Institute Inbrief - 01/03/2016
Welcome to Edition 242 of Institute Inbrief! If you had to endure a traumatic event, would you want to talk about your experiences later? Early models for treating trauma asked clients to do this, insisting that the cure was in the retelling. Just around the millennium, however, research began to show that, while some people were helped by going over the trauma again with a counsellor or other “de-briefer”, many others’ trauma symptoms were exacerbated by the insistence on going over the event. In this edition, we explore this idea through Briere’s “therapeutic window” model.
Also in this edition:
- Latest news and updates
- Articles and CPD information
- Wellness tips
- Social media review
Enjoy your reading!
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Imagine Being Passionate About Your Work
And Assisting People Every Day Lead Better Lives
It’s rare these days to hear people talk about their work with true passion. You hear so many stories of people working to pay the bills; putting up with imperfect situations; and compromising on their true desires. That’s why it’s always so refreshing to hear regular stories from graduates living their dream to be a Counsellor. They’re always so full of energy, enthusiasm and passion. There’s no doubt that counselling is one of the most personally rewarding and enriching professions.
Just imagine someone comes to you for assistance. They’re emotionally paralysed by events in their life. They can’t even see a future for themselves. They can only focus on their pain and grief. The despair is so acute it pervades their entire life. Their relationship is breaking down and heading towards a divorce. They can’t focus on work and are getting in trouble with their boss. They feel they should be able to handle their problems alone, but know they can’t. It makes them feel helpless, worthless. Their self-esteem has never been lower. They’re caught in a cycle of destruction and pain.
Now imagine you have the knowledge and skills to help this person overcome their challenges. You assist to relieve their intense emotional pain. You give them hope for the future. You assist to rebuild their self-esteem and lead a satisfying, empowered life. As a Counsellor you can experience these personal victories every day. And it’s truly enriching. There is nothing more fulfilling than helping another person overcome seemingly impossible obstacles.
Trauma: The Therapeutic Window
If you had to endure a traumatic event – say, dangerous flooding, an out-of-control bushfire, or being caught up in terrorism – would you want to talk about your experiences later? Would you believe that it would help you to heal from them if you did? Early models for treating trauma asked clients to do this, insisting that the cure was in the retelling. Just around the millennium, however, research began to show that, while some people were helped by going over the trauma again with a counsellor or other “de-briefer”, many others’ trauma symptoms were exacerbated by the insistence on going over the event (van der Kolk & McFarlane, 1996; Rothschild, 2000).
Observing that individual clients’ unique ways of processing trauma impacted on their retelling of traumatic experiences, Briere developed a model for assessing and manipulating the intensity of trauma exposure in individual clients which would allow them to remain in a non-re-traumatising “therapeutic window” (Briere & Scott, 2006). Those re-traumatised in a counselling session would tend to revert back to the maladaptive responses they employed to deal with the original traumatic material: typically, dissociating and/or reliance on addictions. The intensity of in-session trauma exposure could be assessed as one of three levels.
Level One: Numb and incongruent: At the first level of response, the client demonstrates minimal emotional stimulation. Characterised by flat affect, the presentation is that of a calm voice tone and numb demeanour. The client’s nonverbal behaviour does not match the content of the trauma being described.
Level Two: Congruent and controlled: At this level, the client is showing some affective stimulation, but does not appear to be overwhelmed or out of control. The nonverbal behaviour is appropriate to the traumatic content, but not to the degree that the person appears to be re-experiencing the trauma.
Level Three: Relived traumatic intensity: At the third and most intense level, the client is highly stimulated; the intensity seems close to the original response to the trauma. The clinician may be able to observe the client actually reliving the trauma in the present: weeping uncontrollably, gasping for breath, and/or displaying behaviours from an earlier age, such as thumb-sucking or rocking. Other clients may dissociate during the session or revert to drug or alcohol usage between sessions. There may be self-destructive behaviours. Obviously, this level of intensity is undesirable, as clients may prematurely terminate therapy or show other signs of resistance when they are so overwhelmed with traumatic material.
Counsellor-managed emotional stimulation
In employing this model of working through trauma with clients, the counsellor’s role is not unlike that of the clinician doing systematic desensitisation with a client. The counsellor is responsible for managing the degree of emotional stimulation in the sessions. If there is inadequate affective stimulation (that is, the client stays at Level One), the person remains within his/her comfort zone and avoids receiving the affective stimulation necessary to develop an increased tolerance for re-experiencing the traumatic material. But if the client becomes overstimulated (that is, Level Three), his or her symptoms generally worsen in the attendant overwhelm.
As clients learn to think about and discuss their traumatic experiences without becoming overwhelmed, they stay in the therapeutic window. Time within this window not only assists in increasing tolerance to the traumatic material, but also facilitates the positive integration of the traumatic memories within the client’s personality and identity. Through repeatedly replaying the painful memories, the client begins to modify the affective response to the trauma. The hyperarousal and avoidance behaviours gradually come to be replaced by healing integration and acceptance of the traumatic experience (Briere & Scott, 2006).
The counsellor’s task with this process is no less than assuming major responsibility for protecting traumatised clients from re-traumatisation. The clinician must be on the lookout for phenomena such as overstimulation, regression, and dissociation (within session) and increases in out-of-session behaviours such as addictive responses. The goals of treatment here are around helping clients develop more adequate coping strategies before they are asked to re-experience the trauma in session. Generally, the skills taught in Dialectical Behaviour Therapy (see Linehan, 1993) can be employed here: problem solving, behaviour change, and emotional regulation, which assist both affective regulation and relational skills (Bicknell-Hentges & Lynch, 2009).
How to up- and down-regulate the intensity
It’s great to say that, as a counsellor, you should keep clients in this therapeutic window. You may be asking how a clinician does that.
Level One: Anchoring the client in the trauma
From Level One, intensity can be increased by asking:
- Affect questions such as “How were you feeling when…?”
- For specific details of the trauma
- The client to describe the trauma step by step
- For visual, kinaesthetic, and auditory memories of the event
- What happened to his/her body (Bicknell-Hentges & Lynch, 2009)
Level Three: Anchoring the client in the present
When clients are at Level Three, the counsellor can down-reregulate the intensity by:
- Asking content questions not specific to the trauma (for example: “How old were you at the time?”
- Using a calm, hypnotic voice to calm the client
- Asking the client to stop talking about the trauma and anchor them in the present
- Rephrasing what the client has just said
- Requesting the client to open eyes and describe the current setting
- Using relaxation and breathing techniques in session
- Asking the client to talk about neutral events in the present (Bicknell-Hentges & Lynch, 2009).
Herman’s stages of recovery
The notion of the therapeutic window is a valid and helpful one given that, at some stage in a client’s healing journey, he or she will typically want – or therapeutically need – to tell the story of the traumatic experience to the therapist. Regardless of the therapeutic approach(es) used, the question arises as to when in treatment that should be. That is, what are the main stages involved in recovery from trauma, what are their respective goals, and at which stage, therefore, may re-telling be most healing? Judith Lewis Herman’s Trauma and Recovery (1994) is a now-classical work which divides the world of recovery from trauma (including ongoing abuse and sexual abuse) into three stages.
Herman noted that the early part of treatment is about dealing with problems the client may be experiencing as a result of the trauma, such as difficulty regulating emotions and impulses or containing aggression, overcoming substance abuse or behavioural addictions, and moving beyond self-harm and dissociation. Thus early goals for treatment include:
- Getting a ‘road map’ of the healing process
- Client and therapist jointly setting treatment goals
- Establishing safety and stability (with respect to body, relationships, and all of life)
- Identifying and connecting with one’s strengths and healing resources
- Learning how to regulate emotions and manage symptoms
- Developing and strengthening skills for managing painful experiences and minimising unhelpful responses to them
The first stage, Herman emphasises, is not about discussing or processing memories of the traumatic experience(s), although she acknowledges that life and treatment are not always perfectly ordered and sometimes it may be necessary to discuss the contents of disturbing memories, and how to manage them, if they are disrupting the client’s life. At this stage, too, problems with alcohol, eating behaviours, physical health, panic attacks, or dissociation may need to be dealt with in order for the therapy to proceed. Similarly, some clients may need to begin either anti-depressant or anti-anxiety medications.
Address these at all stages
The psychological themes that typically emerge from either single-incident or ongoing traumatic experiences are the dynamics of powerlessness, shame and guilt, distrust, and the possibility of re-enacting abusive relationships in current relationships. Such dynamics must be addressed early on if they are obstacles to safety, self-care, and the regulating of one’s emotions and impulses. Therapy can help with identifying and managing habitual behaviour patterns, beliefs, and motivations that may be driving self-defeating or harmful behaviours from “underground” (out of conscious awareness). When clients take responsibility for them, the increased awareness brings increased capacity to choose new, healthier behaviours and actions.
Herman refers to this stage as “remembrance and mourning”, because it involves:
- Reviewing and working with memories to lessen their emotional intensity and to revise their meanings for the client’s life
- Working through grief about traumatic, abusive, or otherwise unwanted experiences and their negative effects in the client’s life
- Mourning or working through grief (especially in cases of abuse) that one did not have, but which would normally seem to be something everyone deserves
If a solid foundation of understanding, safety, stability, and capacity to self-regulate has been established at Stage 1, clients are empowered to decide if they wish to invoke the pain and risks involved with engaging State 2. Not all clients find it necessary to focus on disturbing, intrusive memories, but those who do will be able to process such phenomena in the safe confines of the therapist’s rooms.
Herman’s third stage of recovery focuses on reconnecting with people, meaningful activities, and other aspects of life. It is here that the re-calibrated, re-worked version of events (now transformed via cognitive restructuring, psychodynamic psychotherapy, and/or other means) is able to be re-integrated into the person’s understanding and life: not as it was in its raw, unprocessed form, but as an experience with which one has come to terms.
Having confronted the traumatic past, the client must now create a future. The person has mourned the old self that the trauma destroyed; now a new self must develop. Relationships have been tested and forever changed by the trauma; new ones must develop. The old beliefs which gave meaning to life have been challenged; a new, sustaining faith must be found. In short, the client doing Stage 3 recovery work must reclaim his or her life (Herman, 1992; Hopper, n.d.).
The above notions of the therapeutic window and Herman’s three stages are general considerations for working with trauma, adaptable to most therapeutic approaches used to treat trauma. While trauma treatment is challenging for mental health practitioners, it is empirically shown to be effective.
This article was adapted from the upcoming Mental Health Academy CPD course “Working with Trauma”.
Bicknell-Hentges, L, & Lynch, J.J. (2009, March). Everything counselors and supervisors need to know about treating trauma. Paper based on a presentation at the American Counseling Association Annual Conference and Exposition, Charlotte, N.C.
Briere, J. & Scott, C. (2006). Principles of trauma therapy. Guide to symptoms, evaluation, and treatment. Thousand Oaks, CA: Sage Publications.
Herman, J.L. (1992). Complex PTSD: A syndrome in survivors of prolonged and repeated trauma. Journal of Traumatic Stress, Vol 5, No 3, 377-391.
Hopper, J. (n.d.). Herman’s stages of recovery. One in Six. Retrieved on 28 July, 2015, from: hyperlink.
Linehan, M. (1993). Skills training manual for treating Borderline Personality Disorder. United States: Guilford Publications.
Rothschild, B. (2000). The body remembers: The psychophysiology of trauma and trauma treatment. New York: W.W. Norton & Co.
Van der Kolk, B.A., & McFarlane, A.C. (1996). The black hole of trauma. In B.A. van der Kolk, A.C. McFarlane, & L. Weisaeth (Eds.), Traumatic stress: The overwhelming experience on mind, body, and society (3-23). New York: Guilford.
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How to Close the Chronic Pain Pathway
We would like to introduce you to two people; in fact, more than introduce you. For the next several minutes, we would like you to become these people. The first is a chronic pain patient, and the second is the family member caring for that patient.
We’ll call you Chris. You are of working age and are one out of the every three Australians who live with chronic pain. Yours started years ago at your job at the mail order delivery company. Rushing to get heavy merchandise indoors as a huge rainstorm approached, you lifted and twisted, herniating three discs in your spine. The next morning when you woke up, you couldn’t move. You went back to work, but the deepening pain eventually meant that you had to quit. You tried part-time work, but with the back pain you were somewhat uncoordinated and had several falls, injuring yourself further, you are now unemployed.
Pain, stigma, depression, and constraint
Your back causes you pain all day and keeps you from sleeping at night. It grinds you down relentlessly, so much so that you (like 20% of chronic pain patients) have considered suicide. Yet no medical professional seems to believe you are really in pain. You were not surprised to learn that four out of five people like yourself experience that most others doubt the reality of your pain. You can no longer commit to social events because you will be exhausted the next day. Your world has become narrow – and constrained, because the disability pension does not cover your living costs. Exhausted, depressed, stigmatised, cash-strapped, with eroded self-esteem, you are a shadow of your former active, upbeat self.
Now please de-role from being Chris. For the next few seconds, imagine that you are Pat, the only child of and caregiver for Chris. Chris was widowed a number of years before the accident, so when Chris could not work anymore, you offered to have your parent come and live with you; you work full time and give care to Chris the rest of the time. You are doing your duty, but at great cost to yourself. You are continually exhausted, on edge, approaching burnout, and aware that, as caregiver, you have a 58% higher premature mortality rate than non-caregivers. It is not just the stress of the caregiving that gets you; you also have lost both meaning and hope. You are depressed, with no end to your situation in sight.
Closing the pain pathways
OK, now consider this last bit as yourself. The sketches of Chris and Pat are depressing, but they are all too common. How can we help chronic pain patients or their caregivers? To reduce the $34.3 billion expenditure Australia makes per annum on chronic pain (about $11,000 for each person with chronic pain), we probably need to alter the way you think about it. Medication, physio, surgery, and some allied health modalities are well-known to fight chronic pain. Not everyone knows about retraining the mind and refocusing the attention through Cognitive Behaviour Therapy. Here are three crucial thoughts from CBT to consider if you are either in chronic pain or trying to help someone who is.
1. Focusing on pain means more pain. Every sensation of pain which registers on our consciousness sends a signal through our pain pathways. The more signals we send (that is, the more thoughts focusing on pain), the more pain receptors our nerves create to handle all the signals. The more receptors we have, the more sensitive our nerves become, leading to our spines becoming highly sensitised. The more sensitivity we have, the more pain we experience. The more pain we experience, the more pain thoughts we have, creating a vicious cycle.
2. Attention is finite. To interrupt the above cycle, people can be reminded that each of us has a finite amount of attention to give to life. Putting major amounts of attention onto one’s pain means much less attention for anything else. By inserting pleasurable experiences to life, we increase our production of the so-called “feel good” chemicals – the neurotransmitters – such as the endorphins. With a high percentage of attention on our enjoyable experiences, we emotionally and chemically reduce our pain.
3. Attention is like a muscle. It can be strengthened by using it, and it can be directed to do the “heavy lifting” in whatever direction we require. Therefore, in pain control the objective is “attention enhancement”: growing the capacity for attention and then directing that newly enhanced capacity to those experiences that generate “feel-good” (i.e. pain inhibiting) chemicals, thus limiting or closing the formerly active pain pathways.
All of this means that we help people control their pain by encouraging them to distract themselves from the pain, reducing pain signals, adding in enjoyable sensations and experiences, facilitating the production of pain-inhibiting endorphins. When we help people grow their capacity for paying attention, they are even more powerful at regulating these processes.
Mindfulness exercises and techniques can help people do this. We don’t have space to explain those in this post (watch this space for later posts), but an internet search on the subject yields many interesting mindfulness exercises. Mindfulness exercises are great for both Chris and Pat, and even for those of us blessed to live without chronic pain!
Written by Dr Meg Carbonatto B.S., M.A., and Ph.D.
This article was originally published in Asteron Life’s Balance Blog. AIPC regularly contributes to Balance’s wellbeing blog category.
A Case Using Art Therapy Techniques
Jodie is a 40 year old woman who is married with three children and works full-time in a professional career. She has been experiencing low levels of energy for approximately 18 months along with feelings of stress and overwhelm. While working with Jodie, the Professional Therapist adopts the use of art therapy techniques to allow the client to look outside the box and find novel ways to increase self-awareness, reduce stress, and improve her physical, mental, and emotional well-being. For ease of writing, the Professional Therapist is abbreviated to “T”.
Suicide: Supporting People with Special Needs in Grieving
How can you best offer support to someone who is bereaved by suicide? What attitudes, translated into caring actions, can best facilitate the bereaved person’s coping in the immediate and short term, and their healing in the longer term? In a previous article we provided you with a guide to clarify what you can do to help the suicide-bereaved. In this article we explore special issues and unique grieving needs for a number of groups of people, including parents, children and young people, older people, people with disabilities and minority groups (lesbian, gay, and bisexual people).
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Get Going with Goal-setting
How are you going on your New Year’s resolutions? If you are like an estimated 93 percent of the population, you have abandoned those fine aspirations generated so earnestly in December. Despair not, however; in this article we look at why you should revive your resolutions, turning them into goals. We identify the areas of life where that would be helpful and offer an exercise you can do to bring your goals into sharper focus, giving you greater clarity of purpose.
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