Lynch, J.; Bicknell-Hentges, L.; Garrett-Wilson, S.; & Bibbs, T. (2019) Effective Communication with

Traumatized Individuals: Clinical and Supervision Strategies with Individuals, Couple, and Families.

Proposal submitted to the Annual Conference of the Illinois Counseling Association. Skokie, IL.

Effective Communication with Traumatized Individuals: Clinical and Supervision

Strategies with Individuals, Couple, and Families

Lynch, Bicknell-Hentges, Garrett-Wilson, Bibbs

Program Synopsis:

Counselors working with traumatized individuals are faced with the dilemma of revisiting past trauma

without overwhelming the client. Seasoned counselors will introduce (and demonstrate through clinical

cases) a model of treatment, which reduces the risk of decompensation, resistance, and premature

termination through the “therapeutic window” technique. In this model, counselors learn to assess and

control the client level of emotional stimulation. By integrating this information into an understanding

of the physiological impact of trauma on cognitive processing, participants will also learn best practices

for communicating with traumatized individuals and be able to teach those strategies to others. The

application of these strategies can reduce escalation and improve understanding in a variety of clinical,

relational, educational, and even occupational settings.

Program Goal –

This workshop will introduce a model of working with traumatized individuals within a therapeutic

window of emotional stimulation, which will provide the foundation for developing effective

communication strategies across a variety of clinical and relational settings.

Program Objectives

1. Understand and be able to apply the concept of the therapeutic window in the treatment of trauma

2. Learn how to read and manage the indicators of emotional stimulation in traumatized individuals.

3. Apply this understanding in developing and teaching effective communication strategies.

Part One : Understanding Trauma I. What is trauma and how do people respond to trauma? Trauma (definition) - “When we have encountered an out of control, frightening experience that has disconnected us from all sense of resourcefulness or safety or coping or love (Brach, https://trauma-recovery.ca/introduction/definition-of-trauma/) Examples of trauma –

• Caused naturally - (e.g., earthquake, epidemic)

• Accident/technological catastrophe – (e.g., building collapse, aircraft crash)

• Intentional acts – (e.g., homicide, acts of terrorism, sexual assault) A. Adaptive responses to trauma – Immediate response to stress (such as fight or flight followed by increased fear, anxiety, increased arousal, intrusive thoughts) then a gradual return to more normal reactivity as the experience gets reintegrated into other life experiences and memories. B. Pathological responses to trauma 1. Post traumatic stress disorder - Symptoms: Recurrent and intrusive distressing recollections of the event (repetitive play with trauma themes in young children); recurrent distressing dreams of the event (content may be frightening, but not recognizable in young children); acting or feeling as if the traumatic event were recurring (e.g., sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes); persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness; persistent symptoms of increased arousal; clinically significant distress or impairment in social, occupational, or other important areas of functioning 2. Dissociative disorders 3. Addictive behaviors (substance abuse; compulsive eating, gambling,

shopping, sexual activity) 4. Externalizing behaviors (rage; sexual acting out) 5. Depression – suicidal ideation, cutting or other self-harming behavior 6. Engagement in high-risk behaviors or revictimization (physical fights;

Sexual promiscuity/prostitution/exotic-dancing/unprotected-sex; domestic violence; drinking and driving)

Part Two: Neurobiology of Trauma

I. Autonomic Nervous System (ANS) A. Sympathetic Nervous System (SNS) is adaptive and designed to protect the

body when there is a perception of threat to survival or body integrity 1. Capacity to respond to a life threat is instinctual, inherited, and

common to all species – it is instantaneous and unconscious (Scaer, 2005)

2. SNS activates the fight or flight response when threats are perceived Fight or Flight (or Freeze) through the HPA axis- The hypothalamic

pituitary adrenal (HPA) axis is our central stress response system. ... The

HPA axis is responsible for the neuroendocrine adaptation component of

the stress response.

Hyperarousal – Hypervigilance; blood vessels constrict; heart and

breathing rate increase; increase in perspiration; pupils constrict;

increase of blood flow to the extremities; decrease of blood flow to

the digestive system; adrenalin and cortisol hormone levels increase

dramatically (prepares the body to fight or run from danger)

a. Freeze (when can’t overcome and can‘t flee)– Dissociation: Disengaged, numbing (sometimes fainting); suspension of time and derealization (prepares the body for camouflage or increase survival through compliance or dying will not be as painful if the prey does not walk away)

3. Stress response is vital for our survival, too much has deleterious effects on many aspects of our physiology

4. The brain cannot tell the difference between physical pain and emotional pain or real threats and perceived threats– both trigger the autonomic response

5. Individuals who perceived danger in their environments will elicit an constant autonomic response of alertness – The range of activation can go from a state of vigilance to terror depending on prior memories and experiences

B. Parasympathetic Nervous System (PNS) maintains normal physiological activity when not under stress

1. When stimulated – heart and breathing rate decrease; blood flow to digestive system increases; blood flow to the extremities decreases

2. Puts the “brake” on the SNS.

The Limbic System - The “Emotional” Brain

II. Effects of Chronic Stress

A. Cortical Modulation – Cortex = Thinking Brain Limbic System = Emotional Brain 1. As the brain grows and organizes, the higher more complex areas (Cortex or

Thinking Brain) begin to control the more reactive and primitive functioning of the lower parts of the brain (Limbic System or Emotional Brain) in a normal individual

2. The Brain’s impulse-mediating capacity is related to the ratio of excitatory activity of the lower, more primitive portions of the brain and the modulating activity of higher, subcortical and cortical areas

The body and nervous system react to trauma in a manner that is designed to ultimately protect us and

help us cope.

• Under times of extreme stress, we automatically and without thinking, initiate a fight or flight

or freeze response. We prepare to defend ourselves, run away, or freeze like a deer while our

body is flooded with cortisol and the body's natural opioids. This is of perfect design and

provides the best ways to protect ourselves.

The emotional brain encodes these stimuli so that whenever any similar experience is detected, it is

primed to re-engage in the fight-flight-freeze response. This is an adaptive response designed for

survival – but it can be extremely disruptive when the present situation is not actually life threatening.

Without treatment, some people have great difficulty managing their response to these situations

that evoke this response. The emotional stimulation in these situations tends to reduce the ability of

the cortex to differentiate the response to the original fire and the stimuli from other situations, such

as the smell of smoke from a family cookout or the feeling of being trapped in a crowded event.

Part Three: Effects of Chronic (repeated) Trauma

A. States develop into traits 1. Persistent activation of the neurophysiology of threat will reset the

homeostasis of the organism 2. Persistent hyperarousal will alter the HPA axis system of the Sympathetic

Nervous System 3. Persistent dissociation will alter the opioid (endorphins – the body’s natural

morphine) and dopaminergic (neurotransmitter involved in ADHD, schizophrenia, Parkinson’, reality testing, etc.) system

B. Trauma often changes people Because of our natural tendency to protect ourselves, exposure to trauma often changes people:

• their emotional response,

• identity,

• thinking,

• beliefs, and

• even their nervous system.

Examples - After trauma, we can pay much more attention to our surroundings and other

people, looking for any signs that there might be danger. Traumatic events can alter our beliefs

and identity. We may change from thinking that people are safe to thinking people are

dangerous. We can shift from believing that we are confident and strong to seeing ourselves as

weak, vulnerable, and helpless. We can lose our spiritual faith that something powerful and

good rules this universe.

Body’s highly sensitive natural protective response - “People who have been through trauma are often

confused and overwhelmed with emotions” (2019, Armstrong, Courtney). The body's highly sensitive

natural protective response can have them escalating quickly into hyperarousal with emotions such as

fear or anger. Or in contrast, they may fall into hypoaroused states leaving them numb, disengaged,

immobilized, or dissociated.

Maladaptive coping strategies - It is also common that people may develop maladaptive coping in

attempts to manage their level of stimulation and emotional responses. These can include behaviors

ranging from abuse of drugs and alcohol, binge eating, compulsive spending or gambling, isolation, or

even workaholic behaviors.

Self-judgment - These responses are worsened because individuals typically judge themselves harshly

for these responses. For instance, I might be traumatized and experiencing unmanageable anxiety and

depression. Then I judge myself and feel self-blame for having those feelings.

Clients need to learn that their emotions serve and important purposes as they attempt to meet

survival needs: (These responses actually mean the brain is working properly.

Emotion Action Request Need

Fear Run Away! Avoid! Safety

Anger Stop! Get out of my way! Protection/boundaries

Sadness Withdraw, rest, take stock Healing/respite/care

Disgust Hide, cover up Social approval

Panic/Grief Call the loved one home Care/connection/belonging

*Lara Fielding (2015) as modified by Courtney Armstrong (2019)

Part Four: Treating Trauma I. Hope in Treating Trauma So where is the hope for the self-punishing vicious cycle? There are now many recognized evidence-

based treatments for trauma such as Mindfulness, Meditation, Eye Movement Desensitization and

Reprocessing (EMDR), Prolonged Exposure, Cognitive Processing, and many others. But other research

is showing us that the most important variable in effective therapy is a strong therapeutic relationship

– no matter what treatment model is used. Healing must occur in the context of a relationship.

John Briere (1989, 1996) extensively studied complex trauma and its treatment – noting that how trauma is individually and uniquely processed impacts the result of retelling traumatic experiences II. Levels of trauma processing in therapeutic interventions (An adaptation of Briere’s model) A. Level One – Clinical indicators – flat affect, appears numb, no facial expression, calm voice tone, words and nonverbals do not match in intensity, sounds like a weather report B. Level Two – Clinical indicators – verbal and nonverbal demonstration of appropriate overwhelmed C. Level Three – Clinical indicators – crying uncontrollably; gasping for breath; displays younger or regressed behaviors such as rocking, fetal position, sucking thumb; dissociates; increase in additive behaviors after session; premature termination and other signs of resistance; increased risk of false memories since client is in highly suggestible state during sessions III. The therapeutic window – A. Clients will only experience improvement when counseling stays out of Level Three (too much stimulation, overwhelms the client), yet moves above Level One (has little impact on the trauma symptoms). B. Counselors must assume responsibility for protecting PTSD clients from re-traumatization during treatment (They should check for out-of-session behaviors, such as an increase in symptoms or addictive responses, to indicate the client is becoming overwhelmed) C. Goals 1. Help poorly defended clients develop more adequate coping strategies prior to asking them to re-experience the trauma in sessions (Use relaxation training, stress reduction exercises, cognitive modulation of affect – “This is now. I am safe and protected. I am now in control and will protect myself.) 2. Assure that counseling spends little time in Level Three until counselee can adequately modulate affective response 3. Watch for signs that client has moved out of the therapeutic window a. Increase the intensity when in Level One (Ask affect questions. Ask for specific details of the trauma. Ask client to describe the trauma step-by step. Ask for visual, kinesthetic, auditory, etc. memories of the event. Ask about fears. Ask what happened to their body.)

b. Decrease the intensity when in Level Three (Ask content questions not specifically related to trauma. Use voice tone to calm. Stop the client from talking and anchor them to the present. Repeat and rephrase what the client has just said. Get client to open eyes and described the current setting. Use relaxation and breathing techniques in session. Ask the client to talk about what they had for breakfast or other events in the present not related to the trauma.)

Levels of trauma processing in therapeutic interventions

Level One - Traumatic experienced retold on simply cognitive level - Detachment from emotional impact of trauma - Flat affect, no or inappropriate facial expressions - Calm voice tone - Words and nonverbal do not match in intensity - Sounds like a weather report

Level Two - Traumatic experience retold while expressing affect - Intensity below the initial traumatic experience - Intensity below level which initiates pathological coping - Verbal and nonverbal demonstration of appropriate emotions - Obvious expression of adequately modulated tears, anger,

and/or fear - A sense that the person is feeling yet not overwhelmed

Level Three - Traumatic experience retold while displaying intense, unmodulated affective response

- Results in preferred pathological coping response that individual has relied upon to deal with the trauma

- Uncontrollable crying, gasping for breath; displays younger or regressed behaviors such as rocking, fetal position, sucking thumb; dissociation;

- increase in addictive behaviors after session; - premature termination and other signs of resistance; - increased risk of false memories since client is in highly

suggestible state during sessions) ( - Personal indicators for counselors – counselor feels very

emotionally stimulated; drained after sessions; symptoms of vicarious traumatization; counselor wants to avoid content or client session

- Essentially in Level Three, the client is being re-traumatized during

the session - Symptoms worsen instead of improve

Regulating Intensity Increase Anchor in trauma

- Ask affect questions - Ask for specific details of trauma, step-by-step - Ask for sensory (visual, kinesthetic, auditory, olfactory) memories of

the event - Ask about their fears - Ask what happened to their body

Decrease Anchor in the present

- Ask content questions not related to trauma - Use calming voice tone - Stop client from talking and anchor in the present - Repeat and rephrase what the client has just said - Get client to open eyes and describe the current setting - Use relaxation and breathing techniques in the session - Ask the client about activities before and after present session or other

events not related to the trauma

– Treating trauma is a very fluid process. Counselors need to be extremely active, vigilant, and directive in managing the degree of client emotional stimulation. Counselors must keep the process within the therapeutic window. If, initially the client moves immediately from Level One to Level Three, the counselor must improve coping and only briefly touch traumatic material without overwhelming the client. The process is parallel to the use of systematic desensitization in the treatment of other anxiety disorders (e.g., simple phobias, agoraphobia, panic disorder).

An important step in the healing process - to stop judging themselves and develop self-

compassion

A question to ask would be - “What would happen if you stopped judging yourself for being so ____?”

(angry, depressed, anxious, insecure, controlling, etc.)

Instead offer self-care. Recognize that life like an ocean has waves. If we remember we are in an ocean

then we will not fear the emotional waves. We can recognize them and notice them, but not berate

ourselves for having these responses. We just notice them and have compassion for ourselves.

• After the immediate threat is over, the emotional brain has remembered these events and

responses in implicit memory that has four components – emotional, perceptual, physical, and

procedural actions taken. For instance, in the case of being escaping a dangerous fire, the

implicit memories would include:

o the emotions of fear;

o the perception of the sounds, smells, heat, and sights of the flames;

o the physical experience of difficulty breathing and being trapped by the flames;

o and actions involved in the attempts to scream and escape the danger.

1) to develop adaptive coping strategies to help regulate emotions (and stimulate the

parasympathetic nervous system. Healing occurs with parasympathetic nervous system

stimulation) – there are many different adaptive coping strategies – including mindfulness and

other contemplative practices. Grounding (connecting your body with a supportive surface,

focusing on stimuli currently present) and Breathing exercises. Music, dance, exercise and

moving meditations can be useful. Developing a support community – relationships are healing.

Journaling Practicing gratitude.

2) With adequate coping strategies and in the context of a strong therapeutic relationship,

individuals can revisit their trauma. First it is important to visualize the desired future self -

the “best possible self”

“Let's imagine someone who has been through something very similar to you. Not anybody you

know, just a person we make up who would be similar in age, background, and has gone through a

similar experience. She would understand exactly how you feel. What would you want for her

future? What would you say to her? What would you want her to be feeling, thinking, and doing so

she can be functioning in the most optimal way?”

There is power within every individual to heal – There is a life force that has sustained them, and is

continuing to help them heal – an internal energy that compels them to grow and thrive.

With a revised view of themselves and their responses along with new coping strategies, a

person can revisit the trauma from a new empowered perspective - not as re-experiencing and

being re-traumatized but as viewing the incident on a small screen with them in charge of the

experience and from a current perspective. The narrative can be changed and the memory in

the implicit memories in the emotional brain can be reconsolidated. In this process the

memory is retrieved from long term memory and updated with new information so that the

meaning of the event and what one believes about themselves will be changed. Negative beliefs

attached to the experience are replaced with new desired beliefs. It gives new meaning to the

experience.

A critical part of this process is to not stop the narrative at the point of the traumatic memory,

but to move past that to how she has survived the trauma. This process literally changes the

neural networks in the brain and reverse the brain changes resulting from the earlier trauma.

Post Traumatic Growth - Through building trust and hope in oneself, trauma itself can even create the

opportunity for new growth and renewal. Post-Traumatic Growth is the term for the positive impact

that trauma can have on people.

Part Five – Communication Strategies

A. Learn to recognize when an individual is functioning from an overstimulated Emotional Brain

B. Understand that this person cannot access the Thinking Brain until they have calmed down – It is like

trying to reason with a lizard.

C. Initiate calming and grounding strategies:

adaptive coping strategies to help regulate emotions – there are many different adaptive

coping strategies – including mindfulness and other contemplative practices. Grounding

techniques (connecting your body with a supportive surface, focusing on stimuli currently

present) and Breathing exercises. Music, dance, exercise and moving meditations can be useful.

Developing a support community – relationships are healing. Journaling Practicing gratitude.

D. Use a calm and soothing voice.

E. Wait until the individual is grounded to try to use reasoning and logic. It may have to wait until

another day.

F. Teach these strategies to parents, partners, teachers, etc. in relationships with traumatized

individuals. Conflict between two emotional brains only leads to escalation and crisis. They must learn

to read each other and give the space needed for calming. Each person in the interaction must practice

the calming at the same time.

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Presenters

John Lynch, Associate Professor (jlynch20@csu.edu 773-995-2098)

Lindsay Bicknell-Hentges, Chairperson and Professor (lbicknel@csu.edu 773-995-2210)

Shirlyn Garrett-Wilson, Assistant Professor and Director, Counseling Graduate Program

(sgarre20@csu.edu 773-995-3775)

Tracy Bibbs, Counseling Graduate Program Coordinator (tbibbs 773-821-2807)

Chicago State University, Department of Psychology, Counseling Graduate Program (773-995-2359)