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CHAPTER 1

Introduction to Crisis and Trauma Counseling

Thelma Duffey and Shane Haberstroh

There are critical incidences and traumatic events that occur daily in the lives of unsuspecting people. Every day, women, men, and children are in the midst of living their lives when, much to their horror, crises arise in their

homes, schools, workplaces, and communities. Illnesses, accidents, job layoffs, and sudden deaths occur, seemingly out of nowhere, and people are plunged into crisis. Far too often, communities and the larger world experience critical events and tragedies of significant proportions. When these calamities occur, the media instantaneously broadcasts images of mass murders, war, and acts of terrorism and violence. These tragedies create unimaginable images in the psyches of contemporary society.

Introduction to Key Terms and Philosophies

Crisis

By definition, a crisis is often an immediate, unpredictable event that occurs in peo- ple’s lives—such as receiving a threatening medical diagnosis, experiencing a mis- carriage, or undergoing a divorce—that can overwhelm the ways that they naturally cope. People can experience crises individually or as part of a group, community, or other connected system (James & Gilliland, 2013; Myer & Moore, 2006). Crisis experiences often compromise people’s feelings of safety and can induce feelings of fear, sadness, and even a sense of devastation. Crises can also interfere with a person’s ability to function in the world by negatively affecting several life domains, such as work, family, and social connections. Crises can aggravate existing emo-

Introduction to Crisis and Trauma Counseling, edited by Thelma Duffey, and Shane Haberstroh, American Counseling Association, 2020. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/amridge/detail.action?docID=6173695. Created from amridge on 2024-01-09 01:52:34.

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Chapter 1

tional injuries, further obstructing a person’s ability to respond to the incident. This aggravation can lead to a person’s sense of hypervigilance following a painful and unexpected violation of trust and safety. This violation can increase the intensity of a person’s feelings, resulting in a deepened experience of anger, anxiety, guilt, and grief. Furthermore, the “intensity, duration, and suddenness” (James & Gilliland, 2013, p. 8) of an experience may result in a person’s experience of trauma.

Trauma

Trauma involves an emotional, mental, and physical response to a powerfully neg- ative experience or series of situations in which people perceived that they or a loved one experienced serious psychological, physical, or emotional harm (Sub- stance Abuse and Mental Health Services Administration [SAMHSA], 2014). Trau- ma can result from an event or a series of events that subsequently causes intense physical and psychological stress reactions (SAMHSA, 2014). These experiences can include violence, sexual assault, abuse, neglect, disaster, terrorism, and war. Chronic abuse, abandonment, a tragic loss of a loved one, or war experiences, for example, can all result in trauma that can be both enduring and complex. In those cases in which complex trauma exists, a person experiences serious stressors that “(a) are repetitive or prolonged, (b) involve harm or abandonment by caregivers or other ostensibly responsible adults, and (c) occur at developmentally vulnerable times” (Ford & Courtois, 2009, p. 13).

These stressors can also involve complex interpersonal traumatic experiences such as betrayal, loss, rejection, and relational violence. People suffer trauma indi- vidually and within their communities. These tragedies, and the trauma that ensues, may upend the emotional, physical, and relational landscapes of communities, re- sulting in generational trauma—at times altering the fabric of that community for years to come (Dupré, Dawe, & Barling, 2014). In fact, history has shown how trau- mas and crises have helped shape the values of nations, diverse cultural groups, and generations throughout the years (Martz, 2010). As a result, these societal, cultural, and familial messages often guide an individual’s response to crises and trauma and can either derail or facilitate healing (Duffey, 2005; Hartling & Lindner, 2016). Every day, professional counselors assist people as they navigate life crises and the im- mediate and acute aspects of traumatic events and loss (McAdams & Keener, 2008).

Conceptualizing Crisis and Trauma One of the purposes of this text is to practically identify the many faces of crisis, the ways in which crises can occur, and the relational processes that counselors can use when working through crises and traumatic injuries. We also explore impor- tant distinctions between crises and trauma because, although these terms are at times used interchangeably, there are clear differences that distinguish one from the other. Recognizing and understanding these differences is important to the work of counseling.

For example, although most people experience crises in their lives (e.g., rela- tionship loss, acute illness, job loss, academic disappointments), not every crisis is followed by trauma. In other words, crises, in and of themselves, do not constitute a trauma, and they do not always lead to traumatic responses. In contrast, trauma

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Introduction to Crisis and Trauma Counseling

can be seen as a profound and often overwhelming response to a critical loss or injury, such as accidents, deaths, and acts of violence.

Although crises tend to resolve over time, people undergoing trauma may con- tinually experience flashbacks and other debilitating symptoms, such as night- mares, as well as physical, emotional, spiritual, and social concerns. Trauma can also result in a pattern of acute anxiety, depression, and posttraumatic stress. Like many loss situations, traumatic injuries can affect a person’s personal relation- ships; behavioral, sleep, and nutritional patterns; and ability to function in life. Empathic, informed, relational, and skilled professional counseling can support people undergoing periods of crises and experiences of trauma.

Trauma-Informed Care (TIC) TIC is a model used by counselors and institutions to place trauma assessment, treatment, and recovery as a primary goal for counseling. SAMHSA, an agency within the U.S. Department of Health and Human Services, discussed how TIC involves using every person within an organization—from the president or chief executive officer of a company to the maintenance person, and everyone in be- tween—in the service of health and healing. All parties involved recognize the role of trauma in a person’s life and understand that people use diverse coping mechanisms to deal with trauma. TIC also involves working with the whole being of a person, taking trauma history into account and considering the person’s cop- ing mechanisms. TIC recognizes that trauma can affect a person’s interpersonal functioning, including interaction with others, work performance, and sleep pat- terns (SAMHSA, 2014).

This model considers the way that trauma can influence a person’s daily re- sponses to events, potentially including isolation, anxiety, substance misuse, and over- or undereating that can increase health risks (SAMHSA, 2014). A person’s functioning and emotional, physical, social, and spiritual health can be affected. SAMHSA described how a person’s mind and body can be stuck in a state of threat when experiencing trauma because the brain is unable to filter information tem- porally and contextually. This condition can result in an impaired sense of self and disconnection, not only from one’s body but also from others. Disconnection can lead to a person’s distressing reactions to a traumatic event, including intrusive memories, images, thoughts, and dreams as well as a sense of feeling numb and dissociated. When faced with cues or triggers that mirror the trauma event, a per- son may react as if the trauma is happening in that moment. This experience can be perpetually devastating. As a result, a counselor’s compassion, responsiveness, and resourcefulness can bring needed support and relief.

The Relational Foundation for Crisis and Trauma Counseling Numerous theories related to crisis and trauma counseling support counselors in this important work, and we offer a description and applications of the more pre- vailing theories in the following chapters. We also discuss outstanding resources in subsequent chapters, such as the American Red Cross, the American Counsel- ing Association (ACA), and the National Child Traumatic Stress Network. In this chapter, however, we introduce the works of the Jean Baker Miller Training Insti-

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Chapter 1

tute and the Human Dignity and Humiliation Studies (HumanDHS); moreover, we identify these works and SAMHSA’s TIC model as foundational to this text.

This book is structured to provide counselors and mental health professionals with current essential information and examples of practical application to cri- sis and trauma counseling. Relationally framed, we emphasize (a) the power of the connections counselors form with people in crisis and as they work through traumatic experiences; (b) an intentional focus on safeguarding a person’s dignity throughout the work; (c) the relational, societal, political, and cultural contexts that affect a person’s experience of crisis and trauma; (d) the various contexts in which crises and trauma arise; and (e) the diverse means by which counselors can intervene and support people who face them.

We invited scholars and practitioners experienced in working with crisis and trauma situations to contribute to this book, and together, we draw on our prac- tices and research as we discuss the many dynamics of crisis and trauma and strat- egies to promote hope and healing. With the exception of publicly documented crises addressed in this text, the case examples we use throughout the book are compilations of actual client stories, de-identified to protect confidentiality. Our goal is to provide you with guiding theories and interventions for working with crisis and trauma situations while underscoring the role of humane connection as a most salient feature of crisis and trauma counseling.

Relationship is at the core of counseling, as indicated in its definition (Kaplan, Tarvydas, & Gladding, 2014), and research speaks to the primary role of relation- ship in therapeutic success (Norcross & Wampold, 2018). It is therefore essential that counselors explore the means by which healing and compassionate relation- ships are formed, which is particularly salient when working with people follow- ing traumatic losses. We offer leading theoretical constructs focused on crisis and trauma counseling and integrate guiding relational principles throughout this text. Judith V. Jordan—renowned scholar and cofounder of the Jean Baker Miller Training Institute, which is home to relational-cultural theory (RCT)—also pro- vides a detailed description of the role of connection in Chapter 2. We begin our discussion with a brief overview of RCT.

RCT Counseling theories provide frameworks to understand the human experience. At the most fundamental level, our theoretical perspectives guide the questions we ask, the way we relate to our clients, and how we conceptualize the counseling process. RCT is based on the early works of Jean Baker Miller, who recognized that traditional psychological theories largely ignored the emotional needs of women and marginalized groups (Jordan, 2018; Miller, 1976). Miller (1976) discussed how these clinical models emphasized separation from others as key to human devel- opment (Hartling & Sparks, 2008; Jordan, 2017). In response, she documented what she saw as the undervalued, yet indisputable, relational strengths of women in her book, Toward a New Psychology of Women (Miller, 1976).

Her work with other RCT founding scholars at the Stone Center at Wellesley College evolved into a theory that identified the importance of authentic, mutu- al connection as particularly relevant to the experiences of marginalized groups. Since then, scholars have explored the unique challenges facing many men soci-

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Introduction to Crisis and Trauma Counseling

etally and have described RCT in application to counseling men (Duffey & Haber- stroh, 2014). RCT’s focus on (a) the importance of growth through connection, (b) the societal and cultural influences that affect people’s responses to life and to one another, (c) the role of power and privilege, and (d) the means by which these factors affect a person’s response to trauma and resilience make it a progressive theory relevant to working with men, women, and children.

Relational Principles Relational Neuroscience

RCT’s theoretical principles, particularly as they relate to trauma work, are sup- ported by neuroscientific findings showing that human beings are “wired for con- nection” (Banks & Hirschman, 2015). Dr. Amy Banks, director of Advanced Train- ing at the Jean Baker Miller Institute at Wellesley Centers for Women, has referred to this principle as relational neuroscience. Relational neuroscience addresses the impact of interpersonal exchanges on the brain and identifies the impact of trauma on a person’s neurobiological structure and changing brain chemistry. This change can affect the ways that people who experience trauma interact with others.

For some people who have already suffered compounded losses after trauma, recognition of brain change and its potential impact on relationships can be dis- couraging. Fortunately, research has indicated that people’s brains have the ca- pacity to regenerate and heal. Scientists refer to this occurrence as the brain’s neuroplasticity (Banks & Hirschman, 2015). An awareness that growth-fostering connection with others (Jordan, 2018) and relational counseling experiences can promote brain health and influence neuroplasticity (Banks & Hirschman, 2015; Jordan, 2018) brings hope to people with trauma experiences and direction to their counselors. These concepts are addressed in Chapter 4.

Growth in Connection

According to RCT, the nature of a person’s relationships deeply influences one’s psychological development across the life span (Miller, 2008). Furthermore, mu- tually rewarding social connections facilitate emotional growth and a desire for continued connection (Banks, 2006, 2011, 2016; Lenz, 2016). The concept of growth in connection diverges from traditional psychological approaches that purport in- dependence from others as a cornerstone to growth. In a sense, RCT reinforces the idea that people need one another, and it introduces a model that proposes how people indeed grow in relationship. This paradigm is particularly salient given that the United States, as a culture, commonly privileges stoicism and rugged individualism and often views presenting pain or expressing need as weakness (O’Malley, Arbesman, Steiger, Fowler, & Christakis, 2012).

Authenticity In contrast, RCT recognizes the courage and strength involved in authenticity, and it identifies authenticity—the ability to represent oneself fully in relationship—as central to growth (Jordan, 2018). We believe that RCT’s reframing, and a coun- selor’s conceptualization of the client through this lens, provides a source of direc- tion, hopefulness, and relief for people in crisis.

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Context Professional counselors and mental health clinicians using relationally competent principles consider the life circumstances and contextual factors that affect their cli- ents. Context helps counselors look at all sides of a situation, and it brings perspec- tive to behaviors, attitudes, and feelings that could otherwise be pathologized. For example, far too many women with trauma histories are disproportionately mis- diagnosed with borderline personality disorder (BPD; Cloitre, Garvet, Weiss, Carl- son, & Bryant, 2014; Lewis & Grenyer, 2009). We have worked with several women who held tightly to this BPD diagnosis after receiving it from former mental health professionals. Some of these women may experience “unstable relationships with others, efforts to avoid real or imagined abandonment, identity disturbances, [and other symptomology]” (American Psychiatric Association, 2013, p. 663), which are characteristically seen in BPD. In many of these cases, however, these women also have a history of exploitation, abuse, domination, and other misuses of power. These histories bring context to their diagnoses, and counselors can conceptualize their situations using a trauma-informed (SAMHSA, 2014) and relational lens.

Although diagnoses of BPD can be appropriate, there are several cases in which posttraumatic stress disorder (PTSD) is a more appropriate and realistic diagnosis (Cloitre et al., 2014; Lewis & Grenyer, 2009). For example, there is context to the way these women respond to situations, and their relationships, and focusing on these contexts may help them begin to understand their responses from a perspective that Jordan, Kaplan, Miller, Stiver, and Surrey (1991) described as an “internalized defi- ciency model of women” (p. 26). In these cases, women who internalize these defi- ciencies have difficulty noticing their own strengths and values, and “they end up believing the way they think and feel is unimportant” (Jordan et al., 1991, p. 27). This dynamic can set a woman up to carry a distorted sense of her own value.

Reconceptualizing client concerns from a strength-based, relational lens provides cli- ents with an opportunity to face their crises or revisit their traumatic histories with self- compassion and a perspective that can support posttraumatic growth (Jordan, 2017; Kress, Haiyasoso, Zoldan, & Trepal, 2018), making the contextual aspect of RCT especially rel- evant to crisis and trauma counseling. See Sidebar 1.1 for more information on RCT.

Power RCT examines the difference between power-with and power-over. Power-with re- flects a shared power, whereas power-over involves exploitation, control, or dis- missiveness. These dynamics can be played out within supervisory and personal relationships as well as in exploitive business dealings.

Central Relational Paradox RCT shows that in spite of people’s yearning for connection, they sometimes en- gage in protective, but disconnecting, strategies that prevent their desired con-

Sidebar 1.1 • Relational-Cultural Theory Relational-cultural theory posits that people need healthy and meaningful connections in their lives for growth. Research now shows how the brain is actually wired to desire connection with others and can even grow from healthy connections. With this in mind, how do you instill this hope with your clients?

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Introduction to Crisis and Trauma Counseling

nections. People may hide how they feel or think to maintain some semblance of life-giving relationship.

Strategy for Disconnection and Strategy for Survival Given the protective nature of these disconnections, RCT conceptualizes these strategies for disconnection as also being strategies for survival. When people un- dergo chronic disconnection and worry that further attempts to connect will be met with more rejection or loss, they may behave in ways that keep them out of connection, even though connection is what they truly desire. They may act this way because they see themselves as essentially unfit for connection, or they fear being seen as unfit. In these cases, they may hide aspects of themselves that they consider defective, which results in forsaking their true nature to sustain a rela- tionship or connection. Tragically, these efforts can result in continued disconnec- tion and isolation.

Condemned Isolation When loss through disconnection becomes chronic, or when people are alone in their experiences without support, they may experience what RCT refers to as condemned isolation, which RCT contends is the “greatest form of human suffering” (Jordan, 2008, 2017; Miller, 1976; Pompeo-Fargnoli, 2017, p. 65).

Relational Resilience In contrast, when genuine relational connections are available and people are able to process their experiences in an environment of safety and respect, they are bet- ter able to experience what RCT refers to as relational resilience (Jordan, Walker, & Hartling, 2004, p. 32). Linda Hartling, former director of the Jean Baker Miller Training Institute and current director of HumanDHS, and Evelin Lindner, the founding president of HumanDHS (Hartling & Lindner, 2016), coauthor Chapter 15, which focuses on this important topic. Resilience is experienced in relation to others; therefore, RCT counselors acknowledge connection and mutuality as in- valuable resources in their work with individuals experiencing crisis and trauma (Banks, 2006, 2016; Kress et al., 2018).

Relational Ethics RCT counselors live out their steadfast commitment to the well-being of the cli- ent, which is at the heart of RCT, by practicing relational ethics. Relational ethics is a relatively new perspective that is less widely known than the mainstream ap- proach called principle ethics, which is rule based and rooted in certain “abso- lute” moral principles. In principle ethics, counselors are taught to ask themselves “what should I do?” when faced with an ethical issue, whereas relational ethicists ask themselves “who should I be?” in this relationship with this client. In relation- al ethics, the focus is on the actor rather than the action (Remley & Herlihy, 2020).

Principle ethics privileges an ethical decision-making process that is linear, pa- ternalistic, dispassionate, universal, and abstract. By contrast, relational ethics val- ues a process that is holistic, mutual, intuitive, compassionate, personal, and con- textual. Rather than searching for answers using a step-by-step, decision-making model, relational ethics instructs counselors to be comfortable with the contextual nuances of ethical decision making and to engage clients in this process (Birrell & Bruns, 2016). Finally, rather than taking a mental and emotional step back as the

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Chapter 1

authority to determine and remedy ethical issues, relational ethics teaches coun- selors to remain fully present in the moment with their clients, engaging them in the process.

This is not to say that counselors applying relational ethics do not follow a logical mind-set or minimize professional standards. On the contrary, counselors follow- ing a relational ethical model respect both logic and mutuality when navigating ethical dilemmas. This approach is in contrast to models that promote searching for a universal principle that can be applied to a generalized “other” (Benhabib, 1987). In some respects, relational ethics makes greater demands on counselors be- cause they cannot find answers by simply applying a model or consulting a code (Birrell & Bruns, 2016). However, this approach helps counselors to better grasp the client’s inner world and create a power-with dynamic that strengthens connec- tion and fosters healing.

Counselor Compassion, Responsiveness, and Resourcefulness in Crisis and Trauma Counseling

Think for a minute to a time when you experienced an event that was outside of your control—an experience that may have felt like a punch to the stomach or an unexpected turn of events that some would consider debilitating. Imagine there was a counselor present. Now consider what that counselor could say or do that would, at least in part, create some sense of safety in that moment. You might imagine be- ing comforted, heard, validated, and supported by your counselor. You might also imagine feeling connected with your counselor as you access and brainstorm your shared resources and strengths. Perhaps you can imagine feeling truly cared for and understood as you sort through the shock and loss of this experience. What could the counselor say or do that would communicate an understanding of your pain? What could the counselor do to communicate care and compassion?

Although people vary in the ways they express and receive compassion during times of injury or distress, they all need it. Counselor compassion, responsiveness, and resourcefulness are all vital to any experience with clients undergoing crises and traumatic experiences. Recognizing their impact is an integral part of serving clients in crisis and trauma situations.

Compassion

The Dalai Lama XIV was quoted as saying, “If you want others to be happy, prac- tice compassion. If you want to be happy, practice compassion” (Dalai Lama & Cutler, 2009, p. 18). Compassion is an experience that can move the hearts of those who feel it and those who receive it. Gilbert and Choden (2013) described a coun- selor’s compassion as being particularly relevant, defining it as “a way to develop the kindness, support, and encouragement to promote the courage we need—to take the actions we need—to promote the flourishing and well-being of ourselves and others” (p. 98). This process involves connecting with another’s experience, feeling it, and wishing to make a difference in the experience.

Neff (2011) also offered a conceptual framework for understanding compassion. Much like the experience of RCT’s mutual empathy, in which the counselor is able to communicate to a client a sense of truly being moved and affected by the client’s

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Introduction to Crisis and Trauma Counseling

experience (Jordan et al., 2004), Neff described the first step in experiencing com- passion for others as noticing the suffering. Do we notice someone’s pain? Are we truly attuned to the other person’s experience? We cannot overlook the experience of a person whose experience is far different from ours and also believe we feel compassion. Without connecting in that way, we cannot connect with how difficult it may be to stand in that person’s shoes (Neff, 2011). Neff used the word “compas- sion” to describe the experience of “suffering with.” Through this connection, we feel a sense of warmth, caring, and the yearning to support the suffering person (Neff, 2011). In other words, we recognize and connect with the person’s inherent humanity as well as our own advocacy and sense of making a difference.

Responsiveness and Anticipatory Empathy

Judith V. Jordan highlighted the importance of counselors’ responsiveness in her discussions on anticipatory empathy. Jordan (2017) described responsive- ness as involving a mutual interplay in which counselors use their emotional response to promote the well-being and growth of clients. For example, as counselors, we reflect on and anticipate how our responses may affect our cli- ents. We notice, care, and solicit feedback from clients on how our actions affect them. Feedback is central to a framework delineated within developmental relational counseling, a model that provides a graphic illustration or roadmap for counselors to identify and consider their connection to their compassion and clarity, as well as their awareness of self and others, through feedback (Duffey & Haberstroh, 2012).

On a practical level, what are the ways in which counselors can respond to clients in crisis? For one, counselors working in crisis and trauma counseling recognize the devastation of loss as experienced in their clients’ lives and work with clients accordingly. For example, in the immediate aftermath of a trauma or crisis, counselors attend to a person’s loss of control, desire for safety, and basic needs (Zaleski, Johnson, & Klein, 2016). Counselors working with clients facing critical events focus on issues such as creating safety, assessing needs, providing human connection during a perilous time, and connecting clients with resources.

These responses differ in some ways from treatment for PTSD and other long- term mental health care needs, also discussed throughout the book. For exam- ple, counselors engaged in long-term trauma work, such as treating PTSD, also consider the impact of trauma on the brain and offer resources and interventions grounded in relational neuroscience and principles (Banks, 2011, 2016). Trauma work may also focus on helping clients reevaluate their beliefs about the trauma and, through genuine relating and mutual empathy (Banks, 2016), cope with feel- ings they expected to diminish over time (Mackinnon & Derickson, 2013).

Crisis and trauma work, being systemic in nature, involves not only considering the needs of the client, family, or larger community, but also the readiness and the timely appropriateness of the counselor’s presence and intervention. Counselors, by profession, often feel a desire to intervene and offer support when a need exists. Many times, this support is helpful, and the compassionate response is welcome. However, counselors must be attuned to the desires of the communities and re- spect the resources within the communities as capable and well equipped.

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We (Thelma and Shane) considered these factors when we supported the work in Newtown, Connecticut. These factors were also important for us to remember when we were asked to participate in the counseling recovery services during the after- math of the mass shootings in Sutherland Springs, Texas. In both cases, we offered support when needed and responded to requests as communicated. It is important that counselors should not assume that a community is ready for, or receptive to, outside support. Rather, counselors can stay abreast of the reported needs of the community, connect with the local resources (such as the American Red Cross or other community agencies) and coordinate any efforts that involve travel to com- munities in crisis. See Sidebar 1.2 for more information on community trauma.

Although manualized practices exist and are reported in this text, the authen- ticity, responsiveness, and creativity that counselors cultivate attune them to the losses in their clients’ world. This attunement supports a counselor’s work with clients facing crises and trauma, recognizing that, for some, their world has shat- tered (Duffey, 2005; Duffey & Haberstroh, 2014).

Counselor Wellness in Crisis and Trauma Counseling Counseling as a profession requires both authenticity and empathy, with a goal being to promote healing and growth. Research has consistently demonstrated that the quality of the therapeutic relationship is more predictive of counseling outcomes than any other factor (Ardito & Rabellino, 2011; Lambert & Barley, 2001; Norcross & Wampold, 2018). Because counselors, as relatable and trustworthy peo- ple, are an essential component of effective counseling, it is vital that they nourish their own wellness. Wellness, from a counseling perspective, involves integrating the body, mind, and spirit of a person while connecting with the larger community (Myers, Sweeney, & Witmer, 2000). In other words, when counselors invest in their own wellness, health, and care, they increase the potential for connection with their clients and become more attentive and creative in their work. Clients expe- riencing trauma and seeking counseling need and deserve their counselors’ full and available resources. They need and deserve a genuine connection with their counselors, making self-care an important counselor responsibility.

As counselors, we can better prepare for trauma and crisis counseling by rec- ognizing our own needs and prioritizing wellness and self-care in our own lives. Self-care can be as simple as walking outside on a sunny day to take in some vi- tamin D rays while feeling the warmth of the sun on our faces. Perhaps, self-care can involve talking on the phone with a loved one or someone with whom we can laugh and share. Recognizing what brings us joy is an important job for a coun- selor—taking part in activities that do so are vital.

Research has indicated that higher levels of wellness relate to higher levels of job satisfaction when counseling clients with trauma (Foreman, 2018). Counsel-

Sidebar 1.2 • Community Trauma A community trauma may affect how members of the community see the world and how they respond with each other. What type of community trauma can you think of that has changed a group’s outlook on life?

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ors’ intentional focus on wellness, their access to supportive trauma-informed sys- tems, and a grounded awareness of their thoughts, feelings, and visceral reactions may serve to buffer them from being overwhelmed, avoidant, and rejecting of detailed and horrific accounts shared by clients. Counselors and clients alike can experience secondary or vicarious trauma when hearing about the terrible and heart-wrenching events shared by others. Vicarious trauma can leave counselors with an altered view of themselves and can cause them to reevaluate whether they see the world as a safe place (Foreman, 2018).

When, as counselors, we experience vicarious trauma and do not practice self- care, we run the risk of developing impairments and decrease our opportunities to productively connect with our clients or lead the lives we intend. The ACA Code of Ethics (ACA, 2014) speaks to these issues and requires us to monitor our clinical effectiveness and to reflect on our level of functioning in our work with clients. If we do not engage in these reflections, we may cause harm to our relationship with our clients and their progress, and we may also become negatively affected by the traumatic stories they bring (Foreman, 2018).

Research on counselor wellness is growing in the literature, and it is important that counselors continue to understand ways to create better balance in their lives. The indivisible self model, which is an evidence-based wellness model in which counselors are used as participants (Myers & Sweeney, 2008), has produced in- teresting findings. Research has indicated that counselors-in-training have higher levels of wellness when they participate in a wellness class as part of their aca- demic training (Myers & Sweeney, 2008). By using resources such as the indivis- ible self model, counselors can identify where they stand in their own wellness development (Myers & Sweeney, 2008). Given the avocation of counseling as a career, and the research that demonstrates that counselors involved in career-sus- taining behaviors of balancing professional and personal life thrive (Lawson & Myers, 2011), self-care becomes an increasingly important priority. When we, as counselors, spend time with loved ones and exercise self-awareness, we are better able to navigate the challenges of trauma counseling and experience higher levels of wellness (Lawson & Myers, 2011).

Technology and Chronic Media Exposure During Times of Crisis and Trauma

On September 11, 2001, I (Thelma) awoke to a crisis situation that connected me to a gut-wrenching primal pain I will never forget. My son, Rob, was studying at New York University as a freshman, minutes from the World Trade Center, and his father, Mike, was in Washington, DC. News commentators were frantically describing the terrorist attacks on the World Trade Center and then the Pentagon. I was at home in Texas, and with thousands of miles between us, I was besieged by media accounts of such graphic proportions that I could barely contain myself.

Thankfully, I heard from Mike early in the day, but we did not know our son’s fate for most of the day. With profound gratitude, I can report that my son sur- vived that experience intact. Knowing we would be frantic, Rob hurriedly sent an email message that morning, letting his father and me know that he was okay. However, until we received the message, and for hours that felt like a lifetime, images of the Twin Towers captured by the media personally terrorized me and

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those around me. Days later, I met a new client whose close friend died in the Twin Tower bombings. As she described the televised images she saw of the streets in New York, and as she relayed how horrified and grief stricken she was by the graphic and intrusive images of people attempting to escape, I recalled the graphic depictions that had haunted my own thoughts just days before.

In the current era, technology connects people with information instantaneous- ly. When the news is critical or tragic, the media can be the means by which people first hear devastating news that can rock their worlds and change their lives forev- er. Even people who are not directly affected by the reported events can experience vicarious trauma in the blink of any eye (Comstock & Platania, 2017). Although people are often cautioned to minimize exposure to these events, cell phones and social media make avoiding exposure to tragic events or mass violence challeng- ing. Keep in mind that research has shown that limiting exposure to electronic media can help to reduce vicarious trauma in adults and children (Hamblen, 2016; Wang et al., 2006). However, technology often plays a central role in people’s lives. It is deeply important that counselors recognize the impact of this exposure on their clients and themselves.

Furthermore, understanding the recommendations of groups, such as ACA (2014), surrounding use of technology during critical incidences and trau- matic events is critical. These recommendations include attending to physical and emotional needs, seeking support when needed, monitoring media expo- sure, and engaging in familiar and historically successful activities or coping strategies while remembering what it is that provides comfort and makes life meaningful. Finally, we encourage all counselors to seek help if the experience becomes unmanageable (Dailey, n.d.). Remember that a safe and trustworthy therapeutic relationship, coupled with interventions and approaches geared toward healing and resiliency, can provide comfort and hope in the midst of chaos and trauma.

Case Example and Applications for Hope and Healing The community in which we live is now grief stricken by the suicide of a beloved, bright-eyed, and brilliant young man of 16, “David,” who was victim to the bru- tal and traumatic bullying behaviors of his peers. Despite his family’s attempts to intervene and protect David through every means possible, David could not escape the pain of social exclusion and humiliation, taunting, and ridicule. First perpetuated on the school grounds, and later in cyberspace following his transfer to another school, these experiences proved too traumatic for David to bear.

Consider the crisis to a family in knowing that one of their children is hurt in this way. Bullying and acts of interpersonal violence create crisis situations and traumatic injuries that can result in a ripple effect of pain and devastation for those directly inflicted, for those who love them, and for the communities in which they live. Trauma is not only experienced within the family but also within the commu- nity and, via technology, within communities worldwide.

David’s loss was unimaginable for both his family and the community that loved him. His story touched the lives of people far and wide. In fact, when I (Thelma) served as president of ACA, I selected antibullying and interpersonal

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violence as a presidential initiative. In the midst of that work, I heard of David’s passing. Horrified by this tragic loss, I took his story across the nation, and hun- dreds of counselors participated in these antibullying efforts. Moreover, as a result of his family’s efforts and those of community members and legislators, a new law exists (Senate Bill 179, formerly known as David’s Law, 2017) within the state of Texas designed to protect children in schools against bullying.

In addition to the law, David’s family and volunteers travel statewide to pres- ent information to teachers, students, administrators, and parents, with a goal of protecting children from this devastating injury. David’s parents valiantly share their experience, offer guidance and information on antibullying and character- building resources, and use their loss as a catalyst to save other children from the pain their child could not escape.

David’s parents are not alone. Humbled and propelled by their strength and perseverance, members of the community, our faculty and students at the Uni- versity of Texas at San Antonio, and countless others join them in the challenge of securing safety for all children. The challenge is formidable—too often, injuries and injustices as well as critical events and traumas catapult people’s lives. How- ever, we are heartened in knowing that we can come together to contribute in our own ways, encouraging a climate of compassion and empathy while honoring and promoting David’s legacy of hope, healing, and love.

Factors, Approaches, and Interventions That Foster Healing and Resiliency

Individuals often attend individual counseling with hopes of successfully navigat- ing critical or traumatic events. Other times, couples or families seek counseling during times of conflict, loss, or tragedy. Finally, there are times when tragedies strike an entire community or communities, and counselors are recruited to offer support and crisis intervention. When counselors are open to creating a space for clients that allows connection and mutuality, they humanize the client’s experience in such a way that the client can feel empowered and even hopeful. Throughout the course of this book, we review approaches and interventions used in crisis and trauma counseling and consider factors that support client healing and resiliency.

Future Directions and Emerging Research There are several emerging approaches counselors may encounter when work- ing with clients who live with PTSD. Technological, virtual, brief, and mind-body focused treatments address the complex factors that predict PTSD and posttrau- matic growth. As the horizon of counseling options expand, both counselors and clients have access to more tools, pathways for growth, and approaches that may resonate with individuals’ personal trauma stories and hopes for healing. As new approaches emerge, and the evidence becomes established related to their efficacy, counselors remain mindful of the healing power of relationships to create safety, energize hope, and respect and honor the pain that may haunt clients. Through collaboration and shared decision making, counselors and clients can consider how emergent therapies may be useful.

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Technological Advances: Neurofeedback and Virtual Reality (VR)

Harnessing the power of technology and advanced computer processing, neuro- feedback and VR provide novel avenues to work directly with the brain. Neuro- feedback is a tool that supports clients through visual processing and modulating brain functioning (Thibault, Lifshitz, & Raz, 2016). The goal of neurofeedback is to reduce the autonomic reactions to stressful memories, flashbacks, and emotional pain that may seem uncontrollable at times.

Neurofeedback Neurofeedback is a technology-facilitated process in which clinicians target specific brain regions by using protocols to help clients gain mastery over their brain waves via feedback (Thibault et al., 2016). Qualified counselors who use neurofeedback in practice receive extensive training in neuroanatomy, trauma-focused treatment protocols, the proper application of electrodes on the scalp, and interpretation of the data that informs the treatment process. Neurofeedback studies have produced pos- itive outcomes for clients, even with varied methodologies (Panisch & Hai, 2018). Panisch and Hai (2018) conducted a systematic review of neurofeedback and PTSD and reported that neurofeedback holds promise for reducing PTSD symptoms.

After clients begin their neurofeedback training, they engage in an audiovi- sual experience in which their brain begins to learn or relearn brain wave pat- terns that lead to decreased stress, increased frontal lobe activity, and integration of their thoughts and feelings through physical activation and processing. During this process, the counselor modifies the feedback to slowly modulate their clients’ brain waves according to established protocols. The client experiences images or sounds that alert them when their brain deviates from the treatment parameters. People learn through feedback when their brain is under duress, and they also learn to experience optimal brain wave functioning.

VR Another emerging technology in trauma work involves the use of VR to create envi- ronments where clients can gain mastery over stressful events in real time (Powers & Rothbaum, 2019). Initial studies have shown that the VR setting can be a powerful sensory experience in which clients interact in stressful situations with therapeu- tic support and monitoring. VR environments can create more vivid experiences than memory alone and can help facilitate exposure therapies (Powers & Rothbaum, 2019). As with neurofeedback, counselors and clients should feel comfortable and technically proficient using this technology as a medium to explore traumatic events and recovery. See Sidebar 1.3 for more information on technology usage.

Sidebar 1.3 • Technology Usage Technology can be a useful tool for counselors to connect with people from all over the world. However, disturbing information can reach us as it occurs and in environments where we are not prepared to receive this content. Have you ever experienced a time when you were on your phone or social media and learned about an incident when you felt unprepared? Where were you, and how did this affect you?

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Mind-Body Approaches

In a review of the numerous complementary and alternative interventions for the treatment of PTSD, the mind-body approaches received the most research sup- port (Metcalf et al., 2016). These interventions included acupuncture, emotional freedom technique, mantra-based meditation, and yoga. Each of these methods seems to access the integration of the mind and body in a way that promotes heal- ing. However, because the studies showed limited effectiveness, more research is needed that focuses on alternative and complementary modalities as first line or conjoint therapies in trauma counseling.

Brief and Targeted Approaches

In many current talk-focused treatments for PTSD, clinicians retell and imagine traumatic events in great detail and explore cognitive distortions while using tech- niques to moderate the emotional and visceral impact of the traumatic memories (Najavits, 2015). These approaches focus on encouraging both clients and coun- selors to lean into the potential avoidance that characterizes PTSD. Counselors and clients walk through the terror together and reconstruct new meanings of the trauma. Although research has shown that these approaches are effective, many people do not complete the required number of sessions (Najavits, 2015). Others may choose to avoid the process altogether because they are asked to relive terror- izing moments and profound losses.

Two emerging briefer interventions titled accelerated response therapy (ART; Kip et al., 2015) and written exposure therapy (WET; Sloan, Marx, Lee, & Resick, 2018), may address some of the shortcomings associated with traditional practices. ART and WET distill select therapeutic activities from existing practices and take far fewer sessions to complete. For example, ART uses aspects of eye movement desensitization and reprocessing, cognitive behavioral, and gestalt therapies in a structured, time-limited format. Likewise, WET spans five sessions and focuses on writing about the trauma event while following prompts to process the impact of the event on the client’s life. Much fewer participants dropped out of the WET study compared with existing interventions, and the initial results demonstrated that participants experienced benefits from this modality (Sloan et al., 2018).

All of the emerging research and counseling practices described in this section are based on efforts from counselors, clients, and researchers to provide ongoing opportunities for healing. As new techniques, programs, and interventions gain research support, counselors and clients can creatively tailor a counseling pro- cess that meets clients’ hopes for successful counseling outcomes. We contend that future directions in crisis and trauma work will continue to focus on integrating systems at all levels—from political and institutional structures to neurobiological, relational, spiritual, and emotional realities.

Resources Crisis and trauma work is challenging on all levels and becomes increasingly com- plex when violence affects a community or when a person’s loss is complicated by mixed feelings and circumstances (Westmarland & Alderson, 2013). In addition, although all traumatic situations can create the kind of havoc that leaves people

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reeling, the nature of a person’s relationships can affect the tenor and intensity of the pain that follows. Accessing internal and external resources is paramount for a person in crisis or experiencing trauma. Clearly, crisis and trauma work is multifac- eted and fluid. This kind of work challenges counselors to be present with their own loss, as they engage in and hear devastating stories and circumstances from their clients’ lives, while fostering a counseling relationship grounded in safety and hope.

Therefore, because it is important that, as counselors, we remain equipped with personal clarity, professional acumen, and a relational framework, it is also vital that we connect with those resources that provide self-care and that enhance our own sense of wellness and productivity. We focus on what inspires our sense of self-compassion, compassion for others, and authenticity. In this text, we offer a comprehensive exploration of crisis and trauma counseling using a relational lens and a professional counseling worldview.

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Resources for Crisis and Trauma Counseling American Counseling Association (ACA) ACA provides fact sheets and resources for counselors working with trauma

and disaster mental health. https://www.counseling.org/knowledge-center/mental-health-resources/

trauma-disaster#disaster American Red Cross The American Red Cross provides online and in-person disaster response and

disaster mental health trainings. https://www.redcross.org/take-a-class/disaster-training

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Cognitive Behavioral Intervention for Trauma in Schools (CBITS) CBITS provides free online training to implement the CBITS program in

school settings. https://cbitsprogram.org/ Columbia Lighthouse Project The Columbia Lighthouse Project provides free online training related to the

administration and interpretation of the Columbia Suicide Severity Rating Scale.

http://cssrs.columbia.edu/ Human Dignity and Humiliation Studies (HumanDHS) HumanDHS is a global network of people who commit to stimulate systemic

change—globally and locally—to open space for dignity, mutual respect, and esteem to take root and grow.

http://www.humiliationstudies.org/ Medical University of South Carolina The Medical University of South Carolina provides free online training in

cognitive processing therapy. https://cpt.musc.edu/ National Center for PTSD (Posttraumatic Stress Disorder) Led by the U.S. Department of Veterans Affairs, this site offers resources and

online trainings for working with adults experiencing PTSD. https://www.ptsd.va.gov/ National Center for School Crisis and Bereavement (NCSCB) The NCSCB provides training and free technical assistance to help schools

during crises. https://www.schoolcrisiscenter.org/ National Child Traumatic Stress Network (NCTSN) The NCTSN provides online trainings covering a variety of topics for treating

trauma experienced by youth. NCTSN also offers online psychological first aid training.

https://learn.nctsn.org/course/index.php?categoryid=3 Readiness and Emergency Management for Schools (REMS) REMS provides in-person and online trainings to address crises and violence

in all school settings (K–12 and higher education). REMS also provides templates and recommendations for developing school safety plans.

https://rems.ed.gov/ Stopbullying.gov The stopbullying.gov website provides online training and resources to

address bullying prevention and intervention. https://www.stopbullying.gov/

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Substance Abuse and Mental Health Services Administration (SAMHSA) SAMHSA provides numerous resources focused on trauma-informed care in

behavioral health, PTSD, and suicide prevention. TIP 57: Trauma-Informed Care in Behavioral Health Services:

https://store.samhsa.gov/product/TIP-57-Trauma-Informed-Care-in-Behavioral- Health-Services/SMA14-4816

Suicide and PTSD Prevention Screening and Triage Tools SAMHSA and the Health Resources and Services Administration (HRSA)

offer free evidence-based screening tools and resources. https://www.integration.samhsa.gov/clinical-practice/screening-

tools#suicide Suicide Prevention Resource Center (SPRC) The SPRC provides online trainings and resources focused on suicide prevention. https://www.sprc.org/

Multiple-Choice Questions 1. Relationally framed crisis and trauma counseling would agree with

emphasizing a. The power of connection with clients during crisis and trauma. b. Techniques for clients to practice. c. Intensive inpatient treatment for recovery. d. Pushing the client to process though events quickly.

2. One main goal of this book is to a. Discount previous neurobiology research about neuroplasticity. b. Provide the reader with assessments. c. Provide the reader with guiding theories and interventions. d. None of the above

3. Who authored the book Toward a New Psychology of Women? a. Judith Jordan b. Mark Smith c. Linda Hartling d. Jean Baker Miller

4. Relational-cultural theory (RCT) promotes a. Authenticity and mutual empathy. b. Only cultural influences. c. Techniques. d. Providing various homework assignments for clients.

5. According to RCT, what can mutually rewarding social connections provide? a. Only emotional growth b. Humor and fun c. Disconnections from other relationships d. Emotional growth and a desire for more connection

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Chapter 1

6. RCT also explores cultural influences. Which statement would RCT agree with about culture? a. Cultural influences affect people’s responses to one another and life. b. Culture does not have a vital impact on development. c. Culture is an element that never comes into the counseling session. d. None of the above

7. Relational neuroscience posits that a. Trauma will damage areas of the brain forever. b. Neurons can never reconnect and grow. c. Trauma changes the brain, but healthy social connections can promote

brain health. d. Trauma changes the brain, and there is little a counselor can do to help.

8. If clients are hiding parts of themselves in session and worry about suffering increased rejection, they may be experiencing a. Central relational paradox. b. A disorder. c. Autonomy. d. None of the above

9. Which agency in the U.S. Department of Health and Human Services dis- cusses the trauma-informed care (TIC) model? a. CAAP b. SAMHSA c. SAAMH d. NIHA

10. Compassion is most related to which RCT concept? a. Mutual empathy b. Central relational paradox c. Chronic disconnection d. Relational images

11. The _____ model may help counselors-in-training develop their compassion and self-awareness. a. CBT b. REBT c. Developmental relational counseling (DRC) d. Fundamental

12. According to Myers and Sweeney (2008), counselors may experience higher level of wellness if they participate in a wellness class. a. False b. False, because this will only add another class to the student’s schedule c. True d. True, if all the students have the same self-care plan

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Introduction to Crisis and Trauma Counseling

13. Which statement about neurofeedback is true? a. Neurofeedback puts little shocks into the brain. b. Neurofeedback helps people regulate their brain activity. c. Neurofeedback is not safe for children. d. Neurofeedback is not a good tool for reducing trauma symptoms.

14. New approaches for trauma include interventions that use acupuncture, yoga, and meditation. These are known as a. Behavioral therapy. b. Mystical approaches. c. Mind-body approaches. d. None of the above

15. If people experience a crisis, they will also experience trauma. a. True, because crisis and trauma are the same thing b. True, if the crisis happened when they were older adults c. False, because some people can experience crisis and not trauma d. None of the above

Essay Questions 1. Crisis and trauma counseling is not a new topic. Research is expanding by

incorporating relational theories (e.g., relational-cultural theory [RCT]) and emerging research on neuroplasticity. How have these topics changed coun- selors’ viewpoints on crisis and trauma?

2. In the case example of David, he experienced bullying and felt the pain of social exclusion. Following his death, his family took action and worked to create an antibullying law in Texas known as David’s Law. If you knew a child or adolescent was being bullied or cyberbullied, what type of action might you take, given your role?

3. According to this book, there are new and emerging approaches for helping people who have experienced crisis and trauma. If you had unlimited resourc- es, how would you propose researching crisis and trauma from an RCT lens?

4. According to the Substance Abuse and Mental Health Services Administration (2014), trauma experiences can lead to a wide array of symptoms, including isolation, substance abuse, and anxiety. Considering this information, how often do you feel like trauma plays a part in misdiagnosis?

5. As Chapter 1 states, this book will focus on relational aspects of crisis and trauma. What are the key principles you learned from this focus?

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