Tag Archives: trauma

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.

Healing attachment wounds by being cared for and caring for others

By Adele Baruch and Ashley Higgins October 29, 2020

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

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

Building safety via action-based attunement

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

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

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

The following are offered as examples:

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

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

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

Building resilience via attachment rupture and repair

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

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

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

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

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

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

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

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

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

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

Building self-regulation via emotional flexibility

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

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

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

Building agency via helping others

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

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

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

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

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

Four examples of helping opportunities

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

Example 1: Roots of Empathy

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

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

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

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

Example 2: The Courage and Moral Choice Project

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

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

Example 3: Active bystander training

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

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

Example 4: Transformative Couples Therapy

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

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

Conclusion

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

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

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

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

 

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

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

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

Grappling with compassion fatigue

By Lindsey Phillips August 31, 2020

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

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

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

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

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

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

Defining compassion fatigue

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

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

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

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

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

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

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

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

Symptoms and risk factors

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

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

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

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

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

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

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

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

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

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

Regulating the body and mind

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

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

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

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

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

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

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

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

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

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

Creating emotional boundaries

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

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

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

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

Exercising self-compassion

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

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

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

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

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

Self-regulating in session

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

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

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

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

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

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

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

Helping the helpers during COVID-19

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

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

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

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

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

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

Fostering compassion satisfaction

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

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

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

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

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

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

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

 

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

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