When it comes to trauma, Hillary Cook, a licensed Clinical Professional Counselor (LCPC) with a solo private practice in Boise, Idaho, says a saying she often shares with clients: It is possible to drown in a puddle like in the depths of the ocean.
Trauma is often categorized as “big T” or “small T” – some would even say that it has been oversimplified. Big-T trauma is what many people think of when they hear the word trauma: large-scale, life-shaking events like living through a war or natural disaster. Minor trauma encompasses more common events such as the loss of pets, work stress, parenting struggles, or racial microaggressions, which on the surface may seem smaller. Trauma is a complex issue, however, and all traumatic events – no matter how big or how small they may appear "outside" to others – have the potential to negatively affect the mental health of clients.
Like many counselors who specialize in trauma, Cook has seen clients who minimized their small everyday traumatic experiences or who did not even recognize them as traumatic. Even when clients seek counseling because they realize that something is causing them suffering and disrupting their lives, sometimes they are unable to pinpoint or verbalize the reason, she says. Others may feel ashamed or insecure about how they are feeling. Cook has often heard that customers who were unsure whether their experience warranted advice would prefix their stories with the words "I don't want to waste your time."
Cook, a member of the American Counseling Association, has also worked with clients who dismissed their traumatic experiences by saying, "I didn't go to war," "It wasn't violent," or "I don't know" why she explains to these clients that the crux of the matter is not the traumatic event itself, but how it is stored in their brain. Counseling will not take away this traumatic memory, but it can alter its storage so that the client makes it less painful Cook explains.
Providing psychoeducation is a critical first step in working with clients who have experienced minor trauma, says Debbie Millman, a licensed professional counselor and director of a trauma therapy practice in Madison, Wisconsin. It is helpful to explain to clients the depth and breadth of trauma, which can range from something catastrophic or systemic, she says, to "someone who was not selected for the kickball team [in childhood] and cuts it deeply, and she still lingers today. "
“I see trauma as anything that affects how you see yourself or how you feel now. No matter how big or small it seems, it is worth reconsidering [in counseling]”notes Millman, an ACA member.
It helps clients understand the importance of recognizing and addressing trauma – including everyday ones – with the following illustration: Trauma is like pushing a ball under the surface of a swimming pool. You don't know where it will reappear, but it always will. The same rule applies to trauma: you cannot let it bury; it will keep popping up. The key is to process it.
Jessica Tyler, an Alabama and Georgia licensed professional counselor, views trauma as "any experience that changes your perspective on yourself, others, or the world." For some, this experience could be linked to surviving a terrible car accident. Another person could be because they felt humiliated when their first grader asked them to read something aloud in class. The important point to communicate is that all of these experiences are valid, she says .
"I firmly believe that [with] doesn't help anyone compare suffering," says Tyler. "Suffering is suffering is suffering is suffering, and if we stop comparing the validity of our suffering, we can work on how these experiences can expand us as individuals instead of defining ourselves and our worth."
What is below
Everyday trauma can be associated with grief and loss, attachment problems, racial or cultural problems, panic attacks, self-esteem problems, depression, suicidal thoughts, eating disorders and many other challenges that clients face in counseling. For clinical practitioners, the key is not to take concerns at face value because unprocessed trauma may be a contributing factor or even the root cause, says Susan Gabel, an LCPC in a trauma-focused group practice in the Chicago suburbs.
For example, if a client comes to counseling with symptoms of social anxiety, clinicians should not limit their counseling work to addressing those symptoms or simply viewing the client as socially anxious as they may then be overlooking some of the bigger reasons for the symptoms, explains Fork.
"There can also be things that you do not identify as trauma, such as a parent who has been devalued," she continues. "It's not a big T-trauma, but when you add that up over and over again, they internalize it and it becomes a strong negative realization about how they see themselves and expect people to respond to it."
Low self-esteem, conflict avoidance and philanthropic behavior can be common among clients who have experienced trauma, notes Gabel. For this reason, therapists must bear in mind that clients in therapy can show philanthropic behavior towards a counselor. This behavior can manifest itself in a number of ways, she says, even when clients are not completely honest in sessions because they agree with their counselor, avoid conflict, or want to tell him what they think the counselor wants to hear. These clients can also often apologize during the sessions.
Gabel points out that this fear of conflict may be due to the fact that clients have people in their lives who have had a pattern of reacting negatively to their needs or feelings. Hence, they can reflexively expect this reaction from others, including their advisor.
"For many people, [trauma] tends to focus on larger issues, including their views about themselves, other people's views, and fear responses," says Gabel, an ACA member who holds two trauma certifications . "Assertiveness difficulties [indicate] can be a pattern of relationships in which their needs were not met or they had to appease or do what the other person needed."
Tyler, a clinical assistant professor and coordinator of the mental health clinical counseling program at Auburn University, notes that a client's self-talk can also provide clues that the person has had a history of trauma. Based on the work of North Carolina licensed clinical psychologist Candice Creasman, Tyler urges doctors to listen carefully to a client's “wounded inner child”, which Creasman defines as the voice of his unhealed injuries. Examining how that voice influences a client's beliefs and decision-making can reveal the lived experience that generated the client's problematic thoughts, explains Tyler.
"In my experience, this typically appears as the inner critic we as counselors hear in a client's hostile and harsh self-talk," says Tyler, an ACA member who advises adult clients in private practice Columbus, Georgia. “With clients this can also appear as anger, frustration, controlling or needy behavior in therapy. The wounded inner child tests the therapist's [ability] to appear with care, acceptance and compassion despite [the client’s] behaviors. This inner child is often the impulsive and risky part of a client who 'acts out' despite possible negative consequences. "
Gabel often hears clients speaking their language about feeling worthless, “never enough”, or assuming they are a bad person. Counselors can learn more about a client's history, she says, by questioning these negative beliefs in counseling and asking when and where the client first heard these statements.
Gabel and Cook also note that somatic complaints may suggest that an undetected trauma is below a client's presented concern. Cook finds this particularly in symptoms that clients have examined with a specialist – such as hives with an allergist – without a cause being established.
Both physical reactions and lack of reaction can be associated with an unprocessed trauma. Any kind of tension in the body, including a headache, stomach discomfort, or sensations like chest tightness, can be signs of untreated trauma, says Gabel. At the same time, past trauma can result in a client talking about an experience that would typically evoke an emotional response in an unconnected or unemotional manner, she says.
If not dealt with, minor trauma can become problematic in a variety of ways, says Tyler, and treatment requires counselors to go beyond symptom management with clients. For example, a client's self-protective behavior in romantic relationships might manifest as codependency and philanthropy to affirm their safety and worth as a person. This can leave the client vulnerable to partners who are controlling, manipulative, and even abusive, explains Tyler.
“The concentration on behavior changes and symptom management can bring short-term relief for a certain life situation. However, I find that clients often have difficulty applying these coping skills to new challenges that arise in their lives, ”says Tyler. “I've found more success in therapy when I can identify the cognitive key or beliefs that filter how a client sees and reacts to the world, others, and themselves. This cognitive key can initially serve as a measure of survival – avoidance, distrust, perfectionism – but over time can create obstacles to the client's successful life. … If a cognitive key can be discovered in therapy, the client learns to adapt this 'filter' and to see the world, others and himself in the most flexible and rational way. "
Tyler illustrates this process using the example of a client who experiences panic attacks when she is separated from her young child. The client may find relief after a few sessions if the practitioner focuses on breathing exercises, drug management, and individual mindfulness. This may look successful on the surface, notes Tyler, but the underlying cause of the client's suffering remains unaddressed.
Instead, Tyler says, she would dig deeper into the underlying problems with Socratic issues. This process helps the client “discover a long-held belief that 'I only feel safe when I'm in charge' [which] can provide us with vital data to work with to address the client's filter who goes beyond motherhood and focuses on other parts of her life, ”says Tyler. "This is where I find the greatest change among customers."
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Handle with care
Regardless of whether a client has experienced a major T-trauma or a minor T-trauma, the brain interprets what has happened as harmful to the client, explains Cook. The decisive factor is not how “bad” the event was, but how incorrectly it was stored in the brain.
“The type of trauma or how bad it was does not change the approach [in counseling]. What the customer needs will change the approach, "says Cook.
She advises considering whether the client has adopted healthy or maladaptive coping mechanisms or whether the client has a strong social support system. If not, the counselor should focus on these aspects before delving deeper into the work to help the client process the underlying trauma, she says.
Clinical practitioners interviewed for this article use a variety of techniques, including brainspotting, desensitization and eye movement recovery (EMDR), hypnosis, internal family systems therapy (IFS), and cognitive behavioral therapy (CBT) to help . Clients who have experienced trauma. However, these practitioners emphasized that counselors should focus on self-regulation and social connection with clients and establish coping mechanisms before using techniques to deal with the client's trauma. This applies in particular to clients who have experienced an everyday trauma and who do not recognize its effects on their current concerns.
As a licensed mental health advisor specializing in trauma work, Christine Smith has an extensive toolbox of coping mechanisms to equip clients according to their needs. Coping mechanisms not only help clients with emotional regulation, but also teach them containment skills that they can use to manage their emotions and get on with everyday life after intense counseling sessions dealing with raw or troubling memories, she explains.
"People tend not to use their coping skills until their hair burns," says Smith jokingly. Instead, she works with clients to make coping strategies part of their everyday lives, sometimes even as homework between sessions.
She encourages clients to keep a list of coping mechanisms that they find helpful on a piece of colored paper in a visible place in their home, such as the refrigerator door or the bathroom mirror. She also recommends moving this list regularly so that you don't start to hide it.
“Coping mechanisms themselves are in a certain way trauma work. I tell clients, "We're going to do security, security, security until you roll your eyes, and then we'll do it more." When you don't have a good foundation [before doing deeper trauma work] you're "building a house of cards," says Smith , an ACA member with a solo private practice in Saratoga Springs, New York. "The best coping mechanisms are those that are so integrated into a client's life that they don't see it as coping."
According to Smith, this early work helps form a therapeutic bond with clients and provides the practitioner with an opportunity to ask questions that seed about a possible link between a previous experience and the discomfort that caused the client to seek counseling seek, sow. Questions like "When did you first feel this way?" Can help both the counselor and the client make connections, she adds.
Gabel agrees that coping strategies should be tailored to the individual needs of the client. Deep breathing or mindfulness may be helpful for some clients while others may need to work on skills that they have not fully developed due to their trauma history, such as: B. interpersonal communication or problem-solving skills.
When starting trauma work, Cook often uses EMDR and hypnosis for instant relief from nightmares, flashbacks, and intrusive thoughts to help clients find stability. Only then do they unpack trauma and other related issues such as grief.
Millman begins trauma work by going through the clients' lifetimes and noting events that have shaped them and stuck with them. She also devotes a lot of time to case conception and asks clients about their strengths, personality and likes / dislikes. This helps her to gain a holistic understanding of the client and to establish a therapeutic bond, she says.
Likewise, Cook recommends asking questions that help form a picture of a client's framework, including their social support and how they deal with intense emotions. Knowing more about a client's background could also inform counselors about cultural and racial issues that may be associated with everyday trauma of a systemic nature.
Millman notes that it can be helpful to encourage trauma clients to maintain "emotional leeway" in each session. That means they don't have to rush to a counseling hour after work or after picking up the children from school. Instead, she encourages clients to engage in calming rituals such as a cup of tea or deep breathing exercises before and after the sessions.
Millman, a graduate student in the Counselor Education and Supervision Program at Liberty University, also advises counselors to consider trauma patients when furnishing their office space. She emphasizes the importance of being aware of what counselors expose their clients to. For example, holding fashion or health magazines in the waiting room could be a potential trigger for clients whose trauma stories or related behaviors are related to body image or disordered eating behavior. Instead, Millman suggests creating an atmosphere that is warm and soothing.
“All counselors must be prepared to encounter trauma; it is at the root of so many mental health problems and disorders, ”says Millman. “Everyone needs to have trauma-informed nursing training [and] to be aware of what triggers clients and what expressions or catchphrases you might use that could be problematic for someone. Especially when it comes to race, pay attention to the words you use. Receiving culturally competent, trauma-informed care is really linked to the daily trauma that people are currently confronted with. "
Dig deeper
In counseling sessions, a client's past trauma will "show up when it needs to show up," says Millman. For some people this will happen instantly and it will come out "like a volcanic eruption". Other clients can take up to a year to be ready to talk about. But when they do, Millman says, she can "almost feel the relief in the counseling room," especially for clients who associate feelings of shame with their trauma. "It is as if a weight has been lifted, which has disempowered the hold it has over [them]now that someone else knows about it and can carry it with [them]," she says.
In trauma work, Smith adds, it is not uncommon for clients to bring up a traumatic issue by saying, "I've never told anyone this before, but …" When that happens, Smith tells the client that she is is honored that she trusted her with this information.
"I try never to forget how much courage it takes to go to a therapist's office," says Smith. "I try to be really encouraging, positive, and respectful, and acknowledge the victories they have that other people will not."
Smith finds that work that focuses on emotion regulation can be particularly helpful for this patient population. In some cases, this is simply a matter of discussing and processing interactions and events that clients have experienced since their last counseling session. It can be helpful to "move at the glacier pace" and slowly unpack an incident that worries the customer in minute detail, says Smith. This allows the client to identify the exact moment when they began to feel triggered and lost the use of their self-regulatory skills. Then the counselor and client can talk about what the client could do differently the next time such a scenario occurs.
EMDR can be particularly helpful for working through troubling scenarios and feelings with clients who may not recognize a previous experience, such as minor trauma, as the cause of their discomfort, says Cook. However, these clients will be able to identify the challenge that led them to seek counseling, such as: EMDR enables the practitioner to target and heal clients' distressing feelings and triggers without having to relive the underlying trauma, she explains. The beauty of EMDR, says Cook, is that it allows the practitioner to target a stressful pattern the client is experiencing, which in turn targets everything else that is in that neural pathway, including related trauma .
During EMDR, the client performs bilateral stimulation, such as rhythmic tapping, while discussing a scenario with the practitioner. The process rewires the client's brain, creating a new neural pathway that converts the pattern into one that is stress-free, says Cook.
EMDR enables clients to "see themselves in a different way in a scenario and imagine how they want to feel … without having to go through it" and relive the trauma, she explains.
This was the case with an adult client whose concerns were related to relationship problems and anxiety related to dating. Cook was able to use the customer's specific fears about first dates as a target in EMDR. Cook led the client to share the details of her feelings during her worst dating experience.
"Suddenly things went back a lot [further] and we found that there were some parenting problems [involving verbal abuse] from many years ago in childhood," recalls Cook. “It was really hard for her to hear in the beginning. Much has been denied, [saying] 'this is not trauma'. But then I used an illustration: If you could imagine a little child that was not you, and how would you feel? Then it penetrated and they realized how terrible it was. "
Cook continued to use EMDR as well as CBT to focus on the client's self-esteem and build healthy boundaries. This therapeutic approach built the client's coping skills so that they could focus more on the other person on dates and be less “in the head,” says Cook. When the client was less concerned about what the other person was thinking about him, he could instead focus on making a connection.
EMDR, along with a combination of other therapies, was also helpful to a previous client of Tyler who had concerns about low self-esteem and anxiety. When they began to unpack things in counseling, the client also revealed a history of self-harming behaviors and chronic suicidal thoughts.
“She was successful in her career, but presented herself with chronic and relentless self-talk that was clearly cruel and self-reproachful. Everything was her fault, and everything terrible that had ever happened to her resulted from her failure; she was convinced that she was not lovable and worthless, ”remembers Tyler, who co-moderated the session“ Trauma-Informed Care: Working With Trauma-Related and Survivor Guilt ”at the ACA's Virtual Conference Experience in April.
In counseling, Tyler gently searched with questions to find out where and how this client learned such hypercritical self-talk. The client reported that it was simply "something she had always done," says Tyler.
Tyler gently challenged this thought with psychoeducation that infants are not born with self-loathing; it is something they learn from those around them. Through this lens, she explained to the client how life experiences can reinforce negative beliefs and feelings of rejection. Over time, the client was able to process several early childhood and adolescent experiences that she previously believed were "not traumatic enough" to bring her mental health down to its current state, Tyler recalls.
"However, when you examined these experiences through the lens of their young, vulnerable, and suggestible greatness as a child, it made sense how one thing turned into another that turned into years of affirmative bias," says Tyler. “Through a careful combination of EMDR, CBT, and IFS, she communicated with her younger self and realized that it was really her birthright to be worthy and that, like everyone else, she could make mistakes and learn from them. In addition, every time she was emotionally or physically injured, she betrayed this younger version of herself, which was not adequately protected from the harm and toxicity of others. ”
This change took place gradually during a year of counseling. Eventually, the client's thoughts of self-harm and suicide ebbed, Tyler says, and she took a lens of "gratitude for the younger versions of herself who have endured – and her present adult self, now in control and power to make decisions to nourish and "calm them down on the path of life's challenges."
Not so little
Gabel thinks it is more helpful to look at the client's trauma in a spectrum instead of putting the experiences into “big T” or “small T” boxes. She urges the counselors to remain open-minded, regardless of how severe a client's experience may be – or not.
“Small trauma can add up and contain a lot of force. Complex, relational trauma can be little Ts that add up and become overwhelming, ”says Gabel. “Often [counselors] tries to make a logical sense of it – if this [experience] has an impact on [the client] it must be linked to a past event (e.g. adult peer conflict and bullying in the past as a kid) – although our brain wiring doesn't actually work that way. It's not always logical. "
Smith also encourages counselors to be open to what can be labeled as traumatic. Something that on the surface appears to be a minor trauma, like the death of a pet, can be a great loss to someone who has not had healthy attachments, she notes.
“It is not up to me to decide what a small T-trauma is versus a large T-trauma. Etwas, das klein ist, kann mit etwas verbunden sein, das nicht so klein ist“, sagt Smith. „Was ich mir ansehe, ist jemand, der irgendeine Art von Störung oder Verlust erlebt hat, über den er nur schwer hinwegkommen kann. Sie und ich könnten genau die gleiche Erfahrung machen und Sie könnten unversehrt davonkommen, und ich könnte wirklich leiden, und wir wissen nicht immer, warum das so ist. … bleib einfach offen und neugierig [in counseling sessions]. Meine Klienten sind meine größten Lehrer, und wenn ich sehr genau zuhöre, wissen sie genau, was sie heilen müssen.“
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Zuweisen und Mitbehandeln
Die gemeinnützige Organisation Mental Health America bietet auf ihrer Website jedes Jahr ein Online-Screening zur psychischen Gesundheit an. Im Jahr 2020 nahmen fast 2,5 Millionen Menschen an dem Screening teil, und vergangene Traumata standen nach Einsamkeit als die am häufigsten gemeldete Ursache für psychische Belastungen an zweiter Stelle.
Diese Daten verdeutlichen, was viele Berater in ihrer täglichen Arbeit sehen: Traumata sind allgegenwärtig und können tiefgreifende Auswirkungen auf die psychische Gesundheit haben. Vor diesem Hintergrund müssen sich Kliniker bewusst sein, wenn das Trauma eines Klienten über ihre Expertise hinausgeht. Die für diesen Artikel befragten Berater betonten, dass Trauma ein komplexes Thema ist und Kliniker, die nicht auf diesen Bereich spezialisiert sind, bereit sein müssen, zusätzliche Schulungen oder Supervisionen in Anspruch zu nehmen, Kollegen zu konsultieren oder Klienten für spezialisierte Traumaarbeit zu überweisen.
Die Suche nach externer Hilfe ist besonders wichtig, wenn ein Klient mit seinem Berater keine Fortschritte mehr macht, sagt Hillary Cook, eine lizenzierte klinische professionelle Beraterin in Boise, Idaho.
Eine starke, vertrauensvolle therapeutische Beziehung ist in der Traumaarbeit von entscheidender Bedeutung, bemerkt Cook, und eine Überweisung bedeutet nicht unbedingt, dass diese Bindung zerbrochen ist. Die Klienten können weiterhin mit ihrem ursprünglichen Berater zusammenarbeiten, während sie von einem Spezialisten mitbehandelt werden. In diesem Szenario müsste der Klient den beiden Klinikern die Erlaubnis erteilen, sich gegenseitig zu konsultieren.
„Wir können nicht allen Menschen alles sein“, stimmt Christine Smith zu, eine lizenzierte Psychologin, die sich in ihrer Privatpraxis in Saratoga Springs, New York, auf Traumaarbeit spezialisiert hat. „Wenn ein Berater keine spezielle Ausbildung im Umgang mit einigen der komplexeren Traumathemen hat, scheuen Sie sich nicht, sich auf ihn zu beziehen.“
Konsultieren Sie Standard A.11. des ACA-Ethikkodex von 2014 unter consulting.org/ethics für weitere Informationen zu den ethischen Richtlinien rund um das Überweisungsverfahren.
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Aktionsschritte, um mehr zu erfahren
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Bethany Bray ist eine leitende Autorin und Social-Media-Koordinatorin für Counseling Today. Kontaktieren Sie sie unter [email protected].
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Meinungen und Aussagen in Artikeln, die auf CT Online erscheinen, sollten nicht als Meinungen der Herausgeber oder Richtlinien der American Counseling Association angesehen werden.
