering,” Tyler says. “Suffering is suffering is suffering is suffering, and if we stop comparing the validity of our suffering, we can get to work on how these experiences can expand us as individuals versus define us and our worth.”

What lies beneath

Everyday trauma can dovetail with grief and loss, attachment issues, racial or cultural issues, panic attacks, self-esteem struggles, depression, suicidal ideation, eating disorders and many other challenges that clients present in counseling. For clinical practitioners, the key is not to take those presenting concerns at face value because unprocessed trauma may be a contributing factor or even the root cause, says Susan Gabel, an LCPC at a trauma-focused group practice in the Chicago suburbs.

If a client comes into counseling with symptoms of social anxiety, for example, clinicians should not limit their counseling work to addressing those symptoms or viewing the client simply as socially anxious, because then they may miss some of the larger reasons behind those symptoms, Gabel explains. 

“There can also be things that they won’t identify as trauma, such as a parent who was invalidating,” she continues. “It’s not a big T trauma, but if you add that up over and over and over again, they internalize it, and it becomes a powerful negative cognition of how they view themselves and expect people to respond.”

Low self-esteem, conflict avoidance and people-pleasing behaviors can be common among clients who have experienced trauma, Gabel notes. Because of this, practitioners must be mindful that clients may exhibit people-pleasing behaviors in therapy toward a counselor. This behavior can show up in a number of ways, she says, including when clients are not completely honest in sessions because they want to agree with their counselor, avoid conflict, or tell the counselor what they think the counselor wants to hear. These clients may also apologize frequently during sessions. 

Gabel points out that this fear of conflict can stem from clients having people in their life who had a pattern of responding negatively to their needs or feelings. Thus, they may reflexively expect that response from others, including their counselor.

“For a lot of people, [trauma] tends to lean into larger issues, including their views of themselves, views of others and fear responses,” says Gabel, an ACA member who holds two trauma certifications. “Difficulty with assertiveness can [indicate] a pattern of having relationships where their needs were not met, or they needed to appease or do what the other person needed.” 

Tyler, an assistant clinical professor and coordinator of the clinical mental health counseling program at Auburn University, notes that a client’s self-talk can also yield clues that the person experienced trauma in their past. Drawing from the work of North Carolina licensed clinical mental health counselor Candice Creasman, Tyler urges practitioners to listen closely for a client’s “wounded inner child,” which Creasman defines as the voice of their unhealed hurts. Exploring how this voice influences a client’s beliefs and decision-making can reveal the lived experience that generated the client’s problematic thoughts, Tyler explains.

“In my experience, this typically appears as the inner critic that we, as counselors, hear in a client’s hostile and harsh self-talk narrative,” says Tyler, an ACA member who counsels adult clients at a private practice in Columbus, Georgia. “In clients, this can also appear as anger, frustration, [or] controlling or needy behavior in therapy. The wounded inner child tests their therapist’s [ability] to show up with care, acceptance and compassion despite [the client’s] behaviors. This inner child is often the impulsive and risky part of a client that ‘acts out’ despite the potential for adverse consequences.”

Gabel often hears clients use language about feeling worthless, being “never enough” or assuming they are a bad person. Counselors can learn more about a client’s history, she says, by challenging those negative beliefs in counseling and asking when and where the client first heard those statements.

Gabel and Cook also note that somatic complaints can indicate that unrecognized trauma lies beneath a client’s presenting concern. Cook finds this especially true for symptoms that clients have explored with a medical specialist — such as hives with an allergist — without any cause
being identified.

Both physical responses and unresponsiveness can be connected to unprocessed trauma. Carrying any kind of tension in the body, including headaches, stomach troubles or sensations such as feeling a tightness in the chest, can be signs of untreated trauma, Gabel says. At the same time, past trauma can cause a client to talk about an experience that would typically elicit an emotional response in a disconnected or unemotional manner, she says.

If left unprocessed, little t trauma can become problematic in myriad ways, Tyler says, and treating it requires counselors to go beyond symptom management with clients. For example, a client’s self-protective behaviors could manifest as codependency and people-pleasing in romantic relationships to validate their security and worth as a person. This can make the client vulnerable to partners who are controlling, manipulative and even abusive, Tyler explains. 

“Focusing on behavior modifications and symptom management may bring short-term relief for a specific life situation. However, I find that clients often have difficulty applying these coping skills to new challenges that emerge in their lives,” Tyler says. “I have found more success in therapy when I can identify the cognitive key, or core beliefs that filter how a client sees and reacts to the world, others and themselves. This cognitive key may serve as a survival measure at first — [for example] avoidance, mistrust, perfectionism — but over time can create barriers to the client living a thriving life. … If a cognitive key can be discovered in therapy, the client learns how to adjust that ‘filter’ and see the world, others and themselves in the most flexible, rational way.”

Tyler illustrates this process through an example of a client who experiences panic attacks whenever she is away from her small child. The client may find relief after a few sessions if the practitioner focuses on breathing exercises, medication management and mindfulness with the individual. This may look successful on the surface, Tyler notes, but the root cause of the client’s distress remains unaddressed.

Instead, Tyler says, she would take a deeper look at the underlying issues by using Socratic questioning. This process helps the client “discover a long-held core belief that ‘I only feel safe when I am in charge,’ [which] can give us important data to work with to help address the client’s filter that goes beyond mothering and extends to other parts of her life,” Tyler says. “Here, I find the most potent change in clients.”

fran_kie/Shutterstock.com

Handle with care

Regardless of whether a client has experienced big T or little t trauma, the brain is interpreting what happened as harmful to the client in some way, Cook explains. What matters is not how “bad” the event was but how maladaptively it was stored in the brain.

“The type of trauma, or how bad it was, doesn’t change the approach [in counseling]. What the client needs will change the approach,” Cook says.

She advises considering whether the client has adopted healthy or maladaptive coping mechanisms or if the client has a strong social support system. If not, the counselor should focus on those aspects before diving into deeper work to help the client process the underlying trauma, she says.

The clinical practitioners interviewed for this article use a variety of techniques, including brainspotting, eye movement desensitization and reprocessing (EMDR), hypnosis, internal family systems (IFS) therapy and cognitive behavior therapy (CBT), to help clients who have experienced trauma. These practitioners stressed, however, that counselors should focus on self-regulation and social connection with clients and establish coping mechanisms before deploying techniques to process clients’ trauma. This is especially true with clients who have experienced everyday trauma and do not recognize the effect it is having on their presenting concern.

As a licensed mental health counselor who specializes in trauma work, Christine Smith has an extensive toolbox of coping mechanisms to equip clients with depending on their needs. Coping mechanisms not only help clients with emotional regulation but also instill containment skills they can use to manage their feelings and carry on with everyday life after heavy counseling sessions that deal with raw or troubling memories, she explains.

“People tend not to use their coping skills until their hair is on fire,” Smith says jokingly. She works with clients to instead ensure that coping skills become part of their everyday life, sometimes even assigning them as homework in between sessions.

She encourages clients to keep a list of coping mechanisms they find helpful on a piece of brightly colored paper in a visible spot in their home, such as the refrigerator door or bathroom mirror. She also recommends that they move this list around periodically, so they don’t begin tuning it out.

“Coping mechanisms themselves are trauma work in a way. I tell clients, ‘We’re going to do safety, safety, safety until you are rolling your eyes, and then we’re going to do it some more.’ If you don’t have a good foundation [before doing deeper trauma work], you’re building a house of cards,” says Smith, an ACA member with a solo private practice in Saratoga Springs, New York. “The best coping mechanisms are the ones that are so integrated in a client’s life that they don’t think of it as coping.”

Smith says this early work helps forge a therapeutic bond with clients and offers the practitioner a chance to ask questions that plant seeds about a possible connection between a past experience and the discomfort that caused the client to seek counseling. Questions such as “When was the first time you felt like that?” can help both the counselor and the client begin to make connections, she adds.

Gabel agrees that coping skills should be tailored to a client’s individual needs. Deep breathing or mindfulness may be helpful for some clients, whereas others may need to work on skills that they haven’t fully developed, such as interpersonal communication or problem-solving skills, because of their trauma history.

When starting trauma work, Cook often uses EMDR and hypnosis for immediate relief of nightmares, flashbacks and intrusive thoughts to help clients find stability. Only afterward do they unpack trauma and other related issues such as grief.

Millman begins trauma work by talking through clients’ life timelines, making note of events that shaped them and have stuck with them. She also devotes significant time to doing case conceptualizations and asking clients about their strengths, personality and likes/dislikes. This helps her with gaining a holistic understanding of the client and forging a therapeutic bond, she says.

Similarly, Cook recommends asking questions that help to paint a picture of a client’s framework, including their social supports and how they deal with intense feelings. Knowing more about a client’s background might also inform counselors about cultural and racial issues that can dovetail with everyday trauma that is systemic in nature.

Millman notes that it can be helpful to encourage clients who have experienced trauma to maintain “emotional margins” around each session. This means not rushing to a counseling session from work or after picking their children up from school. Instead, she encourages clients to engage in calming rituals, such as having a cup of tea or doing some deep breathing exercises, before and after sessions.

Millman, a doctoral student in the counselor education and supervision program at Liberty University, also advises counselors to keep trauma clients in mind when outfitting their office spaces. She emphasizes the importance of being intentional about what counselors expose their clients to. For example, having fashion or health magazines in the waiting room could potentially be triggering for clients whose trauma histories or related behaviors are connected to body image or disordered eating. Instead, Millman suggests striving to create an atmosphere that is warm and calming.

“All counselors have to be prepared to come across trauma; it’s at the root of so many mental health concerns and disorders,” Millman says. “Everyone needs to have some trauma-informed care training [and] be aware of what triggers clients and what phrases or buzzwords you might be using that could be problematic for someone. Especially in regard to race, be aware of the words you’re using. Getting culturally competent, trauma-informed care is really connected to [addressing] the daily trauma that people are facing right now.”

Digging deeper

In counseling sessions, a client’s past trauma will “come up when it needs to come up,” Millman says. For some individuals, that will happen right away, and it will come out “like a volcanic eruption.” For other clients, it may be a year into therapy before they’re ready to talk about it. But when they do, Millman says, she “can almost feel the relief in the counseling room,” especially for clients who associate feelings of shame with their trauma. “It’s like a weight has lifted, disempowering that hold it has over [them] now that someone else knows about it and can carry it with [them],” she says.

In trauma work, Smith adds, it’s not uncommon for clients to broach a traumatic subject by saying, “I’ve never told anyone this but … ” When that happens, Smith tells the client she is honored that they trusted her with this information.

“I try not to ever forget how much courage it takes to walk into a therapist’s office,” Smith says. “I try and be really encouraging, positive and respectful of that and recognize the wins that they have that other people aren’t going to recognize.”

Smith finds that work that focuses on emotional regulation can be especially helpful for this client population. In some cases, this involves simply talking through and processing interactions and events clients have experienced since their last counseling session. It can be helpful to “move at a glacial pace,” slowly unpacking an incident the client found distressing down to the minutiae, Smith says. This allows the client to identify the exact moment they started to feel triggered and lost the use of their self-regulation skills. Then, the counselor and client can talk about what the client could do differently the next time this type of scenario arises.

EMDR can be particularly helpful to work through troubling scenarios and feelings with clients who may not recognize a past experience, such as little t trauma, as the root of their discomfort, Cook says. However, these clients will be able to name the challenge that caused them to seek counseling, such as relationship trouble, work stress or panic attacks. EMDR allows the practitioner to target and heal clients’ distressing feelings and triggers without having to relive the trauma that lies underneath, she explains. The beautiful thing about EMDR, Cook says, is that it allows the practitioner to target a distressing pattern that the client is experiencing, which, in turn, targets anything else that is in that neural pathway, including related trauma.

During EMDR, the client engages in bilateral stimulation, such as rhythmic tapping, while talking through a scenario with the practitioner. The process rewires the client’s brain and creates a new neural pathway, revising the pattern into one that is free of distress, Cook says.

EMDR allows clients to “see themselves in a scenario in a different way and imagine how they want to feel … without having to go through it” and relive the trauma, she explains. 

This was the case for an adult client whose presenting concerns involved relationship issues and anxiety related to dating. Cook was able to use the client’s specific anxieties surrounding first dates as a target in EMDR. Cook guided the client to talk about the details of how they felt during their worst dating experiences. 

“All of a sudden, it went much [further] back, and we realized there were some parenting issues [involving verbal abuse] from many years ago in childhood,” Cook recalls. “It was really hard for them to hear at first. There was a lot of denial, [saying] ‘that’s not trauma.’ But then I used an illustration: If you could imagine a small child that’s not you and this was happening to them, how would you feel? Then it sunk in, and they realized how awful it was.”

Cook continued to use EMDR, as well as CBT, to focus on the client’s self-worth and to build healthy boundaries. This therapeutic approach built up the client’s coping skills so that on dates, they were able to focus more on the other person and be less “in their head,” Cook says. When the client worried less about what the other person was thinking about them, they were able to instead focus on finding connection.

EMDR, along with a combination of other therapies, was also helpful for a past client of Tyler’s whose presenting concerns were low self-esteem and anxiety. As they began to unpack things in counseling, the client also disclosed a history of self-harming behaviors and chronic suicidal ideation.

“She was successful in her career yet presented with chronic and relentless self-talk that was significantly cruel and self-blaming. Everything was her fault and everything terrible that had ever happened to her resulted from her failures; she was convinced that she was unlovable and worthless,” recalls Tyler, who co-presented the session “Trauma-Informed Care: Working With Trauma-Related and Survivor Guilt” at ACA’s Virtual Conference Experience in April.

In counseling, Tyler gently probed with questions to identify where and how this client learned such hypercritical self-talk. The client reported that it was simply “something she had always done,” Tyler says.

Tyler gently challenged this thought with psychoeducation that infants are not born with self-hatred; it is something they learn from their environment. Through that lens, she explained to the client how life experiences may reinforce negative beliefs and feelings of rejection. Over time, the client was able to reprocess several early childhood and adolescent experiences that she had previously believed were “not traumatic enough” to cause her mental health to dip to its current state, Tyler recalls.

“However, in examining these experiences through the lens of how young, vulnerable and impressionable she was as a child, it made sense how one thing spiraled into another, which then turned into years of confirmation bias,” Tyler says. “Using a careful combination of EMDR, CBT and IFS, she communicated with her younger self and realized that, in reality, being worthy was her birthright and that she was allowed to make mistakes and learn from them just like everyone else. Moreover, every time she damaged herself emotionally or physically, she betrayed that younger version of herself that was not adequately protected from the harm and toxicity of others.”

This change occurred gradually over one year of counseling. Eventually, the client’s self-harm and suicidal ideation ebbed, Tyler says, and she adopted a lens of “gratitude for the younger versions of herself who endured — and her present adult self who now had the control and power to make choices to nurture and soothe her along the journey of life’s challenges.”

Not so little

Gabel thinks it is more helpful to view client trauma on a spectrum rather than sorting experiences into either “big T” or “little t” boxes. She urges counselors to keep an open mind, regardless of how severe a client’s experience may — or may not — seem.

“Little t traumas can add up and hold a lot of power. Complex, relational trauma can be little t’s that add up and become overwhelming,” Gabel says. “A lot of times [counselors] are trying to make logical sense of it — if this [experience] is affecting [the client], it must be connected to a past event (e.g., peer conflict as an adult and past bullying as a child) — when in reality, that’s not how our brain wiring works. It doesn’t always make logical sense.” 

Smith also encourages counselors to keep an open mind about what qualifies as traumatic. Something that on the surface appears to be a smaller trauma, such as the death of a pet, can be a huge loss to someone who didn’t have healthy attachments growing up, she notes.

“It’s not up to me to decide what’s a small t trauma versus a large T trauma. Something that’s small might be linked to something that’s not so small,” Smith says. “What I’m looking at is someone who has experienced some kind of disruption or loss that they’re having trouble getting over. You and I could have the exact same experience, and you might come out unscathed, and I might really suffer, and we don’t always know why that is. … Just keep yourself open and curious [in counseling sessions]. My clients are my greatest teachers, and if I listen very carefully, they know exactly what they need to heal.”

 

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Referring and co-treating

The nonprofit organization Mental Health America offers an online mental health screening each year on its website. In 2020, nearly 2.5 million people took the screening, and past trauma was second only to loneliness as the most reported cause of mental distress.

This data illustrates what many counselors see in their daily work: Trauma is ubiquitous and can have a profound effect on mental health. With that in mind, clinical practitioners must be mindful of when a client’s trauma goes beyond their expertise. The counselors interviewed for this article stressed that trauma is a complex issue and clinicians who do not specialize in this realm need to be ready to seek additional training or supervision, consult with colleagues or refer clients for specialized trauma work.

Seeking outside help is especially important when a client is no longer making progress with their counselor, says Hillary Cook, a licensed clinical professional counselor in Boise, Idaho.

A strong, trusting therapeutic relationship is crucial in trauma work, Cook notes, and a referral doesn’t necessarily mean this bond is broken. Clients can continue to work with their original counselor while being co-treated by a specialist. In this scenario, the client would need to grant permission for the two clinicians to consult with each other.

“We can’t be all things to all people,” agrees Christine Smith, a licensed mental health counselor who specializes in trauma work at her private practice in Saratoga Springs, New York. “If a counselor doesn’t have specialized training in dealing with some of the more complex trauma issues, don’t be afraid to refer out.”

Consult Standard A.11. of the 2014 ACA Code of Ethics at counseling.org/ethics for more on the ethical guidelines surrounding the referral process.

 

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Action steps to learn more

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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.

Untangling trauma and grief after loss

By Lindsey Phillips May 4, 2021

Death, loss and grief are natural parts of life. But when death arrives suddenly and unexpectedly, such as with suicide or a car accident, the overlap of the traumatic experience and the grief of the loss can overwhelm us. 

Glenda Dickonson, a licensed clinical professional counselor in private practice in Maryland, describes traumatic grief as “a sense-losing event — a free fall into a chasm of despair.” As she explains, the experience of having their everyday lives ripped apart by a sudden and unexpected death can cause people to go into a steep decline. “They are down there swirling,” she says, “experiencing all the issues that are part of grief — shock, disbelief, bewilderment.” 

In some cases, people get stuck in their grief and can’t seem to find a way forward. And in certain instances — such as when someone loses their child — individuals may not even want to get out of that state because, for them, it creates a sense of leaving their loved one behind and moving on, adds Dickonson, a member of the American Counseling Association. 

Elyssa Rookey, a licensed professional counselor (LPC) at New Moon Counseling in Charleston, South Carolina, worked with a client who had experienced two traumatic losses. When the client was 15, his stepfather died from suicide, and when the client was 20, his mother died on impact in a car accident. After the death of his mother, the client started having nightmares and became anxious about the possibility of losing other loved ones in his life. 

Rookey noticed that the client used “I” statements frequently in sessions: “I should have done more to help them. I shouldn’t have said that before she left.” The client blamed himself for their deaths and thought that he was cursed, says Rookey, who specializes in treating trauma, grief and traumatic grief. 

His mother’s death also triggered the client’s feelings of abandonment in connection with his biological father, who had left him when he was a child. At times, the client wanted to avoid others and be alone, but that subsequently increased his feelings of isolation and fear of additional loss. He also hosted feelings of anger about having to “grow up” and assume adult responsibilities, such as paying a mortgage and keeping a piece of property maintained, before he was ready. In many ways, Rookey says, he was “stuck” in the trauma and avoiding the feelings of grief and loss. 

Identifying traumatic grief 

Not every sudden or catastrophic loss results in traumatic grief. Some people experience uncomplicated bereavement. But others may show signs of both trauma and grief. They might avoid talking about the person they lost altogether, or they might become fixated on the way their loved one died.  

Because of the trauma embedded within the grief, it can be challenging to differentiate between posttraumatic stress disorder (PTSD), grief and traumatic grief. “PTSD is about fear, and grief is about loss. Traumatic grief will have both, and it includes a sense of powerlessness,” Dickonson explains. “A person who is experiencing traumatic grief becomes a victim — a victim of the trauma in addition to the loss. … They will assume those qualities of experiencing trauma even while grieving the loss.” She finds that people who have traumatic grief tend to talk about experiencing physical pains, have trouble sleeping and are anxious.

People experiencing traumatic grief could have distressing thoughts or dreams, hyperarousal or anhedonia/numbness, says Nichole Oliver, an LPC in private practice at Integrative NeuroCounseling in Chesterfield, Missouri. She notes that some of the symptoms can be confused with other mental health issues. For example, a person going through traumatic grief may have a loss of appetite and trouble sleeping (which can resemble signs of depression) or have great difficulty focusing (which can look like a sign of attention-deficit disorder). 

On its website, the Trauma Survivors Network lists common symptoms of traumatic grief, which include: 

  • Being preoccupied with the deceased
  • Experiencing pain in the same area as the deceased
  • Having upsetting memories
  • Feeling that life is empty
  • Longing for the person
  • Hearing the voice of the person who died or “seeing” the person
  • Being drawn to places and things associated with the deceased
  • Experiencing disbelief or anger about the death
  • Thinking it is unfair to live when this person died
  • Feeling stunned or dazed
  • Being envious of others
  • Feeling lonely most of the time
  • Having difficulty caring about or trusting others 

Rookey, who also works for the South Carolina Department of Mental Health in partnership with the Charleston County Sheriff’s Office, always screens for trauma because clients may have underlying issues that affect or complicate their grief. When working as a counselor in Miami, she noticed that some adolescents who were court referred for their substance use had also experienced traumatic loss (having a friend who was shot and killed, for example). In these cases, counseling sessions focused on grief, PTSD and anxiety in addition to the issue of substance use, she notes. 

Rookey first meets with clients to get a better sense of their story. These conversations often lead her to ask questions such as “Have you ever felt this sense of loss or fear in the past?” The questioning helps uncover underlying issues that may be affecting the person’s ability to grieve in a healthy way, she explains. For example, a client might reveal that the way they’re currently feeling reminds them of how lost they felt after their parents’ divorce. This may lead to the discovery that the client never fully dealt with that loss at the time, and that is now affecting how they are processing this new loss.

A new layer of loss

“COVID-19 brought a brand-new dynamic to grief,” says Dickonson, who specializes in treating trauma, bereavement, traumatic grief and mood disorders. “People have lost jobs, relationships, businesses and homes. … There is an endless sense of loss that keeps coming on.”  

The pandemic has also added a layer of trauma to expected grief because it has restricted the ways that people are able to mourn death. Rookey, who is also an LPC in Florida, had a client whose husband died not long before the COVID-19 virus reached the United States. After the husband’s death, the client moved from Florida to South Carolina, where her husband was from, because he had always wanted their children to live there. A few months later, the client’s aunt in Puerto Rico died from natural causes, but because of quarantine restrictions, she was unable to travel to attend the funeral. All of these circumstances left the client feeling helpless, frustrated and isolated, Rookey says.  

The COVID-19 pandemic has severely curtailed people being able to grieve communally, which can make even anticipated deaths more traumatic, Rookey notes. 

“Losing a loved one to COVID-19 could definitely complicate the grieving process when people are unable to say goodbye or to be with their loved one when they pass,” says Tamra Hughes, an LPC in Centennial, Colorado. “Those experiences can torment a person who is trying to come to terms with the loss.” 

“And COVID-19 is front and center in all we see and do right now. So, there is a constant reminder of the circumstances of the loved one’s death,” she continues. “These cues can all act as triggers for the client, eliciting negative emotions, physiological reactions and trauma responses.”

Grief is personal

Everyone grieves differently, so identifying traumatic grief in clients is not always a straightforward matter. Hughes, an ACA member who specializes in grief, traumatic grief, trauma, complex trauma and anxiety, says no two cases are the same in grief work. She approaches her work through the lens of the adaptive information processing model of eye-movement desensitization and reprocessing (EMDR) therapy. Among the areas she considers are the client’s level of stability in their life, their attachment style and their mental model of the world. These factors affect the way they manage adversity and trauma, Hughes explains. 

Working as a counselor at a funeral home helped Oliver, an ACA member who specializes in PTSD and grief, understand and appreciate how people’s social and cultural factors (such as personality, spirituality and race/ethnicity) affect how they approach loss and mourning. For example, under some religious beliefs, shame is attached to suicide, whereas others may celebrate it as a brave act. And while some people consider crying a weakness, certain cultures incorporate wailing into their funeral ceremonies. 

Hughes, the owner and therapist at Greenwood Counseling Center, knows that some clinicians are afraid to ask clients about their spiritual beliefs regarding death. She encourages counselors to ask difficult questions such as “What do you think happens to people after they die?” Otherwise, “it becomes the elephant in the room,” she says. “It’s not about putting your own religious or spiritual beliefs on the client. It’s about understanding the [client’s] context … because then you can work within that framework to help them through the grief.” 

Legal proceedings connected to homicides can further complicate a person’s experience with grief. Sometimes people assume that the best way to process their grief and heal is through seeking legal justice, Rookey says. But often, their grieving doesn’t really begin until after they separate the legal aspect from their own grief and trauma, she observes. 

Oliver uses individual clients’ unique life experiences to tailor her psychoeducation efforts and counseling techniques. For example, she may explain trauma symptoms to someone who works in information technology by comparing their body to a web browser that has too many open tabs. This visualization helps the client understand why their body and emotions are overloaded. Then she’ll ask the client to pick which two or three tabs they want to prioritize and work on that session. 

Oliver also has clients put together a playlist of songs that express their current mood and their feelings of mourning, which may be difficult for them to convey verbally. In session, clients can use these songs to explain the way they are processing their grief in that moment. That helps regulate the limbic system, which is the part of the brain involved in behavioral and emotional responses, she says. Oliver also keeps a three-ring binder of images — such as a person bent over in shame or a person torn in half between their heart and brain — in her office. Sometimes she asks clients to select an image that resonates with them as a way to jump-start their conversation. 

Unspoken words 

People may come in for counseling immediately after a sudden loss, or they may wait weeks or even months before seeking help. If the counselor does begin working with the client soon after the loss, their main goal during those first two or three weeks of therapy should be to “hear” the client’s loss and validate their feelings, Hughes says. Counselors could offer some guidance for coping and self-care, but she cautions against making suggestions about how to “heal” because that can sound dismissive. 

Dickonson finds “sacred silence” — silently sitting and being present with a client — a useful tool when working with traumatic grief. “We have to develop the capacity to sit with our client’s anguish, to stay fully present but not be intrusive, and to speak but also know how to be quiet and fully connect. We don’t have to break the silence. … Sometimes that’s what they need. They just need us to be there with them and show them that we care,” she says. 

Dickonson also keeps a tissue box within reach of clients in case they want it, but she does not offer them a tissue if they start crying. “Tears are very cathartic, and if I give you a tissue, it can [insinuate] that it’s time to stop crying,” she explains.

Hughes eventually provides clients with a space to voice unspoken words — what they would have liked to say to their loved one and what they think their loved one would have said to them. “There’s something about articulating it and speaking those words [out loud] … that contributes to helping the brain reconcile some aspects of [the grief],” she says. It also provides clients with an opportunity to get closure on something that feels so abrupt and unfinished, she adds. 

One technique that Dickonson uses with some of her clients as they begin emerging from their grief and have started their journey to posttraumatic growth is to assume the voice of the deceased and then write or record how they believe their loved one would comfort them. As a prompt, she asks clients, “What would your beloved say to you if they were here right now?” 

As clients share their interpretation of their loved ones’ words, Dickonson watches the way their face changes at certain parts and then asks, “How did you feel when you heard what your loved one might have said to you?” She finds this exercise often leads to productive discussions and helps clients give voice to things they might feel guilty for saying themselves. 

Processing the trauma 

When Hughes helps clients process life challenges, including traumatic grief, she addresses their trauma through EMDR. Hughes is an EMDR therapy trainer, the owner of EMDR Center of the Rockies, a member of the board of directors for the EMDR International Association (EMDRIA) and an EMDRIA-approved consultant. “EMDR helps the brain to organize information in a way that is more adaptive. In the case of traumatic grief, it can help foster healing and closure in the grief process,” she explains.

If conflict existed in the relationship with the person who died, clients may need to work through challenges that they had or feelings of guilt or shame that can be present following the loss, Hughes adds. 

A traumatic loss can also trigger a past trauma, which might be the underlying reason for the client’s current complicated grief response, Oliver says. She once worked with a man whose mother had just died. Although their relationship had been strong at the time of her death, the client’s mother had been abusive when he was a child. Her death triggered this past childhood trauma, causing the client to feel not only grief over her loss but also anger for the past abuse and guilt about the relief he felt for no longer having to care for her. The client was afraid to admit these complex feelings to Oliver because he was ashamed for feeling resentment, anger and relief when he thought he should be feeling only grief. The client’s cognitive dissonance disrupted his ability to grieve in a healthy way and further anchored him in a complicated grief response, Oliver notes. She validated his feelings and reminded him that expressing the full range of his emotions didn’t mean that he was attacking his mother’s memory. 

Rookey has used exposure therapy to help clients process unresolved trauma around losses that they experienced firsthand. But she cautions clinicians not to use the approach if they think it could be triggering for a client, especially if the client doesn’t have a good support system. 

Rookey used the approach with a woman who became triggered by the sound of sirens after she watched her partner die from a traumatic accident. While the woman was sleeping, her partner went outside to smoke, and he was shot after being caught in the middle of a botched burglary. By the time the woman woke up and realized what was happening, her partner had crawled inside the kitchen and was slowly dying. She called 911 and held him while she waited for the ambulance. 

It wasn’t just the grief of loss that was traumatic for the client, Rookey explains. It was the trauma of repeatedly asking herself, “Why didn’t I do something to help him?” 

The client began to operate in survival mode and avoided thinking about her loss. But sirens became a trigger for her. When she heard them, she would run to a bathroom and cry. So, Rookey decided to use in vivo exposure to help the client retrain her body and mind to get to a healthy state again. 

First, Rookey asked the client, who worked near a hospital, to step outside whenever she heard an ambulance and listen to the sirens while engaging in calming activities such as deep breathing. After the ambulance passed, the client would repeat positive affirmations (e.g., “It wasn’t that bad”). This slowly exposed the client to the trigger in a safe way. After the client was comfortable hearing the sirens outside her work, Rookey had the client record herself recounting the traumatic incident as if she were reliving it, and she replayed this recording every day. “It’s a way to show your body you can get distressed, can get triggered, can be fearful, but you will be OK,” Rookey says.  

In session, Rookey asked the client what parts of the story affected her most. This questioning helped Rookey discover that the client’s guilt over not preventing her partner’s death was what was holding her back from fully grieving and moving forward. They worked together to reframe the event to help the client realize she was not responsible for the death: Her partner always stayed up late and smoked a cigarette before bed. She had called for help. There was nothing else she could have done. 

Creating new meanings 

What makes a loss traumatic is not only the way the person died but also the meaning attached to the death, Oliver says. She worked with a woman who had developed an irrational thought attached to her son’s traumatic death. The son had been struggling with a drug addiction for a decade, but the night before he died from suicide, they had had a fight and the mother had said some unkind things. She blamed herself for his death. 

“Her core belief [that she was responsible for her son’s death] kept her anchored to the pain of the grief, so we couldn’t process the grief until we relinquished that belief,” Oliver says. 

To begin the process of untangling the client’s negative belief from her grief, Oliver presented another contributing factor to the son’s death. She told the client, “Numerous research studies reveal complex neurobiological changes in the brains of individuals who have completed suicide. Postmortem autopsies reveal that these individuals have 1,000 times the cortisol in the brain, and other systems such as the HPA [hypothalamic-pituitary-adrenal] axis, receptors and neurotransmitters are not functioning normally. That means they do not have access to the prefrontal cortex, the reasoning part of the mind.” 

That information comforted the client. When addressing traumatic grief, it’s often about planting seeds of hope and disentangling the fragmented pieces in people’s minds, Oliver says.  

Oliver continued to help the client find and connect the fragmented pieces through memory reconsolidation, which is the brain’s innate process for transforming short-term memories into more stable, long-lasting ones. Oliver had the client recall the memory of her son’s death, and then they created mismatched experiences in the brain by pairing the client’s belief that she was responsible for her son’s death with the contradictory information that she had supported him through rehab and that he had attempted suicide previously. 

Recalling this information caused a clash with the client’s cognitive distortion that the son’s death was all her fault, Oliver explains. The process helped the client integrate more pieces of the puzzle until she had a clearer picture of the event and was able to get “unstuck” from the negative thought. As a result, the emotionally charged memory (the client’s self-blame) moved from the amygdala to the hippocampus, reducing the trauma response by creating new learning (the realization that her son’s death was not her fault), Oliver adds.

Finding a way forward 

After mitigating the trauma of their loss, clients are ready to take a step forward. “With traumatic grief, it’s about making meaning of the death and who they are now,” Rookey says. “They were on one course … and it got skewed, and now they’re on a parallel path.” After processing through the trauma and grief of the loss, she has clients visualize themselves moving forward on the different path. The exercise encourages them to think about their future and gives them some meaning as they start down this new path, she says. 

Hughes believes the goal is “to get to a place where the grief is replaced by increases in the positive memories of the person and the essence of who they were.” People will still feel sadness about the loss, but this feeling should be more manageable and is coupled with gratitude for the time shared with the loved one, she explains. 

With counseling and support, clients can emerge from the “chasm of despair” — the steep decline they fall into after the traumatic loss — and begin to transform their pain into something positive and potentially powerful, Dickonson says. That might include being more involved with their families, developing a greater appreciation for life or even embracing new opportunities that emanate directly from the traumatic event. “They still feel the sadness,” Dickonson says, “but they are ready to move forward.”

This is when counselors could encourage — but not push — clients to continue their transformation process from the sense-losing free fall to a sense-remaking journey, Dickonson advises. Counselors should also be mindful that when clients come out of the grief abyss, they may replace their grief with another unhealthy coping behavior, she cautions. So, counselors have to continue to support clients as they start this journey forward. 

Rookey and her client who lost his stepfather and mother all before he turned 21 had to address his negative beliefs about his responsibility in their deaths before he could find a way to move forward and grieve in a healthy way. By the end, the young man’s guilt and anger had lessened. He sold his mother’s home, bought a truck and set up autopay for his bills. These were small steps toward him carving out his new identity and moving forward on his parallel path.

 

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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.

The intersection of childhood trauma and addiction

By Shannon Karl April 13, 2021

Substance dependence leads to persistent negative consequences and the loss of human potential. These consequences often include chronic health problems, dysfunctional family environments, harmful economic impacts and premature death. According to the Centers for Disease Control and Prevention (CDC), 21.2 million individuals in the United States met the criteria for a substance-related disorder in 2018. Deaths from overdose have tripled in less than two decades, with over 70,000 annual drug overdose deaths in 2019, 70% of which resulted from opioids such as morphine and fentanyl.

Substance-related disorders include 10 classes of drugs: alcohol; caffeine; cannabis; hallucinogens; inhalants; opioids; hypnotics, sedatives and anxiolytics; stimulants; tobacco; and other/unknown substances. Exposure to childhood trauma increases one’s risk of addiction across classifications, along with deleterious factors such as physical health and socioeconomic challenges. The Adverse Childhood Experiences (ACE) study, originally conducted by Kaiser Permanente and the CDC from 1995-1997, identified categories of trauma that can occur prior to age 18. These include physical abuse and neglect, emotional abuse and neglect, sexual abuse, and household dysfunction — e.g., mother treated violently, household substance misuse, parental incarceration, parental mental illness, and divorce.

These factors make up the 10 components of the ACEs score, with research supporting higher likelihood of substance-related disorders as exposure to ACEs increases. According to the American Society of Addiction Medicine (ASAM), addiction has biological, psychological, social and spiritual manifestations. Given the deleterious nature of addictive etiology, professional counselors need to be aware of the vulnerability to addiction for those affected by childhood trauma. The intersection of ACEs and addiction holds pervasive negative impact across the life span.

The National Institutes of Health (NIH) asserts that traumatic events can serve as triggers for substance misuse. NIH reported that 38% of high school seniors admitted using an illicit substance in 2019, with marijuana being the most frequent substance utilized. Startlingly, 11.8% of eighth graders reported marijuana use. In addition, 11.7% of high school seniors reported daily nicotine use, and more than half acknowledged using alcohol in the prior year.

Exposure to ACEs can lead to toxic stress and myriad negative consequences, often including lifelong deleterious effects on physical and mental health. The high rates of individuals living with the trauma of ACEs is startling — 61% of individuals have endured at least one ACE, and nearly 25% of individuals report three or more ACEs. There appears to be specific vulnerability to addiction for those who have experienced four or more ACEs. The higher the ACEs score, the greater the negative health impact. More than half of adolescents who live with mental health concerns also have diagnosable substance-related disorders, which underscores the comorbidity of the issue.

Ramifications of ACEs can include addiction, reduced access to education, and vulnerability to sexual exploitation and trafficking. Tobacco and prescription drug use is higher among those with ACEs, and illicit drug use increases more than twofold with each positive ACEs category. Other lifelong instability factors that have been shown to correlate with ACEs are high-risk sexual behaviors, early pregnancy, suicide attempts, sleep disturbance, poor dental health and multiple physical health concerns. Both children and adults with extant mental health issues misuse substances at higher rates.

According to the U.S. Surgeon General, approximately 10% of children live with mental health concerns that rise to a clinical level, with major depressive disorder representing a leading cause of disability in children worldwide. Research supports the strong connection between experiencing adversity during childhood and the ensuing development of addiction. More than two-thirds of children will experience a traumatic event before the age of 16. And with the current pandemic, many children are in homes that are violent or otherwise unsafe. Alarmingly, domestic violence incidents were up 30% in 2020, exposing untold youth to at least one of the ACEs factors.

Treatment needs

Reports regarding heightened clinical levels of anxiety and depression among the general population suggest that stress related to the COVID-19 pandemic affects everyone. Adolescence already represents a critical developmental period for initial onset of mental health and substance-related disorders, so the vulnerability for this demographic is further increased. ACEs are a clear and extant risk factor, with survivors of childhood trauma 15 times more likely to attempt suicide, four times more likely to develop an alcohol-related disorder, and 2.5 times more likely to smoke cigarettes. For survivors of childhood trauma, physical and emotional issues often manifest in adolescence and follow into adulthood.

According to the Substance Abuse and Mental Health Services Administration (SAMHSA), 21.6 million people ages 12 and older needed treatment for substance use in the U.S. in 2019, whereas only approximately 2.6 million people (or slightly more than 12%) received it. These are glaring treatment needs that crosscut demographics. Fentanyl, which can be lethal, is sold in multiple forms on the “street,” continuing the opioid crisis in our country. Tens of thousands of overdose deaths occur per year, with close to 11 million individuals disclosing inappropriate opioid use. Those with ACEs scores higher than 6 were over 1,000 times more likely to use injection drugs.

Chronic substance abuse, a clear risk factor for those exposed to trauma, leads to premature death in alarmingly high numbers. Adolescents with experience of major depressive episodes are more likely to use substances across categories. Coincidingly, 60% of U.S. youth with depression do not receive mental health treatment. Addressing the physical and mental health impact of substance use alone is estimated to cost Americans more than half a trillion dollars annually. The CDC has developed a resource that highlights the available research support for evidence-based prevention of ACEs at cdc.gov/violenceprevention/pdf/preventingACES.pdf. These strategies focus on systemic community-based information and training. Emphasis is also placed on physical health, positive behaviors and supportive environments.

Treatment considerations

Certain populations have increased vulnerability to substance-related disorders due to environmental and genetic factors. This stems from the neurobiological underpinnings of the addictive etiology to the effects of toxic stress. Individuals born into households in which they are exposed to ACEs are more vulnerable to addiction, including process addictions centered on gambling, internet gaming, sex, shopping, work, social media and so on. The use of trauma-informed interventions as early as possible can mitigate deleterious effects and provide protective measures against substance-related and other mental and physical health issues. The CDC offers trainings for those interested in learning more about the prevention of ACES (see vetoviolence.cdc.gov/apps/aces-training/#/#top).

All clients should be evaluated for trauma and addiction history. The concurrence of mental health concerns and substance abuse necessitates treatment that addresses these challenges. Trauma increases the already high comorbidity (upward of 50%) between mental health and substance use diagnoses. Prevention and early intervention services can examine frequency, severity and duration of both the trauma experience and the addiction. The conceptualization of substance use disorders occurring on a continuum (as detailed in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders) underscores the importance of prevention and early intervention.

According to the CDC, research shows a propensity to self-medicate with substances to escape or numb negative thoughts and feelings. This suggests that escape from emotional pain triggers the onset of addiction. Women, adolescents and individuals from marginalized populations are most vulnerable to these effects, although anyone can experience childhood trauma and struggle with ensuing addiction.

Clinicians should develop individualized treatment plans and strong referral systems. Genetic and environmental factors work in combination. Thus, we need to gain understanding of these interactive effects. Long-term supports and provision of physical and dental health services can be important for individuals exposed to ACES, especially considering the likelihood of comorbidity with a physical health diagnosis. Increased rates of unemployment and job dissatisfaction represent additional treatment needs.

Relational challenges

Difficulty forming healthy relationships across the life span is a hallmark of surviving childhood adversity. Counseling professionals should thus incorporate strategies for strengthening the family and community. Holistic and family counseling services are beneficial. This includes the provision of psychoeducation and parenting education to address overall life skills, mindfulness and grounding techniques, positive coping strategies and career counseling services. Trauma-focused cognitive behavior therapy (TF-CBT) and multisystemic therapy have shown both short- and long-term benefit with these clients. This can be combined with addiction treatments such as medication-assisted therapy for alcohol or opioid use disorders. The combination of psychoeducation and supportive, trauma-informed and empirically based substance misuse treatments can span the broad needs of this population. All treatment modalities and providers should integrate trauma-informed care.

Early identification and intervention remain important to minimize risks and break deleterious family patterns. Removal of barriers to treatment includes addressing stigma and increasing education for families and communities. Larger scale prevention programs, inclusive of early intervention and postvention services, are indicated. The development of individualized treatment strategies that incorporate trauma-informed interventions are also vital.

Professional counselors are charged to advocate for clients and communities. Screenings in hospitals, clinics and public health facilities can help identify those at risk for substance misuse, especially those with trauma histories, and link them with treatment services. Psychoeducation in schools and community agencies also can improve outreach and access to care. Parenting education classes and life skills trainings are other examples of additive ancillary services. Incarcerated populations are particularly affected, with some studies suggesting a trauma history for nearly the entire population of female inmates. Professional counselors working across these settings should be aware of risk factors and assessment protocols that are culturally competent and inclusive of multiple demographics.

Effective treatments for individuals affected by trauma and addiction can include eye movement desensitization and reprocessing, motivational enhancement therapy, TF-CBT, dialectical behavior therapy, assertive community treatment and family behavior therapy. Psychotropic medication and psychiatric care may be indicated to fully address these complex issues. Some medications may benefit multiple issues (e.g., bupropion for both depression and nicotine dependence). Case management and occupational assistance represent important ancillary services for many clients. Community vouchers can be given for transportation and health care access and allow for possible employment opportunities.

Although thorough and comprehensive treatment can be expensive, it pales in comparison to the economic costs associated with addiction and premature death. With annual estimates for addiction and premature death as high as $740 billion, there is a need for legislation that funds prevention and early intervention services for those affected by trauma exposure and addiction. Given appropriate access to treatment and support, many individuals living with the effects of childhood trauma and addiction can make positive and lasting improvements. The cycle of intergenerational trauma transmission can be broken, providing positive ripple effects for future generations. Individuals can thrive and build healthy families despite their adverse experiences.

Community impact and integrated care

A multitiered approach to looking at immediate issues such as addiction is imperative for individuals exposed to ACEs. Addressing the trauma and providing familial services, social support and preventive measures remains imperative. All professional counselors can emphasize trauma-informed and integrative care. Here are a few simple strategies to tackle this complex issue: Listen with empathy, garner training in trauma-informed practices, develop a strong support and referral system, and provide specialty services to treat the trauma and the addiction. Working together, mental health professionals across disciplines can help survivors of childhood trauma manage life in healthy and productive ways.

The global health pandemic has increased utilization of distance-based services such as telemental health counseling. This modality can provide easier access to services for individuals in rural communities, those with transportation challenges and those with other impediments to treatment.

It remains important to highlight the team approach in addressing the complex issues of childhood trauma, addiction, and the ensuing physical and mental health sequelae. The pervasive nature of this challenge engenders a call to action. Data collection through thorough assessment can inform community decision-making and provide program funding. The Youth Risk Behavior Surveillance System assesses crosscutting data that are available at the local, state and national levels. The National Survey of Children’s Health and the National Crime Victimization Survey also collect data that can inform service provision.

The CDC provides information to promote safe childhood environments and mitigate ACEs exposure and subsequent addiction and disease. On a micro level, professional counselors can focus on parenting and family skills, mentoring, social emotional learning, job skills, and psychoeducation regarding healthy family and interpersonal relationships. On a macro level, professional counselors can promote community connection, mentoring relationships and positive social norms. The critical importance of trauma-informed interventions that are tailored to individual or family circumstances, along with communitywide prevention strategies, are necessary for addressing these serious and prevalent risk factors. These programs can assist children, parents and families beyond mitigation of symptoms.

Family-centered treatments for addiction can address the intergenerational impact. The deficits that come with trauma and addiction are offset by evidence-based interventions and prevention strategies. Access to programs should be available for all levels of care and can be implemented concurrently with ancillary services. Counseling settings can include the home, school or office, and often will involve multiple integrated health care professionals. Given the complexity of the challenge, comprehensive treatment services that include bridging home and school environments and the larger family system remain imperative. The widespread impact of ACEs and their intersection with addiction calls for coordinated care across disciplines. This includes effective tracking and coordination of prevention and intervention services across all aspects of service delivery.

Intergenerational patterns of trauma transmission represent a vicious cycle that professional counselors can help break. Prevention programs must address household dysfunction and adversity, especially considering that ACEs indicate earlier onset of substance consumption. The idea of numbing or comfort-seeking suggests that childhood adversity can lead to addiction through attempts to relieve distress. Quality mental health care can address and ameliorate these maladaptive coping mechanisms. ACEs are also correlated with substance use disorder in older adulthood, underscoring the lifelong ramifications of exposure to childhood trauma.

Addiction treatment facilities partnering with comprehensive and wraparound services can provide targeted interventions to address individual trauma experiences. Tackling the systemic nature of childhood adversity through family services and community advocacy provides additional resources for clients. Professional counselors are an integral part of the overall treatment team. Clients can and do learn new patterns of behavior and positive coping mechanisms that help them live longer, healthier lives. The benefits of prevention and early intervention should not be undervalued. Treatment is ameliorative for trauma and addiction and often engenders positive change in individuals and families.

Professional counselors can assist community members in locating resources and addiction treatment centers across the country via SAMHSA’s national helpline: 800-662-HELP (4357). Viewing survivors of childhood trauma who struggle with addiction or other maladaptive coping mechanisms from a strength-based approach is imperative. These struggles are not born of characterological weakness but result from the impact of lived trauma experiences. Empathy and care go a long way in successful work with trauma survivors.

Conclusion

Abuse, neglect and household dysfunction clearly lead to physical and mental health challenges. The risk of addiction, early death and intergenerational trauma transmission increases with each adverse childhood exposure. Use of alcohol and other illicit substances damages mental and physical health in numerous ways and often intersects with the trauma experience. Vulnerable children and adolescents can and must be protected. Professional counselors play pivotal roles now more than ever.

In 2020, SAMHSA reported a 900% increase in call volume to its disaster distress helpline (800-985-5990). Nearly half of Kaiser Family Foundation respondents asserted that the COVID-19 pandemic is detrimental to their overall mental health. The global health pandemic underscores the burgeoning treatment needs for increasing numbers of vulnerable people. Experiencing trauma in childhood can hinder the individual in all aspects of life. The negative reverberations for families and communities should make this everyone’s issue. Professional counselors hold the potential to help effect positive change for innumerable individuals, families and communities. Let’s make an impact — now and into the future.

 

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Shannon Karl is a professor with the Department of Counseling at Nova Southeastern University, a licensed mental health counselor (supervisor) in Florida, an active member of the American Counseling Association, and a past president of the Association for Spiritual, Ethical and Religious Values in Counseling. Contact her at shannon.karl@nova.edu or linkedin.com/in/shannon-karl-phd.

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

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

The darker side of sleep

By David Engstrom January 6, 2021

“Sleep is the golden chain that ties health and our bodies together.” — Thomas Dekker, 1625

“Without enough sleep, we all become tall 2-year-olds.” — JoJo Jensen, Dirt Farmer Wisdom, 2002

“I love sleep. I’d sleep all day if I could.” — Miley Cyrus, 2019

To me, making those elusive connections between events, experiences and symptoms in our clients’ lives is one of the most exciting parts of counseling. There may be no clearer connection between the mind and body than sleep.

How do you sleep? More importantly, do you know how your clients sleep? When we evaluate our clients’ histories and experiences, one area of behavioral health that is easy to ignore or minimize is sleep. But disturbed sleep is very common among Americans and is connected to many psychological and physical health problems later in life. A more comprehensive assessment may lead to important clues about an experience of early trauma and abuse.

Sarah: Initial assessment

As a consultant at a hospital sleep disorders center in Arizona, I saw “Sarah,” a 30 year-old Hispanic woman who was referred because of severe insomnia. She reported great difficulty falling asleep, and even after she did, she often slept no more than three hours per night, with frequent awakenings.

Sarah was married, had no children and worked as a university professor. She claimed that her marriage was “strong and supportive,” and she greatly loved her work as a professor. She had been prescribed benzodiazepine sleeping medications two years prior, but they were no longer helping, and Sarah feared she was becoming dependent on them.

Sarah was in good physical health but was concerned that she had gained 35 pounds over the course of five years. She had never before seen a mental health professional. Her prior overnight visit to the hospital sleep disorders center had revealed major difficulties in initiating and maintaining sleep. Polysomnographic results confirmed that she took 82 minutes to fall asleep initially and that she experienced five awakenings of greater than 20 minutes each during the night. Her total sleep time was 2.7 hours.

Her sleep problems had been present and worsening since high school, or a span of about 15 years. She presented with severe daytime sleepiness, anxiety and depression. Sarah stated, “I can’t go on like this.”

Sleep facts

Studies from the Centers for Disease Control and Prevention (CDC) reveal the following data about healthy sleep duration (with higher percentages indicating healthier durations):

Geography: Prevalence of healthy sleep duration ranged from 56% in Hawaii to 72% in South Dakota.

Percentage of healthy sleep duration by race/ethnicity: Native Hawaiian/Pacific Islanders (54%); Black (54%); Other/Multiracial (54%); American Indian/Alaska Native (60%); Asian (63%); Hispanic (66%); White (67%)

Although requirements vary slightly from person to person, most healthy adults need seven to nine hours of sleep per night to function at their best. Children and teenagers need even more. Despite the notion that our sleep needs decrease with age, people older than 65 still need at least seven hours of sleep per night. Interestingly, the average total nightly sleep duration fell from approximately nine hours in 1910 to approximately seven hours in 2002.

Prevalence of disturbed sleep

Sleep disturbance is a common problem that affects at least 75% of Americans at some point in their lives. Among the various sleep disorders, approximately 33% of all adults suffer from an insomnia disorder, which can have significant negative consequences if left untreated. Individuals who struggle with chronic insomnia often describe their condition as a “vicious cycle,” with increasing effort and desire put into trying to regain sleep, with negative results.

A 2014 survey conducted by the National Sleep Foundation reported that 35% of American adults rated their sleep quality as “poor” or “only fair.” Difficulty falling asleep (onset insomnia) at least one night per week was reported by 45% of respondents. In addition, 53% had experienced trouble staying asleep (early awakening or maintenance insomnia) at least one night of the previous week, and 23% had experienced trouble staying asleep on five or more nights. Research suggests that sleep problems are worse among women but increase in both genders with age.

Any of us can do a self-assessment of our sleep deprivation, also known as “sleep debt.” You probably have sleep debt if you 1) find yourself drowsy or sleepy during the day, 2) frequently need an alarm clock to awaken and 3) fall asleep very rapidly (less than five minutes) when you go to bed.

Insomnia is not a disease; it is a symptom. It may be 1) associated with medical problems, 2) associated with psychological problems, 3) due to lifestyle, 4) caused by poor sleep habits or 5) any combination of the above.

Sleep deprivation can have many effects, both physically and psychologically. In the short term, it can lead to stress, somatic problems, cognitive difficulties, anxiety and depression. Long-term effects can include cardiovascular disease, obesity, diabetes, cancer and even early death.

Hypnotic medications are frequently used to treat insomnia, but many patients prefer non-drug approaches to avoid dependence and tolerance.

Assessment of sleep disorders

The self-administered Pittsburgh Sleep Quality Index assesses seven components of sleep based on clients’ self-reports. This widely used instrument has been shown to reliably detect clinical levels of sleep disruption in adults across a broad range of ages. Areas assessed include subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbance, use of sleeping medications and daytime dysfunction.

On a more practical level, I have found that having clients keep a simple “sleep log” for two weeks can help to identify sleep problems. I have clients record:

  • The time they go to bed
  • Medication taken (if any)
  • Estimated time to fall asleep (onset)
  • Estimated number of awakenings during sleep
  • Wake-up time
  • Estimated total sleep time
  • Sleep quality (0-10 scale)
  • Daytime alertness (0-10 scale)
  • Level of worry about sleep (0-10 scale)

Sarah: Sleep assessment

Sarah was provided sleep self-monitoring materials to complete over 14 days. Results clearly indicated many awakenings during the night, short sleep times and profound daytime sleepiness. These results were confirmed by polysomnographic data. Assessment results indicated diagnosis of insomnia disorder (780.52/307.42), Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5).

Assessment of childhood trauma

Systematic assessment of childhood trauma has evolved since the original study of adverse childhood experiences (ACEs) by the CDC and Kaiser Permanente in the mid-1990s.

ACEs are classified in three different subsets: abuse (physical, emotional, sexual); neglect (physical, emotional); and household dysfunction (mental illness, incarcerated relative, parent treated violently, substance dependence, divorce). These 10 areas can be incorporated into a structured interview, with questions such as “Before your 18th birthday, did you often or very often feel that you didn’t have enough to eat? Had to wear dirty clothes? Had no one to protect you? That your parents were too drunk or high to take you to the doctor if you needed it? Before your 18th birthday, was a household member depressed or mentally ill, or did a household member attempt suicide?” These questions can easily be incorporated into a routine clinical interview.

In a large study, 61% of adults had at least one ACE, and 16% had four or more types of ACEs. Women and members of several racial/ethnic groups were at greater risk for experiencing four or more ACEs. Exposure to ACEs is associated with increased risk for many health problems across the life span.

As counterpoint, Jack Shonkoff, a pediatrician and director of the Center on the Developing Child at Harvard University, notes “there are people with high ACE scores who do remarkably well.” Resilience, he says, builds throughout life, and close relationships are key. This implies that the ACE score for an individual is not a static number, but more dynamic, because personality traits and life experiences can modify the impact of ACEs.

Effects of childhood trauma and abuse on sleep

In a major population-based study in 2011, Emily Greenfield et al. found that three classes of abuse history were highly associated with a greater risk of global sleep pathology:

1) Frequent physical and emotional abuse with sexual abuse

2) Frequent physical and emotional abuse without sexual abuse

3) Occasional physical and emotional abuse with sexual abuse

The most extreme class of abuse — frequent physical and emotional abuse with sexual abuse — was associated with poorer self-reported sleep across many components measured, including subjective sleep quality, greater sleep disturbances and greater use of sleep medication.

Adults who reported frequent experiences of childhood physical and emotional abuse — regardless of sexual abuse — were found to be at especially high risk for global sleep pathology. Regardless of their experiences of sexual abuse, respondents who reported frequent experiences of physical and emotional abuse were over 200% more likely than respondents who reported no abuse to have clinically relevant levels of sleep pathology.

In 2018, Ryan Brindle et al. concluded that “childhood trauma may affect sleep health in adulthood. These findings align with the growing body of evidence linking childhood trauma to adverse health outcomes later in life.” Furthermore, trauma exposure after age 18 and across the life span did not relate to sleep health, suggesting that trauma experienced at a younger age is a more important factor.

Sarah: Trauma assessment

In gathering Sarah’s history during the first several sessions, she reluctantly revealed that she had been sexually molested repeatedly by her mother’s live-in boyfriend between the ages of 11 and 15. He was apparently dependent on alcohol and other drugs, with Sarah stating that he seemed “drunk most of the time.” She recalled that these events occurred “about twice a month” and consisted of mutual (subtly coerced) sexual touching and fondling, including occasional oral sex but no intercourse. Sarah never revealed this to her mother. Sarah’s obtained ACEs score was five. This finding suggested a second working diagnosis of trauma and stressor-related disorder in the DSM-5.

Possible mechanisms

In theory and research evidence, there is a fairly clear link between chronic stress and increased production of the hormone cortisol, which in turn can accelerate inflammation in the body. This may be a factor that can help explain the trauma-sleep connection.

Stress: In discussing trauma and sleep in children, Avi Sadeh suggested (1996) that stress was among the most powerful contributors to poor sleep. This can include significant life changes/events or threats that demand physiological, behavioral and psychological resources to maintain “psychophysiological equilibrium and well-being.”

Cortisol: Cortisol is produced by the adrenal glands, and high levels of physical or psychological distress lead to increases in cortisol secretion. In a study by Nancy Nicolson et al. (2010), emotional and sexual abuse were most closely linked to increased cortisol levels. Childhood maltreatment is also associated with elevated cortisol.

For clients living with stress and insomnia, cortisol levels remain elevated above normal levels, especially during sleep. With sustained levels of higher cortisol, these individuals remain in a state of hyperarousal, even when they’re asleep, thereby disrupting the overall quality and restfulness of their sleep. Chronic “short sleepers” (those who get five to six hours of sleep per night) have higher levels of nocturnal cortisol secretion in comparison with “normal sleepers” (those who get seven to eight hours of sleep per night).

Inflammation: Research by Janet Mullington et al. (2010) indicates that long-term inflammation may be the common factor in many chronic diseases. Social threats and stressors can drive the development of sleep disturbances in humans, contributing to the dysregulation of inflammatory and antiviral responses.

It is hypothesized that trauma-induced insomnia is a direct result of two interacting variables: physiological hyperarousal and self-defeating cognitive activity.   

Sarah’s treatment

Given that Sarah was suffering from insomnia disorder as well as trauma and stressor-related disorder, it was important to determine which problem needed to be the initial focus of treatment. If we expected that her traumatic history was keeping the insomnia alive, there might have been reason to help her process the trauma first. On the other hand, because her insomnia was having major effects on her mood, concentration and daytime alertness, some justification existed for initially treating her insomnia.

Based on the information obtained about Sarah’s sleep patterns and traumatic history, several evidence-based approaches were used in combination over 11 weekly sessions.

Body scan and breath awareness have both been shown to enhance relaxation prior to sleep. They redirect the mental focus toward the present state of the body and breath. The body scan consists of observing and listening to what bodily sensations are communicating in the moment. It involves noticing areas of tension in the body and inviting these areas to release the tightness.

Breath awareness can consist of slowly accepting the inhale through the nose, deliberately pausing for a moment and then slowly releasing the breath out of the mouth. This regulates the pace of the nervous system and provides an opportunity to mindfully experience the feeling of letting go of what is no longer serving the body. Sarah was provided with audio materials to practice these techniques daily.

Cognitive behavioral therapy for insomnia (CBT-I) is a structured program that aids in identifying and replacing unhelpful thoughts and behaviors that cause or worsen sleep problems with habits that promote sound sleep. CBT-I helps to overcome the underlying causes of sleep problems. It requires the client to keep a detailed sleep diary for one to two weeks. The “cognitive” part of CBT-I teaches clients to recognize and change beliefs that affect their ability to sleep. This type of therapy can help to control or eliminate negative thoughts and worries that keep clients awake.

Sarah recorded her unhelpful automatic thoughts and beliefs about her sleep. These included “Not sleeping well is ruining my life”; “I have to fall asleep right now”; “I’m never going to get over this sleep problem”; and “I am worried that I have lost control of my abilities to sleep.” The A-B-C-D-E system (activating event, belief, consequence, disputation, new effect) was explained to her, and she was instructed in ways to dispute and replace unhelpful thoughts and beliefs. She was successful in describing and challenging these thoughts.

Acceptance and commitment therapy (ACT) is a more recently introduced form of psychotherapy that focuses on mindfulness and acceptance in clients with trauma histories. The underlying theory of ACT is that posttraumatic disorders result from attempting to avoid a past experience at all costs. Thus, a goal of treatment with ACT is to develop more accepting and mindful attitudes toward distressing memories and negative cognitions rather than avoiding them.

Sarah was first introduced to mindfulness as a way to reconnect with the present moment. This built the foundation for increased exposure to avoided thoughts and emotions. Through daily mindfulness practice over 10 weeks, Sarah was able to become aware of painful thoughts that were getting in the way of her sleep and mood. Defusion strategies helped Sarah learn to acknowledge these thoughts as “just thoughts.” Defusion is the separation of an emotion-provoking stimulus from the unwanted emotional response as part of a therapeutic process (think of it as being similar to “defusing” a bomb). Unlike strategies that are more cognitive in nature, the goal is not to challenge thoughts, but rather to acknowledge when thoughts are not helpful, detach from them and move forward. It is not necessary to determine if the thoughts are true or untrue.

One major difference between these two approaches is how unhelpful thoughts are handled. In classic CBT therapy, clients are encouraged to dispute these thoughts and replace them with more helpful ones. In ACT, clients learn to recognize and accept their thoughts but to stand away from them, as is used widely in mindfulness practices.

Outcome of Sarah’s treatment

Following our 11 sessions together, Sarah reported the following:

Although average sleep onset time had decreased only slightly (82 minutes pretreatment to 68 minutes post-treatment), her total sleep time had increased from 2.7 hours to 5.3 hours per night, and her number of awakenings decreased from an average of five per night to one to two per night. She also reported significantly less depression and much more daytime alertness. She was able to go back to work as a full-time university professor.

Summary and takeaways

I have reviewed some important research findings about a potential link between childhood maltreatment and adult insomnia. A case study is presented to help clarify methods for identifying and treating these issues.

In working with people with insomnia over the past 10-plus years, it has become apparent to me that a) many clients who suffer from insomnia do not have (or at least do not disclose) a history of childhood abuse or neglect, and b) among clients who do have a history of abuse as children, some have no apparent sleep problems. Regardless of these outliers, it is clear that sleep patterns should be explored in some depth, and it would be sound clinical practice to always inquire about your clients’ sleep patterns.

 

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David Engstrom lives in Scottsdale, Arizona, and is a core faculty member in the clinical mental health counseling program at the University of Phoenix. A counselor and health psychologist, he is an American Mental Health Counselors Association diplomate in integrated health care. He specializes in weight management, sleep disorders and pain management and is on the medical staff at Honor Health Scottsdale Medical Center. Contact him at David.Engstrom@phoenix.edu.

 

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

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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.