Trauma Counseling

Psychological trauma:

As the name indicates psychological trauma is related to the trauma that results in psychological distress because of some emotionally distressing event. It is explained as:

“Psychological Trauma is a type of damage to the psyche that occurs as a result of a traumatic event” ”.(Judith Harman, 1997.trauma and recovery)”

The sense of being overwhelmed can be delayed by weeks or years, as the person struggles to cope with the immediate danger. The experience has four common traits:

·          It was unexpected,

·          It was psychologically overwhelming

·          The person was unprepared or unable to cope with it,

·          There was nothing the person felt they could do to prevent or mitigate it.

Thus, it is not the event per se that determines whether an experience is traumatic, but the subjective experience of that person.

 History:

The ability to recognize emotional trauma has changed drastically over the course of history. It is basically categorized into three categories. Until recently psychological trauma was noted only in men after catastrophic wars. The women's movement in the sixties broadened the definition of emotional trauma to include physically and sexually abused women and children.

 Now, because of the discoveries made in the nineties known as the decade of the brain, psychological trauma has further broadened its definition. Recent research has revealed that emotional trauma can result from such common occurrences as:

·          An auto accident,

·          The breakup of a significant relationship,

·          A humiliating or deeply disappointing experience,

·          The discovery of a life-threatening illness or disabling condition,

·           Other similar situations.

Traumatizing events can take a serious emotional toll on those involved, even if the event did not cause physical damage. In this way the specification on physical harm was also aborted.

Causes of Psychological Trauma:

Psychological trauma may accompany physical trauma or exist independently of it. Typical causes of psychological trauma are

·          Sexual abuse,

·          Violence,

·          The threat of the witnessing sexual abuse or violence,

·          Catastrophic events such as earthquakes and volcanic eruptions,

·          War or other mass violence,

·          Long-term exposure to situations such as extreme poverty,

·           Milder forms of abuse, such as verbal abuse,

·          Physical assault, including rape, incest, molestation, domestic abuse,

·          Serious bodily harm ,

·          Serious accidents such as automobile or other high-impact scenarios,

·           Experiencing or witnessing horrific injury, carnage or fatalities,

Other potential sources of psychological trauma are often overlooked including:

• Falls or sports injuries,
• Surgery, particularly emergency, and especially in first 3 years of life,
• Serious illness, especially when accompanied by very high fever,
• Birth trauma ,
• Hearing about violence to or sudden death of someone close.

Poor relationship with primary care taker separation very early in life from primary caregiver; It is acknowledged that early life trauma creates vulnerability for experiencing future traumatic responses.

Effects  of Psychological Trauma:

Our brains are structured into three main parts, long observed in autopsies:

• The cortex (the outer surface, where higher thinking skills arise; includes the frontal cortex, the most recently evolved portion of the brain)
• The limbic system (the center of the brain, where emotions evolve)
• The brain stem (the reptilian brain that controls basic survival functions)

Because of the development of brain scan technology, scientists can now observe the brain in action, without waiting for an autopsy. These scans reveal that trauma actually changes the structure and function of the brain, at the point where the frontal cortex, the emotional brain and the survival brain converge. A significant finding is that brain scans of people with relationship or developmental problems, learning problems, and social problems related to emotional intelligence reveal similar structural and functional irregularities as is the case resulting from PTSD.

Common effects of emotional trauma on interpersonal relationships:
• Inability to maintain close relationships or choose appropriate friends and mates
• Sexual problems
• Hostility
• Arguments with family members, employers or co-workers
• Social withdrawal
• Feeling constantly threatened

Difference between normal stress and Psychological Trauma:

The outcome of both can make a healthy difference between  the two as  how much residual effect an upsetting event is having on our lives, relationships, and overall functioning. Traumatic distress can be distinguished from routine stress by assessing the following:

• How quickly upset is triggered .
• How frequently upset is triggered.
• How intensely threatening the source of upset is.
• How long upset lasts .
• How long it takes to calm down.

Individual differences in People:

Some people get traumatized while other remains prone to emotional or psychological trauma. It is because of many situational and environmental factors that also include the individual coping skills as well. The main features influencing are:

·          The severity of the event;

·           The individual's personal history (which may not even be recalled);

·           The larger meaning the event represents for the individual (which may not be immediately evident);

·           Coping skills, values and beliefs held by the individual (

·           The reactions and support from family, friends, and/or professionals.

Various Responses to Psychological Trauma:

There are three types of responses to traumatic event:

·          Proactive Response.

·          Reactive Response.

·          Passive Response.

Proactive responses include attempts to address and correct a stressor before it has a noticeable effect on lifestyle.

 Reactive responses occur after the stress and possible trauma has occurred, and are aimed more at correcting or minimizing the damage of a stressful event.

 A passive response is often characterized by an emotional numbness or ignorance of a stressor.

Those who are able to be proactive can often overcome stressors and are more likely to be able to cope well with unexpected situations. On the other hand, those who are more reactive will often experience more noticeable effects from an unexpected stressor. In the case of those who are passive, victims of a stressful event are more likely to suffer from long term traumatic effects and often enact no intentional coping actions.

After Effect of Psychological Trauma:

Self-destructive coping mechanisms:

After effects can be extremely traumatizing in the forms of reminders as night mares, memories and others. For  avoiding trauma reminders, people use defenses  also called triggers, as this can be uncomfortable and even painful. In many cases this may lead a person suffering from traumatic disorders to engage in disruptive or self-destructive coping mechanisms.

Severe Damage:

 Some traumatized people may feel permanently damaged when trauma symptoms don't go away and they don't believe their situation will improve. This can lead to feelings of despair, loss of self-esteem, and frequently depression. If important aspects of the person's self and world understanding have been violated, the person may call their own identity into question.

Vulnerability to Stress Disorders:

These symptoms can lead to stress or anxiety disorders, or even posttraumatic stress disorder, where the person experiences flashbacks and re-experiences the emotion of the trauma. There is also a distinction between trauma induced by recent situations and long-term trauma which may have been buried in the unconscious from past situations such as childhood abuse. Trauma is often overcome through healing; in some cases this can be achieved by recreating or revisiting the origin of the trauma under more psychologically safe circumstances, such as with a therapist  as if it is actually happening.

 Psychological trauma may cause acute stress disorder (ASD) which may lead on to posttraumatic stress disorder (PTSD). PTSD can also develop without an antecedent ASD and may come on months or years after the trauma. Both ASD and PTSD are specific disorders in which the traumatized individual may experience nightmares, avoidance of certain situations and places, depression, and symptoms of hyper-activation.

When that trauma leads to posttraumatic stress disorder, damage may involve physical changes inside the brain and to brain chemistry, which affect the person's ability to cope with stress.

Sign and symptoms of Post Traumatic Stress Disorder::

Physical
• Eating disturbances (more or less than usual)
• Sleep disturbances (more or less than usual)
• Sexual dysfunction
• Low energy
• Chronic, unexplained pain

Emotional
• Depression, spontaneous crying, despair and hopelessness
• Anxiety
• Panic attacks
• Fearfulness
• Compulsive and obsessive behaviors
• Feeling out of control
• Irritability, angry and resentment
• Emotional numbness
• Withdrawal from normal routine and relationships

Cognitive
• Memory lapses, especially about the trauma
• Difficulty making decisions
• Decreased ability to concentrate
• Feeling distracted
• ADHD symptoms

Behavioral effects:
• Substance abuse
• Compulsive behavior patterns
• Self-destructive and impulsive behavior
• Uncontrollable reactive thoughts
• Inability to make healthy professional or lifestyle choices
• Dissociative symptoms ("splitting off" parts of the self)
• Feelings of ineffectiveness, shame, despair, hopelessness
• Feeling permanently damaged
• A loss of previously sustained beliefs

Positive Aspect of Trauma:

Trauma as a growth:

For most trauma survivors, posttraumatic growth and distress will coexist, and the growth emerges from the struggle with coping, not from the trauma itself.

Some responses of trauma survivors are as follows:

“……………..improved relationships, new possibilities for one's life, a greater appreciation for life, a greater sense of personal strength and spiritual development.”

“Their losses have produced valuable gains ...They also may find themselves becoming more comfortable with intimacy and having a greater sense of compassion for others who experience life difficulties.”

§ Course of Therapy

§  Therapist and Client Role and Function

Therapeutic relationship:

Research has shown that the single most important factor in whether therapy is successful is the degree to which the person is at ease with the therapist, i.e. the interpersonal chemistry - and not the number of diplomas on the therapist's wall.

Confidentiality: One of the most important aspects of the therapeutic relationship is the expectation that your personal issues will remain private. And under most circumstances, anything discussed in therapy is confidential. However, State law has made important exceptions to confidentiality such as when the safety or well-being of children or the elderly is at stake. The development of an active, affective, therapeutic relationship to create a safe, interactive environment. This type of therapeutic relationship provides the context necessary for accessing, reworking, and integrating the traumatic material. It becomes the foundation for treatment; acting as a bridge to facilitate the survivor's reconnection to self and offering a corrective interpersonal experience. Providing, sustaining, and monitoring this type of therapeutic relationship is emotionally demanding and involves unusual challenges and responsibilities for the therapist.

 The therapeutic relationship must withstand and remain constant in the face of conflict, disappointment, disillusionment, the projections and demands of transference and counter-transference reactions, and often profound ambivalence to both the therapeutic process and relationship. Sympathy and good intentions alone are not sufficient and cannot substitute for clinical understanding and effective intervention in treatment with survivors. However, respect and kindness are important ingredients of the therapeutic relationship as these attitudes facilitate important corrective functions in treatment. Often, even well-planned and technically correct interventions will be ineffective unless they are executed within the context of a therapeutic relationship that conveys kindness and respect.

Course of Trauma:

In a "simple" type I trauma there are a number of phases:

These phases can be described as follows:

Latent phase:

When the trauma begins, there is a short latent phase (sometimes lasting only a few seconds). In this phase, the person recognizes that the trauma is occurring and assesses what to do about it.  The decision-making process here is usually very quick and unconscious.  There is almost always an element of shock in this process, but, in most people, this passes quickly, and the person is able to decide on a first course of action.  In some people, however, the shock remains and panic sets in. 

 Full trauma phase:

In general, the person reacts better in this phase than under normal circumstances, and is frequently surprised later at what he or she has done and what his/her emotional reactions were.  The body also reacts during this phase, producing more adrenaline and reacting in specific ways which are known as the "fight or flight reaction". In this reaction, the blood flow to the brain and other organs vital to survival is increased. The body also reacts in other ways which are most appropriate to survival, such as contracting the pupils (to make vision sharper) and shutting down the kidneys and the stomach (to use energy for other purposes).

Temporary adaptation:

If the trauma is very long, a kind of temporary adaptation may occur.  This means that the person will find mechanisms for living which are not "normal" but which, taking into account the personality and circumstances of the person, are adapted in some way to the situation.  These are known as coping mechanisms.These coping mechanisms are extremely important to understanding how people react under difficult circumstances.  In our view, far more research needs to be done with regard to such mechanisms to help to decrease tension and produce better functionality both during and after the trauma.

Crisis phase:

When the trauma ends, the person enters the crisis phase.  During this phase, bodily and psychological functions, which were active during the previous phase, end, and the person feels weak and incapable of doing anything.  This is a very dangerous phase both physically and psychologically, especially after long traumas.  The person does not know how to react and has a great deal of symptomatology.  Anxiety, depression (even suicide), and many other psychological and physical reactions characterize this phase.

Recovery phase:

The person then slowly begins to enter the recovery phase. The person's behavior, attitudes, and general psychological state may be better or worse than before the trauma. One important aspect of this behavior is that coping mechanisms which were present and appropriate during the full traumatic phase may persist and may be inappropriate under the circumstances of stability.  An example is a woman who stayed in the cellar during the bombing of her city but, currently in peacetime, still stays there because the cellar gives her a sense of security.  Furthermore, the basic characteristics of psycho trauma, as discussed above, may be present for long periods and may have to be treated during this phase.  Still another, more hopeful possibility is that the person will have learned from the trauma and will be better able to cope with life.

The Stages of Kübler-Ross.

Elisabeth Kübler-Ross was a Swiss-American psychologist and nurse who worked with cancer patients.  Her stages are still valid for most trauma situations, even if they "only" describe the symptomatology.  Kübler-Ross said that each person goes through the following stages:

·         Denial, during which the person (sometimes completely) denies that the situation exists.

·         "Bargaining", during which the person "bargains" for help, usually with a higher being (example:  "Dear God, if you heal me, I will give all my money to the Church").

·         Anxiety in which the person can have extremely high, but varying levels, of anxiety in fits or continuously.

·         Dependency in which the person can be dependent on alcohol, drugs, or other substances, but also can be highly dependent on other people.

·         Anger in which the person can have anger, in fits or continuously, which has no direction or which can be directed at anybody or anything.  It should be noted that the helper frequently feels that this anger is directed at him/her, whereas it is more likely to be a general phenomenon.

·         Depression in which the person can be depressed even to the point of suicide.

·         Acceptance – in the experience of most workers, this acceptance is only partial.

It has been shown that these stages are not linear, that is, that a stage can be repeated, and that the order given above is not necessarily the same for every person in every situation.  These stages, however, give an indication of what can and generally does happen within a person who has been traumatized.  It is important to take this into account when dealing with such people, even in everyday situations.  Obviously, these stages have great implications for the peace building, mediation and reconciliation processes with regard to the participants in such processes and for the success of such processes.

The Model of Kleber and Horowitz.

Kleber in The Netherlands and Horowitz in the USA developed a model of how people deal with trauma which fits well together with what Kübler-Ross said:

This can be described as follows.  When a person has a traumatic experience, he/she first "cries out", generally during the crisis phase. The person then goes through alternating cycles of denying and re-experiencing the events. During the re-experiencing, the person allows all that he/she can of the experience and the feelings associated with it to enter his/her consciousness.  During the denial phase, the person psychologically puts what has just been re-experienced into place.  Finally, there is acceptance.  This acceptance, as has been indicated, however, is usually only partial.

One of the important implications of this model is that re-experiencing is extremely important if the trauma is to be dealt with in the long term. The strategy of constant denial or forgetting the trauma will thus not solve the problems.  It also implies that stages of "rest" are important for the functioning of the Kleber-Horowitz mechanism and that these also must be recognized by the therapist and the environment.  The balance between these phases is a difficult one and must be adapted to each client individually.

The Stages of Adaptation to a New Situation.

Tauber, in 1993, described a number of phases through which people work when they adapt to new situations.  These are as follows:

·         Arrival.  The person comes into a new situation.  There is excitement and a sense of unreality.  The person's assessment of the situation is not always accurate.  Behavior may be based on false assumptions and expectations.  This may, almost immediately, lead to errors in judgement as to how to deal with the situation, as well as to depression, anger, anxiety, and a wide variety of other problems, particularly problems with relationships with people in the new environment.  A simple example is the arrival at the beginning of this course.

·         Beginning of learning about the new situation.  Here the person begins to come to grips with the reality of the situation and begins to do the things necessary for survival.  How people work through this stage is partially dependent on their own personalities and the support they get from the environment.  This phase can last a very long time and can have many sub-phases.

·         Depression at the new situation.  This occurs toward the end of the previous phase when the person sees his/her own situation and the prospects for the future.  There is frequently disappointment with at least some aspects of the new situation.

·         Anger at the new situation.  This is more or less obligatory and may cause considerable problems, particularly with refugees and asylum seekers, who sometimes lash out at their new countries and situations.  This is seen as "ungratefulness" by their hosts.  It is also difficult for people in the helping professions who may be unaware of the nature of this anger to deal with.

·         Confusion of identity.  The person begins to see something good in the new situation and realizes that the old situation wasn't the ideal that he/she thought it was.  There is thus a question in the mind of the person as to where his/her loyalties lie.  This stage can be confusing both for the person him/herself and for the person's environment.

·         Acceptance and integration.  This, in general, is only partial.  The key to this phase is the acceptance by the person him/herself that there is richness in his/her own diversity and mixture.  What is meant here is that the person accepts the situation with both its good and bad points and learns in some sense to live with it.  It does not necessarily mean that the person is completely accepted by the environment nor that he/she completely becomes like the other residents.

Therapy:

There is no  definitive work on the therapy of psycho trauma.  We will, however, try to give a very basic outline of some of the issues involved and hope that it will be stimulated to look at how these problems can be solved in his or her own situation.

For the client.

There are several basic principles to therapy.  The first is mourning.  Mourning, roughly defined, means being sad for the person or thing which has been lost and, further, putting the object of mourning into place, recognizing his/her/its good and bad qualities.  It is ritualized in most cultures in one way or another.  Problems arise when such rituals have been lost (as is frequently the case in the West) and/or when the amount of loss is so great that mourning becomes difficult, almost overwhelming.  In the former Yugoslavia, there is an additional problem of lack of mourning through denial and through the displacement of the problems into the material realm.  Another principle of therapy is "getting it out and working with it.

It should also be noted that what is appropriate for one culture may not be appropriate for another, and thus extreme care must be taken when applying solutions from outside.

Still another issue is that of the capacity of professionals and non-professionals to deal with the enormous problems faced by many countries.  One answer may be to train persons at a slightly lower level and to assist in the training of higher level professionals to deal with the most severe cases.  Another answer may be "peer counseling", that is, training some members of a group to help other members of that group.  It almost goes without saying that careful and extensive supervision is required in such cases. 

For the counselor: supervision:

 Burnout is the situation in which helpers have gotten to the end of their ability to help in the sense that they are psychologically tired and used up.  This occurs very frequently in the helping professions, particularly when helpers are overworked as is the case frequently in situations where helpers are dealing with underprivileged groups and in (post-) conflict areas and transitional countries. 

It is essential that the problem of burnout among helpers be tackled.  The basic classical way of doing this is through what are known as supervision.  These groups allow for practitioners to express their problems and feelings to other practitioners in a non-threatening context.  This allows for both professionality and solidarity. Burnout control should be built into every conflict or post-conflict or development program, not only for health practitioners but for virtually every group of workers in contact with people in need.  It is also essential for people working under isolated or stressful conditions of any sort.

Specific Effects of Psycho trauma on Various Groups.

Torture victims.

It is beyond the scope of this reader to describe specific methods of torture and their consequences.  Unfortunately, the human mind is extremely creative in this regard, and the consequences can be severe.  Torture can be physical or psychological or both and can have psychological and physical consequences, or both.  Torture victims must always be treated.  Part of the treatment is dealing with the human rights violations.  Unfortunately, torture is all too common and occurs in places where it would not be expected.  Many groups have produced excellent works on torture.  Both Amnesty International and the International Research Center for the Care of Torture Victims in Copenhagen can give further information.  They, and several other groups, have produced handbooks for work with torture victims.

prison, concentration camp and prisoner of war camp victims.

In some countries, this forms a very large group.  Frequently, being a prisoner also means being tortured and there is virtually always mistreatment of some sort.  Again, this is a group which virtually always needs treatment and which frequently does not get it.

With regard to both groups, several points must be made with regard to their societal influence and the influence of such persons when they participate in mediation and reconciliation processes.  Such persons will almost always have psychological problems of one sort or another.  These effects can substantially influence others around them and can even influence the (sub-)societies of which they are a part.  In many cases, they are considered to have superior insights or even to be martyrs because they have passed through a “worthy ordeal” which others have not, and thus they often become very prominent within their societies.  Therefore, their influence on policy-making and on the direction their societies take may be substantial.  In this context, they may be (prominent) participants in the peacemaking, peace building, and mediation processes, and their specific and individual psychological problems and influences may well become significant conscious or unconscious parts of those processes.

This has a number of consequences.  First, it is essential that adequate treatment is available.  Second, these influences must be taken into account by mediators and other participants in mediation and peacemaking processes.

Men.

Men are frequently ignored as a target group of psychosocial programs because it is felt that they are the perpetrators (which is sometimes true), and because they are seen as "strong" and less vulnerable than other groups.  Men are, in fact, extremely vulnerable.  They are the first to be traumatized through war and other violence. 

Children and youth.

A full discussion of the problems of children and youth affected by psychotrauma is beyond the scope .Their problems can, however, be divided into three categories.

We must remember that children and youth of different ages have different methods of thought than do adults and thus they interpret events differently.

Another point to remember with children and youth is that, if untreated, they will almost certainly transmit the trauma to future generations.

Women.

Women in situations of trauma have a number of specific problems.  They may have been the victims of violence during the traumatic events.  We are too familiar with the almost standard sexual abuse of women under such types of conditions.  In post-conflict situations, women are frequently the victims of family violence.  It is most frequently the woman that deals with the children and their problems.   It is also often the woman who takes the role of keeping the family together under difficult circumstances with all the additional stress that this entails.

Refugees and displaced persons.

Refugees and displaced persons must deal with the losses of their homes, belongings, and loved ones, as must all other victims of situations of violence.  Within the group of refugees and displaced persons, however, there is the additional feeling of homelessness, of insecurity, of being a second or third class citizen, and of resentment against and from virtually everyone.

Refugees.

Refugees have a specific set of problems wherever they are.  Even if they are in a country of their own ethnicity, they are frequently looked down upon as "low life" and are discriminated against either by governmental policy or otherwise.  In most countries, especially in the West, they are not permitted to work.  This leads to idleness, depression, and a raft of psychological problems which, in turn, lead to learned helplessness.  These psychological problems, as we have seen above, frequently lead to physical problems. 

Returnees.

The return process, if it ever occurs (and it frequently either does not or takes many years to do so), is in itself a trauma.  Things are not what they were, and it is necessary to rebuild or, rather, build anew, the physical and social structures that constitute life.

Other vulnerable groups.

Still other vulnerable groups are the elderly and the group of relatives of missing persons. 

In general, the elderly are forgotten.  Nevertheless, they do have special needs (particularly physical and medical ones) that are rarely taken into account.  Often, their children desert them and find better circumstances elsewhere.  Furthermore, their hopes are frequently raised and then dashed to the ground.  They may be manipulated for political purposes and have often been used to stir up ethnic hatred.  Again, treatment and careful reintegration of these people into society is needed.  An attempt must be made to de-politicize them and to deal with their human tragedy.

Therapeutic Process and Goals

Counseling and Therapeutic Process:

“Tramatization occurs when both internal and external resources are inadequate to cope with external threat.”(Bessel van Der Kolk ,1989)

Specialized treatment for rapid emotional healing:

Do you know people who suffer from as symptoms of depression, anxiety, phobias, panic attacks, sexual abuse, neglect, abandonment, pains and illness without a known medical cause? Do you know people who have experienced an emotional or physical crisis or trauma and who want the pain, negative symptoms and relationship problems to stop? In the great majority of cases, I can enable them to substantially alleviate their symptoms. No method is completely successful with every client and there are no guarantees.

Unresolved trauma is often the origin of mental disorders--including the diagnoses of depression, anxiety, and panic attacks and is the sole source of post-traumatic stress disorder (PTSD). I am pleased to announce that a psychotherapy practice has been created that is cost and time-efficient and effective in resolving the negative effects of past traumas.

How Do I Know When to Get Help

Trauma can affect anyone at any age. The effects can be mild or severe, creating extreme psychological issues. Any symptoms of trauma should be taken seriously. In some cases however, the effects of trauma can manifest months and even years after the event, so in actuality, it can be difficult to recognize the symptoms. Often people feel they are weak for needing help, especially when they compare themselves to others who may have endured the same traumatic experience. But it is important to remember that everyone reacts differently to trauma and there is no guideline as to how and what someone should feel. What we do know is that the sooner you deal with the symptoms of trauma, the better chance you have for a full recovery and to be free of the effects of these events. If left unresolved, emotional trauma can affect your daily choices and functioning and ultimately, it can manifest into serious psychological disorders with lasting effects. Just as we need help to heal the physical effects of trauma, we also need help to heal the emotional wounds. Counselingoffers a safe and supportive environment to work through these issues.

Counseling for the Resolution of Trauma

Working with a Values-Based counselor to address the effects of a trauma can be a confusing and frightening task to begin. Whether the events occurred in childhood, five years ago, or last week, the impact of these troubling situations is not something we are taught how to resolve. Often, the thought of going through the events again and seemingly reliving the tragedy may appear more than we can bear.

Many times, we learn how to cope and manage the symptoms of a trauma. Whether this is learning to calm ourselves when we experience a panic attack upon the reminder of an event, or seeking solace in our friends when we experience depression or sadness over the effects of the trauma. While these are important and helpful methods to manage the symptoms, a trauma counselor focuses on resolution of the originating feelings and emotions that require coping skills into the future. If individuals have a lack of safety or security as a result of an event that left them exposed, vulnerable, or violated, trauma counseling begins by establishing a sense of safety for the individual.

Therapeutic Starting Points

              

Event oriented therapy

Goals

v  The effect of the event is to be completed

v  The disorder will be nullified; life can go on

v  Life is what happens, not only what can be planed

v  Re-appraisal and re-evaluation of the traumatic events

v  Events are reconstructed as experiences, as self-experience and world-experience

Reaction oriented psychotherapy 

v  Physical reactions e.g. trembling, paralyzed legs, tension of neck and shoulder, lump in one‘s throat

v  Intrusions, night mares, images and sensory memories

v  This reactions are instinctive actions at traumatic events (flight, fight, call for help)

v  In therapy this actions are reactivated and completed

Future oriented therapy

Issues in therapy

v  Setting life goals

v  Find ways for achieving goals

v  Discuss consequence in case of not achieving goals

 The therapy comprises affective aspects of an open future with threatening side and challenging side 

“As anyone knows who has glued things, the things to be stuck together need to be held firmly in a kind of a frame until the glue holds” and boundaries that are created in the therapeutic work are like such a frame.”

Josephine Klein, (1978), Our Need for Others and it’s Roots in Infancy. New York, Tavistock.

Counseling stages

The group program was based on the trauma recovery model proposed by Herman (1992). The first stage is, safety building, the second stage is II/ exploration of trauma, and the third stage is III/ social reconnection.

Stage I

Consequently, the first sessions focused on establishing the feelings of safety and trust within the group, and developing a high level of group cohesion. Also, the participants' strengths were identified and reinforced.

Stage II

The succeeding sessions focused on the problem children identified in their individual contracts, and exploration of their links to the trauma experience. The direction of the counseling: from present symptoms past trauma: starting from symptoms and orientation on the goals defined in the contract with every child, rather than starting from the trauma story. Opening traumatic experiences to the extent relevant for achieving particular therapeutic goals. Use the group dynamic to help each group member to achieve her/his therapeutic goals.

Obstacles to the recovery process

Interventions on removing the obstacles to the recovery process are, also, the essential part of the counseling program at this stage.

That includes interventions on:

Dysfunctional beliefs, coming from families or broader community, (e.g. "I will never recover");

Lack of basic safety (Some parents or communities can not provide basic safety).

Relationships with other traumatized family members might lead to further problems for the child as she/he can not find adequate protection because the whole family is traumatised), etc.

Interventions for these obstacles
mainly consist of

Cognitive reframing and neutralization of dysfunctional beliefs and replacing them with a new belief system

Confrontation and Group discussion

Additional treatments (e.g. family therapy)Or interventions on a community level

Use of expressive techniques

Various group techniques and interventions will be in use to achieve individual goals.

Expressive techniques including:

Clay, paint, collage, drawings a projection of inner condition;

Sand-tray–projection of process and the possibility of following it,) have been used as an independent method of intervention, and in combination with other therapeutic techniques, such as

Role-playing, or Gestalt techniques such as “Double chair”-inner dialogue, imagined dialogue with significant others etc., Fishbowl tecnique...

Stage III

Final stage of the treatment -Closure

The final sessions focused on “here and now”

Consolidation of the achieved goals–emphasis on solutions

Work on social relationships –peers, siblings, parents, and on future plans and goals

Ethical considerations e.g. revenge/forgiving vs. seeking social justice

Evaluation

Evaluation-carried out 2 months after the group program.

The basic aim of the evaluation is to assess if a therapeutic contract with the each child has been achieved. Evaluation is organized through semi-structured interview with each child / parent separately.

With the contractual therapeutic approach evaluating the group program is relatively a simple and clear process.

In case that the therapeutic goals have not been achieved, or have been only partially achieved, further interventions are planed with children and parents.

THERAPEUTIC APPROACHES TOWARDS TREATMENT OF TRAUMA COUNSELING

THERAPEUTIC APPROACHES TOWARDS TREATMENT OF TRAUMA COUNSELING

The Wits Trauma Counseling Model

The Wits Trauma Model is a brief term integrative psychotherapy intervention used for the treatment of psychological trauma. The model has been conceptualized within the integrative psychotherapy paradigm, and Eagle (1998) describes the benefits implicit to an integrative approach. The model was developed by staff of the Psychology department at the University of Witwatersrand. The model was formulated using case material from hundreds of clients presenting with various forms of post traumatic stress.

 The model integrates psychodynamic and cognitive-behavioral approaches for the treatment of psychological trauma. From this perspective, it provides an explanation of how psychodynamic and cognitive-behavioral processes interact to influence the development, maintenance and/or prevention of post traumatic stress symptoms. The epistemological philosophy underpinning the model is perhaps its greatest strength. That is, an explicit recognition that trauma impacts on both internal and external psychological functioning, and thus requires a treatment approach which addresses both internal, psychodynamic processes, as well as intervention which is structured and problem-oriented.

The model is applied in cases of acute stress and post traumatic stress disorder. It is not considered appropriate for use in cases of complex post traumatic stress (Herman, 1992), nor in cases of continuous traumatic stress (Straker & The Sanctuaries Team, 1987; Straker & Moosa, 1994), where a longer term psychotherapeutic intervention is required. The model is short term in nature, ranging from two to fifteen sessions. Here improvement is noted after four to six sessions in the majority of cases.

Outline of the model

The model consists of five components which can be introduced interchangeably depending on the needs of the client. Eagle's (1998) description of these components is used over here.

1. Telling/retelling the story

This involves the client giving a detailed description of the traumatic incident in sequence, including facts, feelings, thoughts, sensations, as well as imagined or fantasized aspects. This allows the client to give expression to the often unexpressed feelings and fantasies connected with the trauma which are often adaptively inhibited during life-threatening situations. Within the safety of the therapeutic context, this expression is usually made possible. In telling the story, a useful question to ask the client is, "what was the worst moment for you?" This provides both the client and counselor with more information about what was the most difficult part of the experience and often points to what needs further exploration. The benefits of telling and retelling the story are many:

• the sharing of feelings and fantasies prevents their repression and displacement into other symptoms;
•  in telling the story the client is able to impose a time sequence onto the event,
• and thus transform what are often sensory and episodic memories to the realm of processed thought and symbolism;
• in psychologically accompanying the client through the traumatic event, the therapist is able to demonstrate the ability to tolerate horrific or overwhelming aspects of the trauma, thus serving as a positive model to clients when the memory is evoked in the future;

• The detailed telling of the story encourages confronting rather than avoiding aversive stimuli and this serves to reduce anticipated anxiety associated with the stimulus.

2. Normalizing the symptoms

This comprises obtaining information about symptoms as well as anticipation of symptoms. The client's symptoms are discussed and empathized with, while at the same time providing education about post traumatic stress symptoms. Therapists make links between the traumatic event and symptoms experienced, as well as reassure clients of the normality of their experience. Reassuring clients that their responses are normal reactions to an abnormal event, as well as educating clients about what symptoms to expect, serves to both reduce the fear that they are going crazy, as well as to reduce the chances of a client suffering secondary traumatisation because of the fear of their reactions/symptoms.

3. Addressing survivor guilt or self-blame

In this phase, feelings of self blame or survivor guilt need to be explored. In many cases survivor guilt may not be present but in practically every case, there are feelings of self-blame. Self-blame may represent a wish to retrospectively "undo" the trauma and restore a sense of control. Self-blame may also relate to the belief that the person could have done more to prevent what happened. Survivor guilt may emerge when someone has died in a traumatic incident. Where clients present with guilt feelings or self-blame in the counseling situation, it is imperative that the counselor take the client through the events very carefully, while at the same time exploring alternative scenarios and how useful these would have been. During this process, clients usually discover that their guilt is irrational and that under the circumstances they did the best that they could. In cases where a client's actions did cause the situation, the counselor needs to help the client separate outcome from intent/motive.

Addressing survivor guilt or self-blame serves various functions:

§  it reassures the client that he/she did the best he/she could under the circumstances;

§  it helps restore self-esteem through affirming any thoughts, behaviors or strategies that were effective in the situation;

§   it reinforces the fact that the client's actions facilitated his/her survival;

§  it addresses concerns clients may have about how their actions affected others;

§  it explores irrational beliefs that may have developed.

4. Encouraging mastery

In this phase of the model the counselor assists the client to carry on with the tasks of daily living and to restore the client to previous levels of coping. One of the most important aspects of coping is adequate support; therefore the counselor encourages building and mobilizing existing support. Where necessary, clients are provided with various techniques to assist with coping. These include relaxation and stress/anxiety management skills, cognitive techniques such as thought stopping, distraction and time structuring, as well as systematic desensitization. In restoring the coping capacity of the client, anxiety is greatly reduced.

5. Facilitating creation of meaning

The final stage of the model is optional and only pursued if the client raises meaning issues. In assisting a client with establishing meaning out of a particular event, it requires the counselor to engage with the client's belief system, be this on a cultural, political, spiritual or existential level. Work in this area is designed to be respectful of the client's existing beliefs and experience, while at the same time assisting the client in deriving some meaning from the event in a way which engenders hope and some future perspective. In essence, this phase of the intervention model can be understood as enhancing the client's ability to understand him/herself as a survivor rather than a victim.

Hence, traditional approaches to treating emotional trauma include talk therapies, Cognitive-Behavioral Therapy (CBT) - intentionally changing one's thoughts and actions and systematic desensitization to reduce reactivity to a traumatic stressor. These approaches to healing trauma were developed without brain science information, and therefore have varying degrees of success.

Recent developments in the treatment of emotional trauma

Recent developments in the treatment of emotional trauma include new, effective forms of psychotherapy and somatic (body) therapies that were developed with new brain science information in mind. Although often intensely interpersonal, these therapies are also psychological and neurological in their focus and application. This group of therapies relies on innate instinctual resources, rather than medications, to bring about healing. They include:

Eye Movement Desensitization/Reprocessing

 (EMDR) was developed by psychologist, Francine Shapiro, after she noticed her own stress reactions diminishing when her eyes swept back and forth as she walked through a Park. It is conducted by licensed mental health professionals who have taken specific training in this complex approach. It combines elements of a range of therapeutic approaches with eye movements or other forms of rhythmical stimulation, such as hand taps or sounds. Theories as to why EMDR is effective are still evolving. Some speculate that the rapid unique therapeutic element of EMDR - the eye movements or other rhythmical stimulation - might help the brain access and process traumatic material.

EMDR has been most effective with single-incident trauma, but its uses continue to evolve in addressing longer histories of emotional or physical trauma, and in balancing other aspects of a person's life.

Somatic Psychotherapies The term somatic, coined by Tomas Hanna, means mind/body or more precisely brain/body. The idea is that to change the body, we have to engage the brain and change the brain - not only how we think and feel, but also the neurological connections themselves. The body, its sensations, and direct sensory experience are referenced throughout the therapeutic process. Somatic therapies include:

Somatic Experiencing: developed by Peter Levine, this approach evolved in part from observations of how animals literally "shake off" traumatic experiences, allowing the body to process stress chemicals completely until they return to normal levels.

Somatic experiencing is a short-term naturalistic approach to the resolution and healing of trauma. It employs the awareness of body sensation to help people renegotiate and heal their traumas rather than relive them. This website also has related articles and a practitioner directory.

The SE therapist may be a licensed professional or unlicensed but with some mental health training. All SE therapists complete an extensive training program, in which they learn to observe the body, facial expressions and gestures carefully and to help the person "thaw" a response that was "frozen" in a traumatic situation

Illustration: the person might be observed to make short gestures that almost appear to be a "pushing" motion, but that Stop abruptly - the therapist might have the person complete the gesture in full, and notice how the body's tension level changes).

Hakomi Method: originated by Ron Kurtz, this system is based on five therapeutic principles - Mindfulness, Organicity, Non-Violence, the Mind-Body Connection, and Unity. It is a body-centered approach for which, in part, the therapist helps the client experiment with small changes in gesture or other movements, to see what differences occur in the processing of emotionally charged content

Illustration: the person might be observed to always make a certain gesture or have a certain posture when talking about the attacker - the therapist might suggest the gesture or posture be changed to a different one as an experiment, and then to notice the changes in feelings or thoughts.

Somatic Psychology: developed by Pat Ogden, this treatment merges somatic therapies, neuroscience, attachment theory, and cognitive approaches, as well Hakomi Method. The approach often uses physical expression to process the energy stored in the body following a trauma, to reset the neurological system into better balance

Illustration: the person might be asked to push the attacker away by forcefully pushing against a wall or against a pillow held by the therapist, to allow the body's neurological and musculature systems to reset them to a more normal level).

AEDP (Accelerated Experiential Dynamic Psychotherapy): developed by Diana Fosha, New York based psychoanalyst, this approach brings the elements of secure attachment into her work with adults. The talk therapy she practices focuses on the mutual exchange of all deeply-seated emotions, bodily awareness and joyous playful exchange.

Conclusion:

Hundreds of clients have been counseled at the Trauma Clinic using the Wits Trauma model. Subjective reports from counselors and clients demonstrate the model's efficacy in alleviating symptomatology in most clients treated using this counseling model. However, the model has not been subjected to evaluative experimental research. All the other somatic models for treatment unaided are not viable; rather an integrative or eclectic approach is necessary for counseling the traumatized patients.