Tag Archives: trauma

Interventions for attachment and traumatic stress issues in young children

By Cirecie A. West-Olatunji, Jeff D. Wolfgang and Kimberly N. Frazier April 2, 2019

Although mental health professionals acknowledge that clinical issues often look different in young children, treatment practices continue to rely heavily on adult literature. These mostly miniaturized forms of adult treatment are often scaled down using more basic language and vocabulary, but they still depend on discovering ways to encourage the verbal communication of children. Furthermore, major deficiencies exist in the mental health care delivery system for children. General neglect and fragmentation of services create obstacles to effective service provision for this population.

Over the past decade, scholars have begun exploring early childhood development and effective counseling interventions, the role of traumatic stress in the presentation of emotional and behavioral symptoms, and the prevalence of attachment issues for young children. In this article, we aim to provide a brief overview of these key advances in what we have named “pediatric counseling.” We also offer 10 evidence-based counseling interventions that stem from our work with young children over several decades.

Early childhood development and counseling

Children are not miniature adults, meaning a paradigm shift and specialized skills approach are required to help them most effectively. Children also go through rapid developmental stages, strengthening the argument that therapy with children should be vastly different from therapy with adults. Thus, professional counselors and other mental health professionals must consider various concepts, issues, techniques and interventions that are cognitively, emotionally, psychologically and developmentally appropriate for children.

During early childhood, defined as birth to age 5, rapid development of gross motor skills (running, climbing, throwing) occurs. Fine motor skills (drawing, writing, manipulating small objects) are slower to develop at this stage, but children should be able to copy letters and small words sometime during the latter half of early childhood. Cognitive development at this stage is based primarily on preoperational thinking. Hence, children in this stage rely heavily on what they see. They can now recall past events and anticipate future experiences that may be similar. At this stage of development, children are very egocentric, commonly overestimate their abilities (e.g., thinking they can carry things that are too heavy for them), and gain increased control of their impulses.

Play is extremely important to social development during early childhood. At about 3 or 4 years old, children engage in associative play in which they learn how to share and interact with one another. During associative play, there are no clear goals for the play and the roles of those engaging in play are not assigned. At about age 5, children begin to create games, form groups and take turns. Children are expanding their vocabularies at this stage, but the words and phrases used to express feelings and emotions remain limited. Because of their limited emotional vocabulary at this stage, children are more prone to act out their emotions behaviorally.

Deficiencies in service delivery:
Some of the major deficiencies in the mental health care delivery system for children include:

  • How children are categorized (i.e., poor conceptualization of children within their ecological context, including culturally marginalized children being overrepresented in the most severe clinical categories)
  • Environmental factors (such as racism and poverty)
  • Lack of empirical data
  • Fragmentation of services

First, children are typically placed in categories of clinical, subclinical and at risk, and they are often in need of services such as remediation and prevention. However, they are largely neglected within the system. This is partly due to clinicians’ lack of training to provide developmentally appropriate clinical care for this age group. Lack of adequate funding and poor communication between providers (such as pediatricians, child care workers, parents/caregivers, social services personnel and professional counselors) are also factors.

Second, some environmental factors associated with higher rates of mental health problems include poverty, racism, abuse and familial problems. Systemic oppression is also linked to both behavioral and affective problems. However, insufficient research has been conducted with young children to provide adequate information about how these environmental factors affect them. 

Third, there is a lack of empirical data on effective treatment for young children. Although the literature is replete with community agency programs and hospital-affiliated programs designed for young children and their families, there is insufficient support for the effectiveness of the treatments and interventions provided.

Finally, there is fragmentation of the services that exist for this population. Mental health services for young children should be initialized by a social service agency or primary care physician. However, this rarely happens. Even when it does, it is unlikely that these professionals have included or interacted with counselors. Thus, many children slip through the cracks and remain unidentified until a crisis arises, meaning they are most likely to receive psychological first aid via psychiatric services.

Counselor training: Experts stress the need for counselor trainees to acquire foundational skills that serve as underpinnings for effective counseling of this population. The major challenge within the discipline of counseling is how to transform these base-level skills into effective techniques and interventions for young clients. Many beginning counselors feel ill-prepared and are often frustrated when they encounter child clients — and preschool-age children in particular. Most counselors begin their training by practicing their counseling skills on classmates and never encounter younger client populations until they are out in
the field. 

Traumatic stress issues

Researchers have suggested that symptoms of traumatic stress in early childhood include interrupted attachment displays of distress such as inconsolable crying, disorientation, diminished interest, aggression, withdrawing from peers, and thoughts or feelings that disrupt normal activities. Traumatic stress, a condition caused by pervasive, systemic external forces, can result in physiological, psychological and behavioral symptoms that negatively affect everyday functioning.

Symptoms of traumatic stress can include hyperarousal or hypoarousal, avoidance and re-experiencing. Hyperarousal in early childhood is often observed through displays of inconsolable crying, flailing about, arching the back and biting. Hypoarousal involves emotional numbing that may be observed as a child who sleeps excessively, displays a dazed expression or averts his or her eyes. Avoidance is characterized by withdrawal, which is often demonstrated as displaying less affection, consistently looking away or avoiding facial contact. Other observable features of avoidance include a fear of being separated from caregivers, refusal to follow directions, disorientation and extreme sadness.

Re-experiencing is often the most subtle of the three symptoms, but it can be observed through the presence of rigid and repetitive patterns. These patterns can include common play leading to outbursts or withdrawal if the pattern is changed or interrupted. The play or reenactments have a noticeable anxious quality to them, or the child appears to space out when engaged in these patterns. One of the most consistent observations of re-experiencing is the presence of nightmares.

Neurological responses to traumatic stress include:

  • Increased levels of adrenaline (activation of the sympathetic nervous system)
  • Decreased levels of cortisol and serotonin (a reduced ability to moderate the sympathetic nervous system or emotional reactivity)
  • Increased levels of endogenous opioids (which result in pain reduction, emotional blunting and memory impairment)

In addition, chronic stress can interrupt cognitive functions such as planning, working memory and mental flexibility. Hence, it is important to systematically assess how children use relationships, interact with others and interact with their environment. Furthermore, when traumatic stressors deplete the coping resources of caregivers, they can become neglectful or show signs of chronic danger, leading to the potential disruption of the attachment system for young children.

Attachment issues

Attachment research describes children’s behaviors along a wellness spectrum from secure attachment (most well) to insecure attachment (where children are at highest risk). With secure attachments, caregivers display relaxed, warm and positive interactions involving some form of direct expression of feelings or desires and the ability to negotiate conflict or disagreement. In this manner, caregivers are encouraging, sensitive, consistent and responsive. With insecure attachments, the child loses confidence to varying degrees in the caregiving system, believing that the caregiver lacks responsiveness and availability during times of distress or trauma.

Securely attached children typically display the following healthy behaviors during the different phases of growth:

  • Phase I (0 to 3 months): Newborns often seek out connection (eye contact and touch) and respond to familiar smells, sights and sounds.
  • Phase II (3 to 6 months): Infants begin to orient to familiar people (preferring those who are familiar to them while avoiding those who are not familiar) and are emotionally expressive, responding to others’ emotional signals.
  • Phase III (6 months on): Infants become wary of strangers and actively seek out familiar caregivers. Additionally, they begin practicing verbal and nonverbal displays of happiness, sadness, anger and fear.
  • Phase IV (from the second to third year on): These young children notably gain increased abilities to negotiate with caregivers (sometimes resulting in short-lived tantrums), are better able to coordinate goals with others (showing adaptable and responsive goals), display increasingly empathic responses to others, and progressively develop greater walking and complex verbal communication skills.

Insecure attachments styles are divided into three categories: avoidant, resistant and disorganized-disoriented. Avoidant attachment styles often can be associated with caregivers who minimize the perceptions of young children, are emotionally unavailable, and assign care of the child to others. This results in young children becoming indifferent to the presence of the caregiver, displaying detached/neutral responses to others, and minimizing opportunities for interaction with others.

Resistant attachment styles are associated with caregivers who resist distress (showing avoidance verbally or physically) and often wait for the child to get highly upset before attempting to sooth. This conditions young children to maximize distress, to resist or display difficultly in being soothed, and to under-regulate their emotions (e.g., responding dramatically to change and acting out dramatically when expectations are not met). Additionally, these children readily perceive experiences as threatening, get frustrated easily, and often approach life anxiously or as if helpless. These children initiate their interactions with others through their distress.

The third and most unhealthy attachment style is disorganized-disoriented. It is associated with caregivers who are often confrontational, helpless, frightened or disengaged (avoidant). These caregivers often passively place children at risk due to the caregivers’ lack of involvement or preventive parenting skills. Their children respond by attempting to adapt to the caregivers’ emotional needs — either caretaking or avoiding. These adaptive behaviors are often observed as consistent displays of confusion, hostility, freezing responses or caregiving responses (e.g., reassuring, pleasing, cheering up).

Counselors’ role: As counselors, we are uniquely trained to meet the needs of young children because of our emphasis on human development, prevention, ecosystems and wellness. Counselors can use three main restorative skills to intervene with young children experiencing attachment issues related to traumatic stress. We can:

  • Set up a safe and warm environment in our clinical settings
  • Display trust through culturally sensitive gestures, tone of voice and facial expressions
  • Nurture a nonjudgmental understanding of young clients while focusing on exploration, empowerment and acceptance

By engaging in these three practices, professional counselors should be able to aid young children in working through a variety of social, emotional, behavioral and learning challenges. Counselors can foster warmth and vitality by employing mutuality and relational socio-dramatic play experiences. Additionally, counselors can create mediated learning so that young children can develop the ability to self-define, contextualize and transform their reality into healthy developmental journeys. This gentle, nonthreatening rebalancing of the energy can create restorative opportunities.

Ten evidence-based interventions

In 2000, Cirecie A. West-Olatunji (one of the co-authors of this article) and a colleague created a program called the Children’s Crisis Unit, in partnership with a local YWCA rape crisis unit, to provide clinical services to young children in a five-county area when referred for allegations of child sexual abuse. Over a four-year period, the Children’s Crisis Unit provided assessment and intervention for children and provided consultation to clinicians, law enforcement, medical professionals and legal professionals, both locally and nationally. During this time, training was provided for counseling, psychology and social work graduate students who learned how to work specifically with clients from birth to age 5.

The following techniques were used systematically with hundreds of clients. Although these interventions may be similar to those used with nonsymptomatic children, in working with young children, there are several unique features, including:

  • Assessment for degree of severity
  • Remediation
  • Involvement of the caregiver
  • Bookmarking for interventions at later developmental periods

1) Popsicle sticks: This intervention can be introduced in the first session with the primary caregiver and the child. One of the appealing things about the use of Popsicle sticks is that they are very inexpensive, meaning nearly any family can afford them. Counselors can use nontoxic crayons or markers and other craft tools such as glitter, buttons, yarn and nontoxic glue. Counselors direct the caregiver-child dyad to use the Popsicle sticks to create individual members of their family as dolls. This activity can be continued at home between sessions. This intervention facilitates bonding and trust, decreases anxiety, is client-centered and culturally appropriate, and allows children to tell their story.

2) Feeling faces: This activity provides easy access for the counselor because various versions can be downloaded from the internet. Use of the feeling faces allows children to identify with other children and their facial expressions. In the exercise, the counselor directs the child to select those faces to which he or she is drawn to determine thematic links between the selected faces. The counselor then hypothesizes and contextualizes the presenting problem. This activity is useful in remediating flattened affect, with the counselor directing the child to mimic faces that match a range of emotions.

3) Storytelling: Narrative activities allow children to tell stories of their own choosing or give a particular recounting as directed by the counselor. Storytelling also allows the caregiver to recount or read the child a story that represents some resolution to the problem. Additionally, this activity permits the counselor to a) read the child a story representing some resolution to the problem and then engage in dialogue about feelings or b) collect pre- and post-observational data regarding the child’s responses.

4) Puppets: This intervention is helpful in allowing children to use dramatic play to express their feelings, recount a story or “restory” prior negative events. It can be particularly useful when the caregiver is actively involved in the puppet intervention. Puppets can be of the caregivers’ own making or ones that are available in the clinical room. Smaller and isomorphic puppets work better with infants and toddlers, whereas 3- and 4-year-old children are more likely to respond to animal-shaped and larger puppets.

5) Anatomically and culturally correct figurines: These figurines can be useful in cases of physical and sexual abuse because children are more likely to provide an accurate accounting when directed to engage in dramatic play. This intervention allows children to reenact situations that they have experienced. Additionally, it offers opportunities for children to point to parts of the body on the figurines as well as on themselves. This activity can provide the counselor with an assessment of the child’s developmentally appropriate knowledge about sexuality.

6) Dollhouse: This intervention offers a physical example of the home that can be used to explain what happens in the home from the child’s perspective. Use of a dollhouse can aid in accessing the child’s memories more easily based on familiarity with household items rather than starting from scratch. This activity allows counselors to be either:

  • Directive with the child, using prompts such as, “Tell me what happens in this room” (while pointing to a specific room in the dollhouse)
  • Nondirective with the child, permitting the child to have free-flowing play with the items in the dollhouse (while making observational notes)

7) Play dough (modeling clay): Modeling clay provides a kinesthetic, moldable medium that children can use to contextualize and express feelings involving sensory experiences. This intervention permits children to create representations of their family members by providing definition to body parts and facial expressions, and thus connecting emotions, experiences and people to the critical event. Play dough activities allow counselors to direct children to mold important people (both family members and nonfamily members) in their lives.

8) Freehand drawing: This activity offers children the opportunity to creatively express what is happening for them in the moment. Tools for this activity are based on the child’s developmental level and might include crayons, markers, pens, pencils or chalk, depending on the child’s age and motor skills. Counselors can use this activity to promote comfort, connection, nurturance and fun for children.

9) Kinetic family/human figure drawing: Kinetic family drawing is a more directive technique that allows children to articulate how they see themselves in relation to other family members. This activity allows for dialogue between the parent and child in terms of perspectives of the family. The counselor offers paper and drawing instruments and directs the child to draw a picture of her or his family. (Note: Try to avoid stick figures, depending on the age of the child.)

10) In vivo parent-child observation and feedback: This intervention permits the counselor to assume an observer role as the parent and child interact. It can be either directive or nondirective. This activity allows for a real-time view of the interaction quality between the parent and child, providing insight into parenting style and skills as well as attachment issues. In vivo observations afford counselors the opportunity to prepare the clinical room with play materials and direct the parent to engage with the child (or, in a nondirective way, allow the parent and child to interact without instructions). Thus, the counselor can step back to observe (either in the clinical room or in an adjoining room with a one-way mirror). If the counselor is in the room, she or he can provide instant feedback and redirection, if necessary.

It should be noted that when working with preverbal children, counselors should rely on nonverbals such as body language, facial expressions, physiological responses and the child’s attention and focus. Also, be aware that children’s comprehension develops earlier than their language abilities. It is important to remember that children understand more than they can communicate.

Extending our reach

The counseling profession is poised to serve as a leading provider of much-needed services to young children. Our focus on prevention, environmental context, development and wellness makes us uniquely trained to assess, intervene with and investigate clinical issues in early childhood. The benefits for us as a profession are numerous and extensive.

First, by incorporating a focus on young children, we can increase our role definition by providing psychological consultation to children, parents, and child care providers in day care centers (such as Head Start) and preschools. Second, we move from the implicit to the explicit. Many practicing counselors are already working with young children in their agencies, schools and private practices. However, without counselor educators and policymakers explicating guidelines for practice, the profession lacks a systematic response to ensure application of evidence-based interventions. Third, we can expand our involvement in addressing the needs of this clinical population by securing grants from federal agencies and private foundations; attending think tanks and conventions where other health professionals are gathering to discuss the needs of young children; and advocating for increased coordination of service providers across all service delivery platforms and agencies. Finally, we can advocate for ourselves by becoming more visible within the larger health care community.

Recommendations: Existing courses in counselor education need to incorporate a paradigm that includes training specifically geared toward clinical populations from birth to age 5. The major challenge within this discipline is how to transform base-level skills into effective techniques and interventions for young clients.

School counselors especially need to have specialized skills and training so they are equipped with tools that acknowledge characteristics and cultural nuances that are specific to child populations. Allowing graduate students to become familiar with the pediatric population early in their training begins the process of conceptualizing young children in the context of a holistic, strength-based and culture-centered approach.

Some professionals have offered a solution to this dilemma by suggesting a framework that incorporates exposure to a variety of populations or the use of various subspecialties. In such a framework, counselor educators systematically incorporate broad content knowledge of specialized populations that is applied throughout the curriculum. Family courses could focus on the specific issues that pediatric members of the family system face and how these issues affect the entire family’s functioning. In addition, family courses could focus on interventions geared toward young children that incorporate the entire family, hence aiding the family to function more effectively. Counseling courses on theory and technique might add discussions on how to incorporate young child development and issues into concepts and interventions that are specific to various counseling theories.

Finally, to further develop our understanding of what practicing counselors actually do when working with young children, it is important to perform additional counseling research. One way of advancing our knowledge in this area might be the use of a Delphi study. This systematic approach, which would gather a panel of experts through a nominations process, could be used to generate ideas, gain consensus and identify opinions of a wide range of counseling professionals without face-to-face interaction. This method could provide a means of bridging research and practice to reach a common understanding of what steps can be taken to explore our conceptualization and assessment of and intervention with young children.

In sum, counselors have the ideal training to work closely with young clients and to provide culturally appropriate interventions to address the unique needs of this client population. Use of developmentally informed and ecosystemic frameworks will allow counselors to be accurate in their conceptualization and treatment of young children.

 

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Cirecie A. West-Olatunji serves as associate professor in counseling at Xavier University of Louisiana (XULA) and as director of the XULA Center for Traumatic Stress Research. She is a past president of the American Counseling Association and the Association for Multicultural Counseling and Development (AMCD). Internationally, she has provided consultation and training in southern Africa, the Pacific Rim and Europe. Contact her at colatunj@xula.edu.

Jeff D. Wolfgang is an assistant professor in the Department of Counseling in the College of Education at North Carolina A&T State University. His research focuses on multigenerational effects of trauma on young children and their families. Contact him at jdwolfgang@ncat.edu.

Kimberly N. Frazier is an associate professor in the Department of Clinical Rehabilitation and Counseling at the Louisiana State University Health Sciences Center-New Orleans. Her research focuses on counseling pediatric populations, cultured-centered counseling interventions and training, systemic oppression and trauma. She is a past president of AMCD and has served as an ACA Governing Council representative. Contact her at kfraz1@lsuhsc.edu.

 

Letters to the editor: ct@counseling.org

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.

Counseling individuals of African descent

By Malik Aqueel Raheem and Kimberly A. Hart March 5, 2019

In 1963, James Baldwin wrote that to be Black and relatively conscious is to be in a state of rage almost all the time. The historical record of people of African descent is filled with triumphs and trials. The great empires and kingdoms of Africa, including Egypt, Mali and the Moors, experienced vast triumphs. Records of tremendous successes, such as those led by Mansa Musa, Hannibal, Queen Nana Yaa Asantewa, Shaka Zulu and Amenhotep IV, demonstrate the great history of people of African descent prior to the trans-Atlantic slave trade and colonization.

The trans-Atlantic slave trade had a unique impact on Africa and on individuals of African descent. Historians report that Brazil was one of the last governments to make slavery illegal in the Americas, in 1888. However, long after slavery formally ended in the United States — in 1865 with ratification of the 13th Amendment — the psychosocial oppression of people of African descent continued. For the next 100 years, Black codes and Jim Crow laws were influential in creating a second-class citizenship for people of African descent. In 1964, the Civil Rights Act was signed, appearing to offer the full promise of freedom, but the civil right for freedom remained existent in theory only. A separate existence dominated by institutional racism — highlighted by such laws and policies as redlining, the federal crime bill of 1994 and the school-to-prison pipeline — was the actualized manifestation of post-slavery experience for many individuals of African descent.

In 1991, the movie Boyz N the Hood included an opening scene of four young males of African descent walking through the neighborhood of South-Central Los Angeles. This could have been any urban area in America during the height of the crack epidemic and the infamous “war on drugs.” One of the four young men shows his peers the remains of a dead body among the weeds of an empty lot. Similar scenes have transpired regularly across the United States and throughout the African diaspora. It stands as one example of the trauma being experienced in many urban areas and inner cities today.

The crises of institutionalized racism, race-based oppression and racial trauma are significant aspects of the intersectionality of individuals of African descent. Counselors need to understand the meaning and impact of this intersectionality on the students and clients they counsel. Understanding the core constructs of historical and complex crisis and trauma for individuals of African descent who present in counseling is an essential phase for developing counselor efficacy.

Definitions

The information presented in this article can be understood and discussed using the definitions that follow. Scholars such as Derrick Bell, Patricia Williams, Kimberlé Williams Crenshaw and Mari Matsuda have contributed to critical race theory. According to the theory, racism has three levels: institutional, individual and internalized. Racism is to be understood as discrimination, marginalization or oppression inequitably inflicted upon individuals identified as belonging to a socially constructed racial category. Racism requires the combination of prejudice, power, access and privilege. For an individual to be racist, he or she must have access to an element of power and privilege to oppress the group being prejudicially discriminated against.

In the 2007 article “Racial microaggressions in everyday life,” Derald Wing Sue and colleagues defined racial microaggressions. Racial microaggressions are brief and commonplace verbal, behavioral or environmental indignities that are used, unintentionally or intentionally, to communicate hostile, derogatory or negative racial slights and insults to the targeted person or group based on their socially constructed racial category.

In 2003, William Smith coined the phrase racial battle fatigue. The term captures the psychological attrition that people of color experience in their daily encounters as they try to deflect racial insults, stereotypes and discrimination. Racial battle fatigue is the cumulative debilitating effect of being on guard against attacks about or because of one’s socially constructed racial category. It is also a theoretical framework for examining social-emotional-psychological stress responses such as frustration, anger, exhaustion, physical avoidance, psychological withdrawal, acceptance of racial stereotypes, and verbal, nonverbal or physical fighting back related to the experience of racism and racial microaggressions in acute episodes or chronic intervals.

Culture is a collective constellation of behavioral norms, values, spirituality, traditions, history, language and unique variables such as food, music, dance and clothing that guide and influence a people’s cognitive and affective complexity. This in turn determines their behavioral response to life circumstances. Culture frequently is identified by ethnic populations. However, the concept of culture is not restricted by ethnic groupings. Microcultural norms influence the unique intersectionality experiences of microcommunities and individuals within identified cultural groups.

Intersectionality is a term coined by Crenshaw in 1989. It is used to recognize systemic influences on individual identity, positionality, access and experience narratives. The primary influence on Crenshaw’s discussion of intersectionality was the exclusion of differential narratives of women of African descent during the feminist movement in the United States. Intersectionality is used in identification of nonmajority sociopolitical experiences that were suppressed by individuals operating from racist and heterosexist sociopolitical majority narratives. Intersectionality is understood to encompass microcultural influences such as religious diversity, nation of origin diversity, gender expression diversity, sexual orientation diversity, ethnic diversity and generational diversity.

White supremacy is the belief and practice that individuals who racially identify as White are superior to all other races, especially to people of African descent or Black people. Within this belief system, people of Whiteness and White culture are considered rightful dominators in dictating normalcy and social policies. Neely Fuller said, “If you do not understand White supremacy, what it is and how it works, everything else you think you understand will confuse you.” The supremacy of Whiteness, like racial categorization, is a sociocultural myth. Nevertheless, these constructs influence trauma.

Trauma is defined as an emotional response to distressing or life-threatening events. Traumatic events overwhelm a person’s ability to cope, leaving the person fearful of injury, mutilation or death. Trauma has affective, cognitive and behavioral influences on human development and functioning. Some trauma is communal in that a collective of individuals sharing some community or temporal space connection is affected by a single traumatic event (e.g., the trans-Atlantic slave trade). Individual trauma affects one individual at one point in time. Complex trauma is identified by compound experiences (i.e., more than one traumatic event is experienced before the healing of a previous trauma or serves to restimulate a traumatic response to a distressing event that was previously managed). Trauma can manifest through vicarious experiences, transgenerational events or the experience of persistent adverse events that may not have been traumatic in isolation. There are different types of trauma and levels of traumatic responses. Trauma is individualized on the basis of perceptions of events and the person’s ability to cope in the present moment of the crisis.

Race-related trauma

A multicultural assessment of problematic behavior for people of African descent should not be limited to a description of mental and emotional deficits or to observations of atypical externalized behaviors. An accurate multicultural assessment must include responses to psychosocial and environmental conditions in which the observed behavior might be a normative and rational response. Behavioral pathology of people of African descent can be a consequence of ecological systems rather than intrapsychological deficits.

Racism is a psychological disease; racism is pathology cultivated through transgenerational neglect, and it has negative influences on perpetrators of racism, victims of racism and racism survivors. Unfortunately, as individuals in society have refused treatment for so long, people of African descent have continued to experience overt and covert culture-deteriorating suffering and trauma as the result of being targets of racism. Racism is both extremely common and extremely complex. Racism is entrenched in societal history, institutions and policies, with the exerted supremacy of Whiteness perpetrated and perpetuated as a societal norm.

Racism is pathology of power marked by ignorance. In 2013, racism scholar and healing racism advocate Lee Mun Wah described the privilege of numbness as an outcome of racism that is experienced by individuals of Whiteness. The privilege of numbness is a paradoxical term used to articulate the adverse impact of racism that influences the ability of individuals of Whiteness to perpetuate racism. Privilege in this equation of racism is one’s positionality of normativity. This privilege is the gift of psychological and emotional numbness resulting in not having to think about:

  • The construct of race or racism
  • How racism is oppressive
  • How complicit and explicit racists are advantaged in direct relationship to the oppressive trauma of individuals of African descent

This article focuses on direct counseling for individuals of African descent. However, it should be noted that healing the trauma of racism needs to include healing the numbness of racists. In general, this includes individuals of Whiteness within institutions of Whiteness reallocating their forcibly gained and complicity perpetuated power that has been used for oppressing individuals through policies and institutional norms.

Individuals of African descent commonly experience racial microaggressions. Racial microaggressions are communications of assumptions, including assumptions of intellectual inferiority, assumptions of criminality, assumed superiority of White values and culture, and assumed universality of the Black experience. People of African descent experience unrelenting forms of direct, vicarious and institutional oppression, marginalization, discrimination and microaggressions. Many of these incidents manifest as hypersurveillance, stigmatization, provocative irritations and recurrent indignities, and people of African descent experience these microaggressions daily. Microaggressive events can accumulate and compound into experiences of racial battle fatigue and race-based trauma, some of which is experienced by a collective group of individuals during the same time period.

Community-experienced trauma

One example of community trauma is the economic devastation in communities of people of African descent resulting from periods of deindustrialization in many urban areas. The convergence of deindustrialization and racial desegregation created losses in vital social and economic capital among communities of African descent. Increases in unemployment and underemployment quickly snowballed into lost wealth and concentrated poverty within communities of African descent.

Although deindustrialization was not targeted racism, the intersection of racism was a compounding factor in the unfortunate and traumatic impact on communities of African descent. Within this atmosphere of community poverty and a reduction in already sparse resources, a dynamic and traumatic upsurge of violence, drugs and institutionalized mass incarceration was also experienced in many of these communities.

Another example of community trauma is manifested through interpersonal violence and economic deprivation within communities of African descent. Men of African descent are the primary targets of this trauma. Nonetheless, women and children of African descent are also exposed to violence in the streets, violence in the schools and violence in the homes. The violence experienced within communities of African descent is a multifaceted intersection of trauma. Structural and institutional racism and oppression have created pandemic conditions of poverty and violence in these communities. By oppressive design, these communities have been deprived access to develop viable, legal and consistent wealth-producing economic avenues. Racist, oppressive and marginalized social structures have translated into drug, sex and weapons trafficking becoming the most consistently accessible sources of economic survival for communities of African descent.

Men of African descent

Men of African descent are disproportionately represented among both perpetrators and victims of violent crimes. According to the National Center for Health Statistics in 2017, men of African descent were nine times more likely than White men to be victims of homicide. Historically, men of African descent were (and continue to be) feared as a threat to the status quo of White supremacy. This social fear remains cloaked in racial stereotypes today. Stereotypically, men of African descent are prejudicially viewed as intimidating, scary and dangerous.

Educational disparities have created a cultural experience known as the school-to-prison pipeline within communities of African descent. The school-to-prison pipeline refers to policies and practices that push children at risk for school failure and civic disengagement due to poverty and marginalization out of the classroom and into the juvenile and criminal justice systems. Current policies such as “zero tolerance” in disciplinary actions have resulted in more suspensions, expulsions and even arrests by law enforcement officers who are typically assigned to schools in areas that are predominantly populated by people of African descent. Students of African descent are six times more likely than White students to be affected by such policies.

Women of African descent

Multigenerational and transgenerational trauma — in the form of coercive segregation of female/male units during slavery, lynchings, sexual violence, murder and intimate partner violence in different forms — have historically been a part of life for women of African descent.

It was previously documented that women on average made 71 cents to every dollar that men made; in comparison, women of color made 65 cents. Reports in 2018 included a marginal increase, with women in America making an average of 80 cents for every dollar that men made. However, that average included a decrease for women of African descent, who received only 63 cents per dollar that men made.

Violence perpetrated by men who are usually their community partners is one of the leading causes of death among women of African descent. A complicated lack of protection from men who were their life mates was a strategy that slave owners and post-slavery oppressors used to dismantle communities of African descent. This also prolonged trauma responses within these communities.

Another part of the marginalization and trauma for women of African descent involves their social image. Within literature and media, Black women are often stereotyped as one of four archetypes: Jezebel, Mammy, Matriarch and Sapphire. Jezebel is characterized as a woman who uses her sexuality as a weapon. Although these women do not necessarily engage in sexual relations, they utilize the lure of sexual possibility and overt sexual innuendo to navigate access and fulfillment of their life desires. Mammy is the woman primarily observed in roles of upkeeping other households; historically, she was the maintainer of a White family’s home and children. The Matriarch is the head of household of the Black family. Also called Medea or big momma, these woman provide protection, wisdom, connection, gospel and community history to the family.

Traditional family structures within communities of African descent include extended family units that are seamlessly interwoven into the family concept. The Matriarch was often the oldest living woman in the family unit, whereas Sapphires were usually women who had an aggressive attitude toward men. These woman were full-hearted and physically strong. They often worked to match men in traditionally male roles, which is often portrayed as an emasculation of their male counterparts. Sapphires are also portrayed as lacking maternal drive and striving for individual equality to the point of pushing men away. The strength and community utility of these archetypes are frequently ignored, whereas exoticism and exploitation of these stereotypes are perpetuated as a means of ongoing marginalization of women of African descent.

Counseling approaches and interventions

As individuals of African descent experience various adversities, crises and traumas related to racism and cultural discrimination on individual, community and generational levels, counselors can offer supports for healing trauma. Counselors must be aware of this history and the current sociopolitical institutions that traumatize and retraumatize individuals of African descent before healing work can begin.

Postmodern, humanistic and cognitive approaches have proved to be efficacious for counseling people of African descent. Other approaches are also being used with this population, however. For example, an African-centered psychological approach has been created as an alternative paradigm. This approach is grounded in traditional African spiritual philosophy but can easily be adapted for the specific religion/spirituality of the person of African descent. Because counseling is a sacred and spiritual relationship between the counselor and the client, it is important that the foundation of the therapeutic relationship be built on authenticity, trust and respect. Important interventions for counseling individuals of African descent include a focus on identity congruence, invitation for repair and the use of spiritual or religious connections salient to the individual or community.

Identity congruence: Culturally competent counselors need to be knowledgeable and sensitive to ethnic and racial issues. Ethnic identity is an aspect of a person’s social identity and self-concept derived from knowledge of their membership in a social group and the value and emotional significance they attach to that membership. Racial identity is one’s psychological response to one’s race. Racial identity reflects the extent to which the person identifies with a particular racial or ethnic group, the person’s self-perceptions because of their identified race and how that identification influences perceptions, emotions and behaviors toward people from other racial/ethnic groups.

Invitation for repair: Multicultural competence principles are rooted in internal awareness and critical reflexivity. Counselors must be aware of their biases and sociopolitical blind spots that might affect the therapeutic relationship. Multiculturally therapeutic relationships can be established using invitation for repair, as described by Malik Aqueel Raheem, Charles Myers and Scott Wickman in 2015.

Invitation for repair is acknowledging that overt and possibly covert differences in experiences exist between the mental health professional and the client. The invitation involves requesting that the client correct the counselor if the client feels that the counselor is not connecting or does not have empathy for the client’s intersectionality. Multicultural social justice principles exhort counselors to become more active advocates in addressing the institutional and environmental factors that influence client distress and trauma.

Spirituality and religion: A protective factor for many people of African descent is their connection between spirituality and psychological well-being. Research has shown that people of African descent are able to regulate and resolve distress through the practice of their spirituality or religious beliefs. Counselors should inquire about and create intervention opportunities that infuse these religious or spiritual norms. This approach will help to develop and maintain therapeutic alliance and efficacious therapeutic outcomes.

According to John Dillard, spirituality is a view of an individual’s place in the universe or a personal inclination or desire for a relationship with a transcendent power or God. Religion is an organized social means through which people express spiritual beliefs. Spirituality and religion do not necessarily have positive correlations for people of African descent. Spirituality can be experienced independent of religious contexts, and not all religions promote spirituality as part of their practices. However, many individuals of African descent are simultaneously religious and spiritual.

A majority of people of African descent identify as Christian from various religious microcultures of Christianity. There is also a movement toward infusing traditional African spirituality into some of their Christian practices. In addition, many in the African diaspora were from West African, and it is estimated that 30 percent of these Africans who were brought to the Americas were Muslim. In Islam, Sufism is the more mystical aspect of the religion. It is believed that the spiritual aspect of Sufism helps the Muslim to have a deeper and stronger connection with Allah (God). In 2018, scenes from the movie Black Panther depicted visitations to the “ancestral plane.” While in the ancestral plane, individuals could discuss issues with their ancestors. The belief that ancestors are ever-present and guiding forces is common among individuals of African descent. The tradition of libations (the ritual pouring of a liquid or other element to honor ancestors) or the West African practices of Vodun (more commonly known as Voodoo in the United States) may also be relevant for some clients of African descent.

Summary

As counselors work with individuals of African descent, acknowledgment of racism and oppressive structures that influence clients’ trauma experiences and trauma responses is vital to building therapeutic alliance. Interventions such as invitation for repair are most effective when used in the present moment of a psychological, affective or behavioral injury to the individual or the therapeutic relationship. Humanistic counseling approaches, including validation and implementation of relevant spiritual or religious practices, have also been shown to be effective for working with individuals of African descent.

 

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

Malik Aqueel Raheem has more than 10 years of clinical experience and seven years as a professional counselor educator at California State University, Fresno. Contact him at malik2xl@gmail.com.

Kimberly A. Hart focuses on multicultural inclusion as an area of counseling practice, counselor preparation and research. She provides presentations and training on mental health and intersectionality. Contact her at hartkimberly27@gmail.com.

 

Letters to the editor: ct@counseling.org

 

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

Touched by trauma

By Laurie Meyers February 22, 2019

Licensed professional counselor (LPC) Ryan T. Day often refers to himself as a trauma survivor turned trauma therapist. When he was 11, Day was molested several times by a family friend. He had also already endured serious bullying brought on by a temporary childhood speech impediment. Day eventually began to act out and get into trouble at school. At age 13, as punishment for this misbehavior, he was severely beaten by his father, a preacher in a Pentecostal African-American church who interpreted the saying “spare the rod, spoil the child” literally.

Once he was molested, Day says he began to feel that something was wrong — he was constantly angry and often used his fists to express that anger. Day knew he wasn’t feeling “normal,” but it didn’t occur to him that what he was feeling was tied to the molestation. He says there was simply no awareness of any kind about trauma in his community, which he describes as a rough area of Richmond, Virginia, where residents learned to ignore the sounds of gun shots and to turn away from domestic violence.

“I never knew that violence was an issue,” Day says. To him, it was just a normal part of life. Nor did Day know what sexual abuse was. Although he took a sex education class in high school, he says that sexual violence was never mentioned.

Day was also an athlete in high school, but instead of changing clothes in front of other students, he would retreat to a bathroom stall. “I felt uncomfortable around males. I didn’t trust men,” he says, adding that his feelings were not about homophobia but simply about not feeling safe. “Locker room shenanigans triggered me and made me want to fight or freak out.”

Still grappling with emotional and personal barriers as a young adult, Day earned his bachelor’s degree in information technology and then decided to become a counselor. He says his counseling program didn’t emphasize self-assessment, however, so it wasn’t until he confronted a crisis during his internship that Day finally made the trauma connection.

During this time, Day had become suicidal, in part because he realized he was married to someone he didn’t love. Day says he hadn’t learned how to establish personal connections growing up, so, as he puts it, “I married the first person to show me some affection and love.” The religious tradition in which Day was raised didn’t consider divorce an option. In addition, Day and his wife were expecting a child, so he didn’t see a way to escape the stress of his marriage.

Fortunately, one of Day’s supervisors realized that he was experiencing a crisis and referred Day to a therapist. Day was in therapy for five months before he started talking about his childhood. The therapist helped Day see how his traumatic childhood experiences had shaped him and, in some cases, held him back.

After Day earned his counselor licensure, his first few clients were adolescents who had experienced multiple traumas and were living in violent neighborhoods. Their experiences paralleled Day’s own, and he realized that his personal history with trauma gave him extra insight. And that was it — Day decided to become a trauma specialist, and he’s never looked back, including presenting an education session on complex trauma at the ACA 2018 Conference & Expo in Atlanta.

Like Day, many clients don’t initially present to counseling for trauma but rather for help handling other issues. “You have an individual coming in for treatment, coming in for depression, etc., but the further you get into [the person’s] history, there’s so much more story,” Day says, adding that it’s like unpeeling the layers of a client’s life.

Day doesn’t screen for trauma during a client’s first session — he prefers to reserve that for beginning to build the therapeutic relationship. But he does complete a screening within the first few visits, often using the Life Events Checklist from the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

Day says he also probes for trauma as he listens to clients’ stories, asking questions such as “Have you had trouble sleeping?”; “Are you having any relationship issues?”; “Have you ever been in a serious romantic relationship?”

Why the questions about relationships? Day explains that difficulty forming and maintaining personal relationships is a hallmark symptom of complex trauma, which is different from — and not as familiar to most people as — posttraumatic stress disorder (PTSD).

Complex trauma vs. PTSD

PTSD is typically considered to be the result of a single traumatic event that occurs at any point over the life span, whereas complex trauma is the result of repetitive trauma that begins early in life and endures for a prolonged period of time, explains Cynthia Miller, an LPC in Charlottesville, Virginia, whose practice specializes in trauma. Complex trauma might result from numerous occurrences of the same kind of trauma — such as ongoing physical or sexual abuse — but it can also develop from the accumulation of different kinds of trauma.

“It’s the difference between taking a single blow versus absorbing multiple blows over the course of years,” says Miller, an American Counseling Association member. “The accumulation of those blows causes a different kind of damage than what is caused by a single blow. The damage doesn’t impact just one system but multiple systems. With a single blow, I may have swelling and bruising and scarring, but that will be confined to one area. With multiple blows over time, I will have bruising and swelling in multiple places at different times and scar tissue all over.”

People with complex trauma or PTSD may experience some of the same symptoms, such as hyperarousal, disturbances in cognition, intrusive memories and avoidance of triggers, but there are critical differences between the two types of trauma. For instance, people with complex trauma have much more trouble with interpersonal relationships and their overall self-concept, Miller says. “In addition to all the usual PTSD symptoms, they will struggle with their sense of identity, with building stable relationships and with making meaning of the world and their lives,” she explains.

Miller says it is vital that counselors understand and recognize the differences between PTSD and complex trauma because misdiagnoses are common. Complex trauma is often mistaken for borderline or other personality disorders or, in some cases, diagnosed as PTSD with co-occurring mental health issues such as depression, anxiety and somatic disorders.

“People can end up with a bunch of different diagnoses which don’t really encapsulate and accurately formulate the total problem. The trauma gets lost in the various diagnoses,” Miller says.

In addition, the treatment approach for complex trauma is not the same as that for PTSD. “Treatment differs mostly in the sequence of interventions one might use, along with the length of treatment,” Miller explains. “Gold-standard interventions for PTSD typically involve the exposure and reprocessing therapies like EMDR [eye movement desensitization and reprocessing], prolonged exposure therapy, etc. Those treatments can be effective, but they can also destabilize clients, at least in the short term, and clinicians need to be really careful to ensure that clients have strong and varied coping skills in place before doing exposures.”

Although prolonged exposure therapy and EMDR are popular therapeutic methods that can be very effective, Miller believes clinicians should be more flexible in their approaches to treating trauma. “It’s great to be trained in EMDR or prolonged exposure therapy, but those approaches don’t work for every client,” she stresses. “Some clients are just dubious of them, others don’t want to do the exposure, and others just aren’t comfortable with it. [Also,] people don’t necessarily need to process the trauma in order to get better. I’ve had clients come into my practice who have stopped seeing other therapists because the therapist was too wedded to a particular approach and, when the client expressed discomfort with it, the therapist either couldn’t or wouldn’t adapt. You have to be able to tailor treatment to the client, not tailor the client to the treatment.”

Miller routinely uses cognitive behavior therapy (CBT) and psychoeducation to help clients understand what is going on with them, how trauma has impacted their life and what can be done about it. “This, in and of itself, is really helpful for clients,” she says. “They often believe that they are deficient in some way and have caused all their problems. Once I explain what [complex trauma] is and how it affects people, they really start to understand themselves better and feel less shame.”

Miller recommends workbooks such as Life After Trauma: A Workbook for Healing by Dena Rosenbloom, Mary Beth Williams and Barbara E. Watkins and Seeking Safety: A Treatment Manual for PTSD and Substance Abuse by Lisa M. Najavits. The workbooks “have great psychoeducational handouts and readings for clients that provide education on how trauma affects the body and the brain,” she says. “I typically use the first few sessions of therapy to go over the handouts and help clients notice ways in which what is described applies to them and does not apply to them.”

Regardless of the methods clinicians choose, the initial stage of any therapeutic intervention for complex trauma should focus solely on client safety, helping them remain in the present and build their coping skills, Miller says. She adds that this is usually the longest phase of treatment.

To help clients learn how to stop symptoms such as flashbacks and dissociation, Miller teaches grounding skills. “Groundings skills involve different ways of trying to get the brain’s attention, helping it focus on what is literally happening in the moment instead of focusing on a memory from the past or checking out entirely,” she explains. “Grounding skills can involve techniques that use the five senses or techniques that attempt to engage the cognitive portion of the brain.”

Exercises that involve the senses include tasks such as asking clients to feel their feet on the ground, inhaling a relaxing scent such as lavender or running cold water over their hands. “We [also] might teach them how to describe everything they are seeing around them in detail, as if they were trying to paint the picture of a room with their words,” Miller continues. “One of my favorite grounding skills for using in emergencies is holding an ice cube in the palm of your hand or against your cheek. The sensation of cold, and then nonharmful pain, tends to get the brain’s attention fairly quickly and help someone reorient.

“Cognitive grounding skills can include things like reciting the ABCs backward, or naming every state in alphabetical order or [naming] every make of a car that one can remember. These skills try to engage the frontal cortex, which tends to go offline when someone is having flashbacks or dissociating.”

Miller also helps clients reframe their cognitions, making them aware that their past is not continually playing itself out in their present. “We help them notice how today is just today,” she says. “For example, clients often have difficulty with the anniversaries of traumas that have happened to them. They get anticipatory anxiety and, as the date approaches, they will fall apart. We work in therapy to help them notice ways in which the upcoming date is different from the date of their trauma. The year is different, their age is different, the people around them are different, their life circumstance is different, etc. It’s helping them be fully in their present and in the reality of that instead of in their past.”

Counselors also need to be mindful of the accumulative physical toll of long-term trauma, Miller adds. Research has shown that experiencing trauma — especially when it is prolonged and repetitive — rewires the nervous system in ways that cause hyperarousal and persistent anxiety. This continuous stress causes the body to release cortisol, which can cause chronic inflammation. Over time, the inflammation leads to negative health effects. To help counteract this cascade of neurological and physical damage, practitioners can teach clients skills for calming their nervous systems, Miller says. Again, counselors should tailor the treatment to the individual client. Some clients may find yoga or meditation helpful, whereas others might benefit more from neurofeedback.

Triggers and trauma responses

Debbie Sturm, an LPC in Virginia and South Carolina, has extensive experience working with trauma survivors. Currently an associate professor and director of counseling programs at James Madison University in Harrisonburg, Virginia, at one point Sturm counseled clients through the state of South Carolina’s crime victims support service, which allows people who have experienced a crime to receive 20 state-funded counseling sessions.

Sturm’s clients had experienced a range of terrifying incidents. Among others, she worked with a bouncer who had been shot at work, a woman who had been stabbed and left for dead by someone trying to steal the cash from her paycheck, people who had witnessed a homicide and a client who had been held captive by an abusive family member. Some of her clients also lived in violent neighborhoods or had histories of adverse childhood experiences. “[All] of my clients, however, were just regular people going about their daily lives [who had] experienced something awful,” says Sturm, a member of ACA.

Most of the people Sturm counseled didn’t necessarily meet all the criteria for PTSD, but they all presented with numerous trauma symptoms. The core issue for these clients was that the distress of what had happened, combined with how unfamiliar, uncomfortable and often frightening these new symptoms were for them, caused them significant difficulties. Typical symptoms included anxiety, fear, hypervigilance, sleep and eating disturbances, a compromised sense of safety and, sometimes, anger, resentment, blame or self-blame, shame and helplessness.

“For those who experienced violence, the shock of the violence and the damage to [their] personal sense of safety, control or power could be profound,” Sturm says. However, the intensity of the trauma response did not necessarily line up in the expected way, Sturm continues.

Many people assume that the most “serious” or violent events are more traumatic than a less dramatic experience, but that is often not the case, she says. A person’s trauma response is always unique to the individual and the circumstances surrounding his or her traumatic experience. “It’s really important for the clinician to hold that belief and really honor whatever response each individual is having,” Sturm emphasizes.

The treatment path that Sturm followed with each client revolved around how that person was experiencing his or her symptoms. Sturm says that identifying clients’ triggers played an important role in their recovery. She did that in part by asking: “When do you feel like things are at their worst? What is happening around you? What do you do for comfort or reassurance? As you feel that sense of fear or hypervigilance welling up, how can you start to recognize it sooner and listen to what it’s telling you?”

“Helping people really recognize when their [sense of] fear and lack of safety is starting to elevate can also help them get out of a situation or connect to something or someone safe sooner,” she explains.

Interestingly, the triggers were not always tied directly to the client’s trauma. For example, one client who had been sexually assaulted at work would “lose time” whenever she saw a white truck. The vehicles had no connection to her assault, but for whatever reason, they triggered her, Sturm recounts. But for other clients, the triggers were connected to their previous traumas.

The search for what triggered trauma symptoms provided some therapeutic benefit in and of itself, Sturm says. The clients’ “discoveries” also allowed Sturm to suggest strategies for responding to their fears. For example, the client who feared white trucks connected a sense of safety to her mother, so Sturm suggested that when she was driving and spotted a white truck, that she pull over and call her mom.

Employing such strategies helped Sturm’s clients increase their sense of efficacy, power and control because they were no longer passive captives to their symptoms. Instead, they were armed with strategies that brought comfort and helped dispel their fear.

A person’s traumatic response is typically adaptive and can even be protective, Sturm says. “For example, consider hypervigilance. If something horrible has happened and your sense of safety is shattered, the most adaptive and protective thing you could do psychologically is to be on alert. After all, the world is now proven to be quite unsafe. So, be alert!”

At the same time, the state of alertness involved in hypervigilance is very uncomfortable, can be frightening and takes a toll on trauma survivors psychologically, neurologically and biologically, Sturm says.

Traumatic environments

In some cases, a certain place is the trigger for the person’s trauma response because it isn’t safe and will never become safe, Sturm says. Part of trauma therapy might involve talking with clients about the possibility of removing themselves from that environment. Unfortunately, leaving isn’t always an option.

ACA member Leah Polk, a licensed master social worker with Change Incorporated in St. Louis, asserts that trauma can never be treated separately from the environment in which it occurred. While some survivors of traumatic events go on to reestablish safety in their lives, others must continue living in places that are directly linked to their traumas or in environments that are violent or dangerous, such as unsafe neighborhoods, war zones or violent homes. Ultimately, practitioners must accept that they cannot prevent clients from experiencing or reexperiencing traumatic events, stresses Polk, whose specialties include helping clients recover from trauma.

However, to help clients cope, counselors can support the survival skills that these clients have while distinguishing the times and places in which those skills are useful or necessary, Polk explains. “For example, perhaps it’s crucial to be vigilant while walking home alone at night from the bus stop, but that same vigilance is not required at one’s place of work or a doctor’s office,” she explains.

Practitioners can also provide clients a safe place to express the emotions tied to the burden of living in an unsafe environment, Polk says. Clients can express the sadness and frustration of not having their needs met, the pain and anger caused by social and economic oppression, and the fear that comes from living in an unpredictable and chaotic environment.

Polk says counselors can become a safety resource for clients wrestling with trauma by modeling a consistent and predictable relationship within a contained environment. “Often … clients’ trauma is founded by a violation of trust, confidence or safety from what should have been a trusted figure in their lives,” she explains. “Without establishing an explicit alliance within the [therapeutic] relationship, much of this work is nearly impossible.”

Polk also works with clients to identify other sources of support in their lives, such as caring relationships or enjoyable hobbies and interests. To help regulate emotional arousal, she teaches clients relaxation techniques such as brief meditation, deep breathing, body scanning (to identify where in their bodies they might be holding tension) and progressive muscle relaxation.

Miller has also worked with clients who could not escape traumatic environments. “I would have loved to send my clients in prison to entirely different communities and home environments when they finished their sentences,” acknowledges Miller, who has previously worked with female inmates at correctional facilities. “It would have helped a lot, but it’s just not possible. So, what do you do when [clients] have to go back to the same environment?

“It’s not a great solution, but I think part of what you can do is help clients learn how to take control of what they can in an environment that feels uncontrollable. You can help them learn to set better boundaries around how they will allow themselves to be treated. You can teach them skills for asking for help when they need it. You can link them with supportive resources. You can also help them focus on their strengths and resiliencies and learn how to calm their system when there’s chaos all around them. Any little bit of control someone can feel is better than feeling no control at all.”

For many clients who have been through complex trauma, especially those who have been physically or sexually abused, the idea that they can have any say over how people treat them is a new concept, Miller says. “They are very used to being controlled by others and being told who they can and can’t talk to, what they can say and what they can’t, where they can go and where they can’t, even down to what they can eat or wear. They are also told that they must do whatever people want them to do. So, helping them set boundaries begins with helping them see themselves as people who have rights and who don’t have to tolerate any and everything.”

When counseling these clients, Miller says, “we work on building self-esteem and teaching assertiveness skills. Just helping them learn how to say ‘no’ can take time. We practice it in session through role-plays. We also focus on helping them learn ways to keep themselves safe when saying no to someone who might not take kindly to it. This can include having them take a personal safety class or a self-defense class that is geared specifically toward [assault] survivors. It can also include talking through how to determine how much risk is involved in a given situation.”

Body guards

When it comes to cases involving sexual trauma, the person’s own body can feel like the “unsafe environment.” Therefore, feeling safe in one’s own body constitutes the core of work with these survivors, says Laura Morse, an LPC and a sex and relationship therapist in Lancaster, Pennsylvania, who specializes in helping clients recover from trauma.

Morse starts by providing psychoeducation about the fight-or-flight response to trauma. This step helps normalize the symptoms that her clients are experiencing. Morse also teaches clients how to self-soothe and ground themselves. She pairs mindfulness and deep-breathing techniques with tapping, using either EMDR or self-tapping. During the tapping work, Morse has clients practice deep breathing accompanied by a calming scent, which gives them a method to ground themselves and self-soothe wherever they are.

Polk notes that clients with a history of complex trauma may never have possessed a sense of confidence or autonomy about their bodies. She uses mindfulness-based stress reduction exercises to help clients integrate the mind and body. This might include a guided meditation in which the client’s anchor of awareness is an upward scanning of the body, from toes to head. During the exercise, the client may notice that certain areas within the body elicit specific emotions or sensations.

“Once the client is discovering feeling in these areas, the client may offer compassionate thoughts or phrases to the impacted areas,” Polk says. “The client may also be encouraged to continue compassionate exercises such as offering gratitude for the ways in which their body has helped them survive trauma.”

Clients can also explore nonsexual touch, such as different temperatures (a cold compress versus a warm bath) or textures (a soft brush versus a silk ribbon) and journal about their experiences, says Polk, who is also seeking certification as a sex therapist.

“If the client wants to move toward reclaiming their sexuality, it may be important to discuss their sexual self-perception and relationship with themselves,” she says. “Are they able to achieve pleasure through masturbation? If not, what seems to get in the way? If certain touches are uncomfortable or triggering, the client’s sense of choice must be paramount — they can choose to try something different or set a limit around specific experiences.

“For example, while caressing and external stimulation may be pleasurable, penetration leaves the client feeling overwhelmed and tearful. Therefore, the counselor would encourage the client to observe their thoughts and feelings about their self-exploratory experience and determine what feels right for them in that moment. The sense of agency that comes with integrating the mind and body, along with rediscovering self-pleasure, can be a life-changing concept for survivors of chronic sexual trauma. Therefore, the counselor must give plenty of patience and space for these experiences.”

Sexual assault survivors also frequently experience problems with sexual intimacy. Says Morse, “I use the dual-control model for sexual intimacy to empower survivors to understand the ‘brakes’ that are keeping them safe [but] may be preventing them from enjoying experiences that they used to in the past. And then we begin to learn ‘accelerators’ of what is helpful.”

Brakes are sexual-inhibition factors such as a history of trauma, body image issues, relationship conflict, unwanted pregnancy, depression, anxiety or, as Morse puts it, “everything you see, hear, touch, taste, smell or imagine that could be a threat.”

Accelerators are sexual-excitation factors such as a partner’s smell or appearance, a sense of novelty, new love or “everything you see, hear, touch [or] smell that is a turn-on,” Morse says.

Morse also helps clients who are in relationships to create sexual scripts with their partners. “When creating a sexual script with a couple, I will do the exercise both with the couple [and] individually,” she says. “I ask the couple, with their permission, if we can create a line-by-line script of the actions that lead to intimacy. This may start with affection at breakfast or date night, well before intimacy in the bedroom begins.”

Creating the script encourages couples to reflect on their usual sexual patterns and, in individual sessions, allows each partner to express any barriers they may be experiencing or areas where novelty or changes could be incorporated.

Polk believes that when clients who have experienced sexual trauma say they are ready to reengage in partnered sex or physical intimacy, it is important for the counselor to assess how they came to that conclusion. “While being supportive of their desires, the counselor may want to ask if this interest arose from their partner, from their own interests or collaboratively. The client’s sexual self-efficacy, or ability to reliably communicate and have sexual needs met, is of paramount interest when approaching this topic.”

Sexual assault survivors who are already in a sexual relationship may also find that trauma symptoms create barriers to intimacy. Clients may experience psychological symptoms such as depression, PTSD, traumatic reenactment and anxiety. Decreased libido or arousal and painful sex are also common, as are sexual avoidance and conflict in the relationship.

To combat these negative impacts, Polk helps clients create a sexual consent model. “The sexual consent model is used to negotiate sexual boundaries and mutual agreements between partners,” she explains. “This is more than a ‘yes’ or ‘no’; [it] is explicit and entails ongoing dialogue between partners. Research currently tells us that men are more likely to see consent as a one-time event, so gender scripts must be considered when approaching this model.”

Polk provides examples of possible script dialogue:

  • “I know I said oral sex was OK last week, but right now, I am uncomfortable.”
  • “If we try this position, it doesn’t mean that you have to always do this.”
  • “After sex, can you make time to cuddle so that I am not left alone?”
  • “While having sex, I noticed that you got unusually quiet. Is everything OK?”

Morse recommends sensate therapy to her clients. She describes sensate therapy as a series of sex therapy exercises that allow for sensual touch to be achieved without anxiety. “Typically,
this will start with just having a couple carve out time twice a week where intimacy is not centered around the genitals and penetrative sex,” she says. “Masters and Johnson initially developed a series of exercises which are now commonly adapted based on a couple’s specific needs.”

Morse recommends the book Sensate Focus in Sex Therapy by Linda Weiner and Constance Avery-Clark for counselors who want to learn more.

Trauma education

Day believes there are still too many people walking around with trauma who have no idea that they can be helped. He says counselors need to be proactive in educating the public about trauma because many of the people who could benefit will never show up in their offices. Day also stresses the need for trauma education in schools but says that because school counselors have so much on their plates, clinical counselors need to step in and be willing to give their time.

“Counselors don’t always have to sit behind the desk,” he states. “Go to places where people are uncomfortable about having these conversations, such as schools, community centers, churches.”

One of the things that Day loves most about being a trauma counselor is getting the word out. He gives presentations, participates on panels and has even talked about trauma on the radio.

“Individuals have to have that conversation,” he says.

 

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Additional resources

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

Counseling Today (ct.counseling.org)

  • “Moving through trauma” by Jessica Smith
  • “The Counseling Connoisseur: The contour of hope in trauma” by Cheryl Fisher
  • “Informed by trauma” by Laurie Meyers
  • “Salutogenesis: Using clients’ strengths in the treatment of trauma” by Debra G. Hyatt Burkhart and Eric W. Owens
  • “Coming to grips with childhood adversity” by Oliver J. Morgan
  • “The toll of childhood trauma” by Laurie Meyers
  • “Traumatology: A widespread and growing need” compiled by Bethany Bray
  • “All trauma is not the same” by Tara S. Jungersen, Stephanie Dailey, Julie Uhernik and Carol M. Smith
  • “The high cost of human-made disasters” by Lindsey Phillips
  • “Lending a helping hand in disaster’s wake” by Laurie Meyers

Books and DVDs (counseling.org/publications/bookstore)

  • Disaster Mental Health Counseling: A Guide to Preparing and Responding, fourth edition, edited by Jane Webber and J. Barry Mascari
  • Youth at Risk, sixth edition, edited by David Capuzzi and Douglas R. Gross
  • Crisis Stabilization for Children: Disaster Mental Health, DVD, presented by Jennifer Baggerly

Webinars (aca.digitellinc.com/aca/pages/events)

  • “Traumatic Stress and Marginalized Groups” with Cirecie A. West-Olatunji (CPA24341)
  • “Counseling Students Who Have Experienced Trauma: Practical Recommendations at the Elementary, Secondary and College Levels” with Richard Joseph Behun, Julie A. Cerrito and Eric W. Owens (CPA24339)
  • “Counseling Refugees: Addressing Trauma, Stress and Resilience” with Rachael D. Goodman (CPA24337)
  • “Dissociation and Trauma Spectrum” with Mike Dubi (CPA24333)
  • “Children and Trauma” with Kimberly N. Frazier (CPA24331)
  • “ABCs of Trauma” with A. Stephen Lenz

Podcasts (aca.digitellinc.com/aca/store/5#cat14)

  • “Treating Domestic Violence” with Tali Sadan (ACA282)
  • “Counseling African-American Males: Post Ferguson” with Rufus Tony Spann (ACA285)
  • “Harm to Others” with Brian VanBrunt (ACA248)
  • “Child Sexual Abuse Survivors, Their Families and Caregivers” with Kimberly Frazier (ACA200)

ACA Mental Health Resources (counseling.org/knowledge-center/mental-health-resources)

  • Gun Violence
  • Trauma and Disaster

ACA Interest Networks (counseling.org/aca-community/aca-connect/interest-networks)

  • Traumatology Interest Network

 

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

 

Letters to the editorct@counseling.org

 

 

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

PTSD and climbing out of the valley of the shadow of death

By Shirley Porter January 31, 2019

Max came into my office and sat down. He was a big guy in his late 30s. When I asked how I could help, he responded that he believed he had posttraumatic stress disorder (PTSD). When I asked what led him to this conclusion, he said he had been a sniper in the military and had been abused as a child. (Author’s note: The name of this client has been changed, but the content is accurate in accordance with his written and informed consent to share his story.)

My approach to trauma work has evolved over the years based on what we have come to learn about trauma through research, as well as on my own clinical observations. My therapeutic approach is rooted in client-centeredness, transparency, reverence, compassion and a belief in client strength and resiliency. On the basis of these values, essential components of this approach include accessible language/education, collaboration and evidence-based practice.

When it comes to education and accessible language, the use of metaphors can provide our clients with a much-needed bridge to understanding and normalizing their experiences. Active collaboration with our clients allows them the opportunity to find their power and use it. Because the experience of trauma often involves a feeling of loss of control and having things happen against one’s will, safe and respectful practice requires that clients be informed and willing participants in all aspects of the therapeutic process. And, finally, using evidence-based interventions allows us to provide professional, competent care in helping clients to alleviate their distress, process their trauma and reclaim their lives.

Introduction to the valley of the shadow of death

I often use the metaphor of the “valley of the shadow of death” to explain to my clients the experience of PTSD and the stages of healing. Some clients recognize this metaphor from the Bible’s well-known 23rd Psalm, which begins, “The Lord is my shepherd …” However, its use does not require any spiritual or religious belief on the part of the client or the therapist. I chose this metaphor because of its power.

As I wrote in my book Surviving the Valley: Trauma and Beyond, trauma occurs in “a dark and desolate place that exists in the shadow of some kind of significant ending — a real or symbolic death. In this place, you are apt to feel a profound sense of loneliness, despair and hopelessness. … There are no obvious pathways out of the Valley. The terrain looks treacherous and foreboding. It is difficult to know where to begin.”

In the valley of the shadow of death, the sky is often starless. It can be difficult to recall better times or to hope for them in one’s future. Experiences that send one into this valley typically involve the experience of witnessed, threatened or metaphorical death (e.g., the “death” of trust, innocence, a sense of safety, the belief in fairness or justice). Hope can be elusive.

In my practice, this metaphor has proved to be a powerful means of helping clients find the words to explain what their experience has felt like. I typically introduce this concept somewhere between the first and second phases of trauma work, but I am explaining it to readers here so that the metaphor will make sense from the outset. What follows is the phases of trauma work, explained from the perspective of the metaphor of the valley of the shadow of death.

Phase 1: First things first

Max had never been assessed for PTSD previously. His symptomology was intense. At times, he could be completely dissociated from his body, such as when he walked on a broken leg for a week because he did not feel the pain.

Emotionally, Max was numb. He hadn’t felt emotions for years. He lived his life in survival mode — making him fantastic in a crisis — but Max’s body and mind were always on high alert for threats. He was exhausted, having flashbacks and starting to experience life-threatening medical issues.

We began our work together by assessing and identifying his injuries and normalizing his symptoms. I also started to reflect back his strength, resiliency and courage. At the same time, I was clear with him that he deserved, and would need, external supports along the way. We worked on connecting him with resources for veterans and with medical supports. Max found the metaphor of the valley of the shadow of death to be an apt representation of what he had been living.

 

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Once we have determined that our clients are in the valley, we need to identify, assess and begin to respond to their injuries. There also may be crises that require our immediate attention and response. 

Some clients will have landed hard in the valley. They may have physical injuries in addition to the psychological ones. Before we even think about moving forward or delving into details of the trauma, we need to identify and assess injuries by asking clients which ones are causing them the most distress currently. (I use the Traumatic Stress Symptom Screening Checklist, which I developed and included in my book Treating PTSD: A Compassion-Focused CBT Approach.) At this point, we can discuss whether mobilizing community, medical, family or peer supports might be helpful to the client. If the client needs help connecting with these supports, we may need to liaise or advocate on the client’s behalf.

Reassurance is a component of this phase. Some clients may be carrying the added burdens of guilt or shame that can come with the misunderstanding that if they were stronger, they would not have ended up in this dark place. Thus, we may need to let them know that traumatic stress reactions are not a result of weakness or character flaws; rather, these are normal reactions to what they have been through.

Given that despair and hopelessness can be part of the symptomology of individuals who find themselves in the valley, checking for suicidal ideation and intent is also essential at the start. If a client is suicidal, it is best we are aware of this at the outset so that we can conduct a risk assessment, create a safety plan with the client and mobilize appropriate resources.

Some clients will not have the strength at this point to hold on to hope. With these clients, I tell them that with all they are dealing with, I recognize that their strength might be lacking, but not to worry because I will hold on to hope for them. I further reassure them that I fully believe we will be able to get them to a point where they can effectively manage their distress and reclaim their lives. (Many of my clients in this situation have responded with relief and gratitude.)

Clients might also be living in unsafe environments that require safety planning or other interventions. This can be another piece of assessing and responding to crises in this phase.

Phase 2: Stabilization and gathering tools for the journey

Throughout the course of trauma work with Max, I provided him with information on how trauma, and specifically complex trauma, can affect the mind and body. He was familiar with the fight-or-flight trauma responses but had not realized that his capacity to respond so effectively in high-risk situations was a result of conditioning through his military training. His experiences and symptoms started to make sense to him, and thus his shame receded.

Max had learned to ignore his physical needs at an early age, which is common with children who suffer from chronic childhood abuse. The first homework assignment that I gave him had three parts to it: 1) to notice when he was hungry and to eat; 2) to notice when he had to go to the bathroom and to do so; and 3) to notice when he was tired and to go to sleep. He smiled when I gave him this assignment and asked how I knew.

Max related to the image of the “warrior spirit” (described further later in the article). Although it had meant something else in his military life, we redirected the energies of his warrior spirit to focus on protecting his healing and well-being.

 

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After assessing and attending to injuries and addressing any crises that clients might be facing, it is time to help them get their bearings in the valley and gather the tools they will need for their stabilization and containment — both for use now and on their trauma processing journey (should they choose to take this path).

Some clients will need time to rest and heal before moving on to the next phase of trauma work. We would not expect someone who has just been injured to begin what could quickly become a treacherous climb. Likewise, our clients will need to be stabilized before moving forward in trauma work. They need to be at a point at which they can successfully tolerate or reduce their distress without moving into crisis.

Education is an important component of this phase. Our clients need to know what is normal and what kinds of challenges they might encounter on their journey in the valley. Knowledge about how trauma affects the mind and body can provide our clients with footholds in the valley. We want to help them better understand trauma — specifically, what types of experiences can lead to traumatic stress responses, how people tend to react during traumatic events and the range of normal reactions following such events.

Our clients need to be aware that normal reactions following trauma might include difficulties in the physical, emotional, cognitive and spiritual aspects of their lives. During this part of the work, we are normalizing their reactions during and following their trauma experiences while empathizing with their current distress. It is important that we use easy-to-understand language and concepts in recognition that when our clients are in the throes of severe PTSD symptoms, they can handle only small, personally meaningful pieces of information. 

This part of the work also involves helping our clients identify and become comfortable using the tools and resources that will assist them in better tolerating or reducing the distress that they might encounter on their healing journeys. In my work, I have come to recognize 10 such resources or tools to support clients in their journeys.

Within the clients

1) Recognizing their “warrior spirit” within. This involves giving a name to the persona we want to encourage clients to connect with in terms of dual awareness — the strongest, wisest part of who they are that has allowed them to survive the trauma and brought them to this place.

2) Reducing commitments to reduce distress and give clients the time and space to heal.

3) Confronting or advocating with the people, systems, etc., that were involved in causing the trauma in an attempt to address these wrongs or to achieve a sense of justice (when it is safe to do so).

4) Using distraction strategies. These are actions that clients can take to remove themselves from spirals of nonproductive, stress-elevating thinking. Examples: going for a walk, texting a friend, cleaning, drawing.

5) Using mindfulness strategies. This involves moving clients’ awareness from their distressing reliving of past negative events, or their distressing fears of what might happen in the future, to the present moment via the five senses. Examples: noticing a favorite color in the room; feeling the chair one is sitting on; picking up a stone and noticing its texture, color and shape.

6) Using self-soothing strategies. This involves using the senses to calm, soothe or reenergize. Examples: sipping a hot drink, listening to music, inhaling the scents of nature, wearing soft and comfortable clothes, looking at a picture of a loved one.

Through connection with others

7) Seeking counseling support with a mental health professional who specializes in trauma work.

8) Seeking medical support to address physical or psychological pain resulting from injuries or symptoms that are causing distress.

9) Seeking spiritual support from a religious/spiritual leader or peer.

10) Accepting offers of support from caring friends, family members or peers to do household tasks, help with children or take on other responsibilities.

Phase 3: Beginning the climb

Since Max’s life seemed to go from one crisis to the next, it took some time for him to get to a place in which he wanted to start the climb out of the valley. We started with eye movement desensitization and reprocessing (EMDR), but he didn’t want to continue with it because he found the distress that ensued in the days that followed too disruptive to his academics (he was in a college program). Neither did he feel that he had time to do the homework that came with traditional cognitive behavior therapy (CBT). So, I adapted my interventions and created a compassion-focused CBT intervention that we could use in session.

Using a varied approach that met Max’s needs during any given session, we went down many paths together — grief and loss, guilt, shame, anger, dealing with relationship boundaries and so on. Over time, Max began to experience emotions again and had to learn how to manage them. He also started learning to respect his body and its needs. He became very proficient at self-care.

 

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Some of our clients will not want to proceed with the journey to climb out of the valley. For them, stabilization and containment will be enough. Given that the climb out of the valley can be life-threatening if people go into it unprepared or unwilling, we should never push our clients to take this step. Trauma is often about loss of control or boundary violations. Healing cannot be. We need to respect our clients’ decisions and inner knowing.

For those clients who wish to proceed with the climb and who appear to be strong enough and well-resourced enough to manage it, we have a number of evidence-based options to offer them. As trauma therapists, I believe we need to be skilled in more than one evidence-based trauma-processing intervention (e.g., EMDR, trauma-focused CBT, CBT). Too often I hear of clients being blamed when they don’t fit with the therapist’s approach. Being client-centered as a therapist means that we need to select or modify interventions to best fit the needs of individual clients.

Often, our clients will need to travel many pathways related to their trauma. These pathways might explore issues of grief and loss, the question of forgiveness of others and self, anger, ongoing depression and anxiety, the adjustment of relationship boundaries and so on. Each individual client’s pathway will be unique. Each individual client will lead. We will accompany, providing a safe, professional alliance and skilled interventions to assist the client in moving through, and eventually out of, the valley.

Phase 4: Living with the scars and reclaiming one’s life

Max became aware of how the trauma experiences he had survived had changed him. He learned to appreciate his resilience, adaptability and survival skills. He also came to acknowledge and embrace the truth of his strength and courage. Through accepting who he was, and is, along with his entire story, Max came to a place of peace.

During our last few sessions together, Max spoke about the newfound sense of peace he possessed. For our final session, I wrote him a letter reminding him of where he had started and highlighting his subsequent successes. I also recalled the qualities in him that I had come to admire. Finally, I reinforced in the letter the message that he possessed all that he needed inside of himself to deal with whatever challenges he encountered, but I reminded him that if he ever needed support again, he knew how to ask for it.

 

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Some of our clients will have lived in the valley for several months or years. For these clients, the thought of leaving the valley can invoke both excitement and fear because they will be learning to live in a new way. Thus, the last phase of our trauma work involves assisting clients as they learn to live with the scars (visible or invisible) of their trauma experience; reclaim their lives; acknowledge and celebrate their successes; and move forward on life’s path without us.

PTSD does leave scars, but those scars need to become part of one’s story, not all of it. In this final phase, we work with our clients on how to move forward in reclaiming their power and their lives. Sometimes we will need to assist them in identifying community resources that can continue to support them (such as peer support groups) or causes in which they can become involved that will be meaningful to their healing. Clients living with a disability or chronic pain resulting from their trauma experiences might need a team of medical professionals to provide ongoing support.

This is a time for clients to make conscious and informed decisions concerning how they will move forward in creating their lives outside of the valley. What kind of person do they wish to be? What are their hopes and dreams? Who do they want to have walk beside them on their journey? Do they have certain relationships that need to end or change? These are some of the questions that our clients might explore as they exit the valley. 

This final phase is also a time of celebration, kind of like a graduation, as we prepare and plan for the end of the therapeutic relationship. With that being said, some clients will worry about addressing future challenges without our support. In such cases, we can do some role-playing and problem-solving in advance to help alleviate their concerns regarding potential future challenges. For some clients, this might be an opportunity to rewrite their expectations regarding relationship endings. In collaboration with our clients, we can plan how our last sessions will play out.

Somewhere in this phase, we can also take the time to remind clients of where they began in the valley and where they are now, of how they have changed and what they have accomplished. Although this is something we should be doing in each session whenever there is a success, in this final phase we have a chance to summarize all of these successes at one time so that we can both appreciate the extent of their progress. This is often overwhelming for clients — in a positive, celebratory way — as they come to realize how incredible their healing journey out of the valley has been and as they start appreciating the depths of their own strength and resiliency.

 

 

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

Shirley Porter is a registered psychotherapist and a registered social worker who has been providing trauma counseling for more than 25 years. She currently works in the counseling department at Fanshawe College and is an adjunct clinical professor at Western University, both in London, Ontario, Canada. She is the author of two books on trauma: Surviving the Valley: Trauma and Beyond, which was written for survivors of trauma and their support people, and Treating PTSD: A Compassion-Focused CBT Approach, which was written for therapists.

Contact her at traumaandbeyond@gmail.com or via her website, traumaandbeyond.com.

 

 

Letters to the editor: ct@counseling.org

 

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

What’s left unsaid

By Lindsey Phillips January 3, 2019

A child discloses that her grandfather has been sexually abusing her, and the mother’s response is shock that his abuse didn’t stop with her when she was a child. This scene is not uncommon for Molly VanDuser, the president and clinical director of Peace of Mind, an outpatient counseling and trauma treatment center in North Carolina. As she explains, adult survivors of child sexual abuse often assume that the offender has changed or is too old to engage in such actions again. So, the abuse persists.

Concetta Holmes, the clinical director of the Child Protection Center in Sarasota, Florida, has treated clients with similar intergenerational abuse stories. “In that unresolved trauma … what has happened is now a culture of silence around sexual violence that is ingrained in the family,” she says. “That [affects] things like your feelings of safety, security [and] trustworthiness, and it reinforces that you should stay with people who hurt you.”

Kimberly Frazier, an associate professor in the Department of Clinical Rehabilitation and Counseling at Louisiana State University’s Health Sciences Center, acknowledges that people often don’t want to think or talk about child sexual abuse, but that doesn’t stop it from happening. The nonprofit Darkness to Light reported in 2013 that approximately 1 in 10 children will be sexually abused before they turn 18.

Because of the culture of silence that surrounds child sexual abuse, it is safe to assume that the true number is even higher. Cases of child sexual abuse often continue for years because the abuse is built on a foundation of secrets and fear, Frazier points out. Survivors frequently fear what will happen to them (or to others) if they tell, or the shame they feel about the abuse deters them from disclosing.

Societal norms can also diminish a survivor’s likelihood of disclosing. For example, society has for decades implicitly sanctioned sexual interactions between boys who are minors and adult woman, but it is still abuse, says Anna Viviani, an associate professor of counseling and director of the clinical mental health counseling and counselor education programs at Indiana State University. Holmes adds that gender stereotypes such as this can cause boys to feel as though they shouldn’t be or weren’t affected by sexual abuse, which is not the case.

“I think the biggest fallacy [counselors have] is that [child sexual abuse] is going to impact people from a particular demographic more than another,” Viviani says. “Childhood sexual abuse cuts across every demographic. I think the sooner we can accept that, the sooner we’re going to be better at identifying clients when they have this issue in their history.”

Putting on a detective hat

Identifying signs of child sexual abuse is neither easy nor straightforward. Part of the difficulty lies in the fact that the signs are not clear-cut, says VanDuser, a licensed professional counselor (LPC) and an American Counseling Association member. Regressive behaviors such as bed-wetting can indicate abuse, but they might also be the result of other changes such as a recent move, a new baby in the family or a military parent deploying, she explains.

VanDuser also warns that child sexual abuse is insidious because a lot goes on before the offender actually touches the child. “Childhood sexual abuse sometimes leaves no physical wounds to identify,” she says. Some examples of noncontact abuse include peeping in the window at the child, making a child watch pornography or encouraging a child to sit on one’s lap and play the “tickle game.” Such activities are part of the grooming process — the way that offenders build trust and gain access to the child.

In addition to physical signs such as bladder and vaginal infections, changes in eating habits, and stomachaches, survivors of child sexual abuse also demonstrate behavioral and emotional changes. One major warning sign is if the child displays a more advanced knowledge of sex than one would expect at the child’s developmental stage, VanDuser says.

Other possible behavioral signs include not wanting to be alone with a certain person (e.g., stepfather, babysitter), becoming clingy with a nonoffending caregiver, not wanting to remove clothing to change or bathe, being afraid of being alone at night, having nightmares or having difficulty concentrating. In general, counselors should look for behaviors that are out of character for that particular child, VanDuser advises.

Viviani, a licensed clinical professional counselor and an ACA member, also finds that people who have experienced child sexual abuse have higher rates of depression, anxiety, panic disorders and posttraumatic stress disorders.

Because the signs of child sexual abuse are rarely clear-cut, counselors must be good investigators, Viviani argues. In her experience, adult survivors present with an array of symptoms, including health concerns, relationship problems and gaps in memory, so counselors have to look for patterns to discover the underlying issue.

If counselors notice any of these signs, VanDuser recommends asking the client, “When did this problem (e.g., bed-wetting, cutting, nightmares, acting out in school) begin?” Counselors can then follow up and ask, “What else was going on at that time?” The answers to these questions often reveal the underlying issue, she notes. For example, if the client responds that his or her depression or vigilance to the environment began around age 12, VanDuser says she will dig deeper into the client’s family relationships.

Frazier, an LPC and a member of ACA, suggests that counselors can also look for patterns in a child’s drawing — for example, what colors they use, how intensely they draw with certain colors, or if they scratch out certain people or choose not to include someone — or in the choices children make with activities such as feeling faces cards (cards that depict different emotional facial expressions). When Frazier asked one of her clients who had come to counseling because of suspected sexual abuse to select from the feeling face cards, she noticed the client consistently picked cards with people wearing glasses. Frazier later discovered that the child’s abuser wore glasses.

For Frazier, becoming a detective also involves going outside of the office to observe the child in different spaces, such as in school, in day care or at the park. Frazier includes the possibility of outside observations in her consent form, so the child’s parent or guardian agrees to it beforehand. She advises that counselors should take note of whether the child’s behavior is consistent across all of these spaces or whether there are changes from home to school, for example. In addition, she suggests asking the parents or guardians follow-up questions about how the child’s behavior has changed (e.g., Has the child lost the joy of playing his or her favorite sport? Is the child withdrawn? Is the child fighting?).

Speaking a child’s language

Young children may not have the words or cognitive development to tell counselors about the abuse they have been subjected to. Instead, these children may engage in traumatic play, such as having monsters in the sand tray eat each other or being in a frenzied state and drawing aggressive pictures, VanDuser says.

“One of the most important things for clinicians to remember when they’re working with kids and abuse is that it’s really critical to be working within the languages that children speak,” says Holmes, a licensed clinical social worker and a nationally credentialed advocate through the National Organization for Victim Assistance. “Children speak through a variety of different languages that aren’t just verbal. They speak through play. They speak through art, through writing [and] through movement, so it becomes really important that clinicians get creative in using evidence-based practices and different modalities to talk with children through their language. … Talking in a child’s language allows them to feel like the topic at hand is less overwhelming and less scary.”

For example, children can use Legos to build a wall of their emotions, Holmes says, with counselors instructing clients to pick colors to represent different emotions. If orange represents sadness and red represents frustration and 90 percent of the child’s wall contains orange and red Legos, then the counselor gets a better visualization of what emotions are inside the child, she says.

Next, counselors could ask clients what it would take to remove a red brick of frustration or what their ideal wall would look like, such as one that contains more bricks representing happiness or peace. Counselors can also ask these clients to rebuild their Lego walls throughout therapy to see how their emotions are changing, Holmes says. This method is easier than asking children if their anger has decreased and by how much, she adds.

Frazier, past president of the Association for Multicultural Counseling and Development, a division of ACA, also finds that working with children keeps counselors on their toes. Children are honest and will admit if they do not like an intervention, so counselors have to be ready to shift strategies quickly, she says. For this reason, counselors need to have a wide range of creative approaches in their counseling bag. She recommends drawing supplies, play school or kitchen sets, play dough and sand trays.

With sand trays, Frazier likes to provide dinosaurs and other nonhuman figurines for children to play with because it helps them not to feel constrained or limited. This allows them to freely let a dinosaur or car represent a particular person or idea, she explains.

Frazier also recommends the “Popsicle family” intervention, in which children decorate Popsicle sticks to represent their family members and support systems. This exercise provides insight into family dynamics (who is included in the family and who isn’t) and allows children to describe and interact with these “people” like they would with Barbie dolls, she says.

Frazier advises counselors to keep culturally and developmentally appropriate materials on hand. For example, they should have big crayons for young children with limited fine motor skills, and they should have various shades of crayons, markers, pencils and construction paper so children can easily create what they want.

Being multiculturally competent goes beyond ethnicity, Frazier points out. Counselors should understand the culture the child grew up in and the culture of the child’s current locality because what is considered “normal” in one city or area might differ from another, she says. For example, in New Orleans, where she lives, people regularly have “adopted” family members. So, if a child from New Orleans were creating his or her Popsicle family, it wouldn’t be strange to see the child include several people outside of his or her immediate family and refer to them as “cousin” or “aunt,” even if they aren’t blood relatives.

Thus, Frazier stresses the importance of counselors immersing themselves in the worldview of their child clients. “You can’t be a person who works with kids and not know all the shows and the stuff that’s happening with that particular age group, the music, the things that are on trend and the things they’re talking about,” Frazier says. “Otherwise, you’ll always be behind trying to ask them, ‘What does that mean?’”

With adolescents, Holmes finds narrative therapy to be particularly effective, and she often incorporates art and interview techniques into the process. For example, the counselor could ask the client to draw a picture of an emotion that he or she feels, such as anger. Next, the client would give this emotion a name and create a short biography about it. For example, how was anger born? How did it grow up to be who it is? What fuels it? Why does it hang around?

Next, Holmes says, the counselor and client could discuss the questions the client would ask this emotion if it had its own voice. Then, the client could interview the initial picture of the emotion and use his or her own voice to answer the questions as the emotion would. The answers provide insight into the emotional distress the client is feeling, Holmes explains.

Frazier will do ad-lib word games with older children, who are often more verbal. While clients fill in the blanks to create their own stories, she looks for themes (e.g., gloomy story) or the child’s response to the word game (e.g., eager, withdrawn). 

Long-lasting effects

Unfortunately, the effects of child sexual abuse don’t end with childhood or even with counseling. “Children revisit their trauma at almost every age and stage of development, which is every two to three years,” Holmes notes. “That might not mean they need counseling each and every time, but they find new meaning in it or they find they have new questions … or new emotions about it.”

Viviani, VanDuser and Frazier agree that recovery is a lifelong process. As survivors age, they will have sexual encounters, get married, become pregnant or have their child reach the age they were when the abuse occurred. These events can all become trigger points for a flood of new physical and emotional symptoms related to the child sexual abuse, Viviani says.

Often, an issue separate from the abuse causes adult survivors to seek counseling. In fact, VanDuser says she rarely gets an adult who discloses child sexual abuse as the presenting issue. Instead, she finds adult clients are more likely to come in because their own child is having behavioral problems or because they’re feeling depressed or anxious, they’re having nightmares or they’re married and have no interest in sex.

Adults survivors often experience long-term physical ailments. According to Viviani, who presented on this topic at the ACA 2018 Conference & Expo in Atlanta, some of the ailments include diabetes, fibromyalgia and chronic pain syndromes, pelvic pain, sexual difficulties, headaches, substance use disorders, eating disorders, cardiovascular problems, hypertension and gastrointestinal problems.

Another long-term issue for survivors is difficulty forming healthy relationships. Because child sexual abuse alters boundaries, survivors may not realize when something is odd or abusive in a relationship, VanDuser says. For example, if an adult survivor is in a relationship with someone who is overly jealous and possessive, he or she may mistakenly translate that jealously into a sign of love.

Child sexual abuse can also affect decision-making as an adult around careers, housing, personal activities and sexual intimacy, Viviani notes. For example, one of her clients wanted to attend a Bible study group but didn’t feel safe being in a smaller group where a man might pay attention to her. In addition, Viviani finds that adult survivors sometimes choose careers they are not interested in just because those careers provide a safe environment with no triggers.

To help adult clients make sense of the abuse they suffered as children and move forward, Viviani often uses meaning-making activities and mindfulness techniques. She suggests that counselors help these clients find a way to do something purposeful with their history of abuse, whether that involves sharing their story with a testimony at church, volunteering for a mental health association or participating in a walk/run to raise awareness of suicide prevention.

Finding self-compassion

Survivors of child sexual abuse often blame themselves for the abuse or the aftermath once the abuse is revealed, especially if it results in the offender leaving the family, the family losing its home or the family’s income dropping, VanDuser says. One of her clients even confessed to thinking that she somehow triggered her child sexual abuse from her stepfather.

“Sometimes the worst part is the dread [when the child knows the sexual abuse is] coming eventually. So, sometimes a teenager will actually initiate it to get it over with because the only time they feel relief is after it’s done,” VanDuser explains. “Then they know for a while that they won’t be bothered again.”

Counselors often need to shine a light on survivors’ cognitive distortions to help them work through their guilt and shame, VanDuser says. She tries to help clients understand that the sexual abuse was not their fault by changing their perspective. For example, she will take a client to a park where there are children close to the age the survivor was when the abuse happened. She’ll point to one of the children playing and ask, “What could the child really do?” This simple question often helps clients realize that they couldn’t have done anything to prevent the abuse, VanDuser says.

Viviani takes a similar approach by talking with clients in the third person about their expectations of what a child would developmentally be able to do in a similar situation. She asks clients if they would blame another child (their grandchild or niece, for example) for being sexually abused. Then she asks why they blame themselves for what happened to them because they were also just children at the time.

“As you frame it that way, they begin to have a little bit more compassion for themselves, and self-compassion is something that’s so important for survivors to develop,” Viviani says. In her experience, survivors are hard on themselves, often exercising magical thinking about what they should or should not have been able to do as a child. “As we help them develop self-compassion and self-awareness, we see the guilt begin to dissipate,” she adds.

Regaining a sense of safety

Safety — in emotions, relationships and touches — is a critical component of treatment for a child who has been sexually abused, Holmes stresses.

Counselors should teach clients about safe and unsafe touches, personal boundaries and age-appropriate sexual behavior rules, adds Amanda Jans, a registered mental health counseling intern and mental health therapist for the Child Protection Center in Sarasota. Counselors can also help clients “understand that they are in charge of their bodies, so even if a touch is safe, it doesn’t mean they have to accept it,” she says.

Hula hoops provide a creative way to discuss personal space boundaries with clients, Holmes notes. Counselors can use hula hoops of different sizes to illustrate safe and unsafe boundaries with a parent, sibling, friend or stranger, she explains.

VanDuser helps clients engage in safety planning by having them draw their hand on a piece of paper. For each finger, they figure out a corresponding person they can tell if something happens to them in the future.

Counselors can also take steps to ensure that their offices are safe settings. Jans, an ACA member who presented on the treatment of child sexual abuse at the ACA 2018 Conference, uses noise machines to ensure privacy and aromatherapy machines to make the environment more comfortable. She also has a collection of kid-friendly materials, so if a child starts to feel dysregulated during a session, he or she can take a break and play basketball or color.

Likewise, if clients are hesitant to discuss the topic, Jans allows them to take a step back. For instance, she has clients read someone else’s experience (either real or fictional) rather than having them write their own story, or she has clients role-play with someone else serving as the main character, not themselves. This distance helps clients move to a place where they eventually can discuss their own stories, she says.

Another technique Jans uses to ease clients into writing and processing their own stories is a word web. Together, Jans and a client will brainstorm words related to the client’s experience and put the words on a web (a set of circles drawn on a paper in a weblike pattern). Jans finds this exercise helps clients get comfortable talking about the subject and, eventually, these words become part of their narrative.

VanDuser also suggests getting out of the office. Sometimes she takes child and adolescent clients to a store to get a candy bar. On the way, she will ask them what they are feeling or noticing. If clients say that someone walking by makes them feel strange, VanDuser asks how they would address this feeling or what they would do if someone approached them. Then they will talk through strategies that would make the client feel safe in this situation.

Taking back control

Survivors of child sexual abuse often feel they can’t control what happens around them or to them, Frazier says. So, counselors can get creative using interventions that return control to these survivors and make them feel safe.

Viviani helps clients regain some sense of control in their lives by teaching grounding and coping skills. “Coping skills are so important to helping them begin to trust in themselves again so that they have the skills to really uncover and deal with the abuse,” she explains.

In sessions, counselors can help clients recognize what their bodies feel when they are triggered. Then they can help clients learn to deescalate through grounding skills such as noticing and naming things in their current surroundings or reminding themselves of where they are and the current date, Viviani says. Rather than reliving the incident — being back in their bedroom at age 5, for example — clients learn to ground themselves in the here and now: “This is Jan. 10, 2019, and I’m sitting in my office.”

VanDuser highly recommends trauma-focused cognitive behavior therapy (TF-CBT) for work with survivors of child sexual abuse. TF-CBT is a short-term treatment, typically 12-16 sessions, that incorporates psychoeducation on traumatic stress for both the child and nonoffending parent or caregiver, skills for identifying and regulating emotions, cognitive behavior therapy and a trauma narrative technique.

For a creative approach, VanDuser suggests letting children use crayons and a lunch bag to create a “garbage bag.” She first writes down all the bad feelings (e.g., fear, anger, shame) the client has about the abuse. As the child finishes working on one of the bad feelings, he or she puts the feeling in the garbage bag. When all the feelings are in the bag, VanDuser lets the client dispose of it however he or she wishes — by burning it, burying it, throwing it in the actual garbage or some other method.

Jans and Holmes suggest empowering clients by giving them some control in session. For example, if clients are feeling sad, the counselor can remind them of the coping strategies they have been working on (perhaps progressive muscle relaxation and grounding techniques) and ask which one they want to use to address this feeling. The counselor could also list the goals of therapy for that day and ask clients which one they want to work on first, Holmes says.

Holmes acknowledges that clients may never make sense of the abuse they suffered, but counselors can help them make sense of the abuse’s impact and aftermath. For Holmes, this meaning making involves clients being empowered to reclaim their lives after abuse rather than being held hostage by it, realizing that trauma doesn’t have to define them and learning to be compassionate with themselves.

The hero who told

Holmes encourages counselors not to shy away from discussing child sexual abuse. “If clinicians hesitate, clients will hesitate. If the clinician avoids it, the client will avoid it,” Holmes says. “It’s the clinician’s responsibility to take the lead on this topic. Sexual abuse is so widespread in our society that we do our clients a disservice when we don’t incorporate sexual abuse histories into our [client] assessments.”

Typically, however, counselors are not the first person a child will tell about the abuse. Often, children first disclose the abuse to a teacher or other school personnel, and their reaction is crucial in ensuring that the child gets help, Viviani says.

Thus, she advises counselors to partner with schools and child advocacy organizations to educate them on what they should do if a child discloses sexual abuse. “They need to know what to do,” Viviani emphasizes. “They need to know what to say to support that child because we may not get another chance, at least until they hit college age when they’re not under that roof anymore, or we may never get that chance again.”

Counselors must also empower survivors of child sexual abuse. “They shouldn’t be waiting for the therapist … or their best friend to ride in and save them. We want them to be the hero of their own story,” Holmes says. “And how we do that is through finding ways they can start to recognize and make safe and healthy decisions about different pieces of their life, and we want to model that even within the therapy environment.”

The end result of TF-CBT is the child writing his or her own narrative of the sexual abuse. VanDuser emphasizes that no matter how the child’s sexual abuse story begins, it always has the same ending: the hero — the child — who told.

 

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Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist living in Northern Virginia. Contact her at consulting@lindseynphillips.com or through her website at lindseynphillips.com.

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