Practical Counseling Techniques for Victims of Trauma

For survivors of trauma, what are effective counseling techniques that are integrated with a Christian worldview? Find answers below in this article adapted from Counseling Techniques: A Comprehensive Resource for Christian Counselors (John C. Thomas, General Editor), from the book's chapter on trauma-focused treatment, written by Heather Davediuk Gingrich.

First, some background on the source: Counseling Techniques is a comprehensive reference for the broad spectrum of Christian counseling practitioners and students, presenting counseling techniques through three lenses:

1. Theory-based counseling, including cognitive, emotional, behavioral, and spiritual strategies, and more;
2. Constituent-based counseling, with a focus on children, teenagers, couples, and families;
3. Issue-based counseling, including domestic abuse, self-injury, sexual abuse, shame, trauma and more.

Counseling Techniques is an important book because whether you're a novice or experienced counselor, it's often difficult to find a single, trustworthy reference for applying strategy, intervention, or technique to therapeutic situations. Counseling Techniques meets that need for all types of counseling practitioners.

Trauma-focused Counseling Strategies

Why is trauma-focused counseling so important? Dr. Heather Davediuk Gingrich frames the issue: since "approximately six out of every ten men (60 percent) and five out of every ten women (50 percent) will experience at least one trauma in their lifetime" (466), Christian counselors in all roles and at all levels of experience need to equip themselves to offer help.

Counselors need to understand two categories of trauma:

The first includes victims of natural disasters, combat trauma, and single-incident trauma, which often result in a diagnosis of post-traumatic stress disorder (PTSD). The second encompasses chronic, relational trauma, such as child physical, sexual, psychological, or spiritual abuse or neglect and is referred to as complex trauma (CT). Complex trauma has a more complicated presentation . . . Recommended treatments for PTSD are primarily behavioral and cognitive behavioral techniques. Treatments for CT, on the other hand, are multifaceted because the focus needs to be broader than dealing solely with post-traumatic symptoms. (466-67)

Dr. Gingrich's chapter in Counseling Techniques primarily focuses on complex trauma (CT), and so does this article, though Gingrich's chapter does include some comments applicable to working with PTSD. Dr. Gingrich's chapter addresses the theology and psychology of trauma and specific strategies for care. She also offers practical insight for trauma treatment using a standard three-phase model of care for the treatment of individuals who have experienced complex trauma.

Below is a brief overview of the three-phase model of care for trauma survivors. This article won't give you all the wisdom or clinical knowledge in Gingrich's chapter, but it's  a quick reference to best practices for treating survivors of complex trauma.

Phase One: Safety and Symptom Stabilization

Given the length of commitment, not all complex trauma (CT) clients will be able to work through all three phases discussed here. However, "While the core issues will not be addressed if you only do phase one work with a counselee, increased symptom containment can help an individual function better, even if full healing does not take place" (471). Gingrich outlines several important aspects of this phase that will offer practical help.

Ensure safety within the therapeutic relationship

Complex trauma (CT) is relational trauma, usually at the hand of someone in a position of trust and involving a sense of betrayal. Therefore, "Not only is developing a sense of safety essential before trauma processing can begin, but the therapeutic relationship in and of itself can be the source of the greatest healing for CT survivors who have been harmed in the context of a relationship" (471).

Gingrich offers two primary strategies to develop this crucial sense of safety:

1. Developing rapport. "Specific techniques such as empathic reflection (i.e., reflecting content and feeling), using appropriate genuineness and self-disclosure, having a nonjudgmental attitude, and being emotionally present are essential" (471) for this therapeutic relationship. 
2. Being and remaining a safe person. "Building rapport helps a client to feel safe, but you must actually be a safe person and remain safe in order not to further damage a CTS [complex trauma survivor]. Specific strategies involve the following" (472):
   • Remember that every client is unique. "Just because something worked well for one client does not mean that it will necessarily work for another, even if they are both CT survivors" (472).
   • Know your limitations. You will benefit your client by seeking "appropriate training opportunities, read in the field, and get trauma-sensitive supervision. However, if you are in over your head despite seeking guidance, refer out to an expert" (472).
   • Warn of impending change. "Any change from the familiar will be potentially unsettling for a CTS because her abuse was often so unpredictable. Therefore, giving warning in advance of anything different is important" (472).
   • Keep appropriate boundaries. As increased intimacy develops "regularly check your own mental health through getting your own counseling, working on self-of-the counselor issues with a supervisor, or asking for feedback from mentors, friends, or family members who know you well" (472–473).
   • Keep confidentiality. "If the CTS feels as though you have broken confidentiality, the therapeutic relationship will be impaired or destroyed. Make sure that you clearly outline the limits of confidentiality in your informed consent statements" (473).

Safety from others

Gingrich advises not to assume your client is safe. "Therefore, assess for intimate partner violence," particularly since "CTSs may be so accustomed to severe abuse that they do not identify the emotional, sexual, or psychological abuse by a spouse or romantic partner as problematic" (473). While not even a counselor can keep another person safe, "if you are aware of the danger, you can work with the CT client to develop safety plans that can help to reduce the risk of harm" (473).

Safety from self and symptoms

"CTSs sometimes feel that they are at the mercy of their own self-destructive or suicidal impulses as well as their post-traumatic symptoms" (474). Often reexperiencing intrusive symptoms such as flashbacks or intense spikes of anxiety motivate a CTS to seek help. While behavioral interventions can help, Gingrich has found some lesser-known techniques to be valuable in helping clients find relief and safety. She considers both types of strategies in the remaining section.

Behavioral techniques

Chapter 6 of Counseling Techniques ("Behavioral Strategies") discusses many strategies that are applicable to survivors of any type of trauma. Those that fall under the heading "Exposure and response prevention (ERP) techniques" are of particular benefit. "The hallmark of the intrusive and hyperarousal post-traumatic symptoms is anxiety" (474). So she recommends such behavior techniques to desensitize trauma clients from their anxiety.

Exposure therapy, or prolonged exposure therapy

"The idea behind exposure therapy is to expose clients to situations that serve as trauma triggers, that is, expose them to environmental cues that can elicit a fear response that is associated with the trauma (Briere & Scott, 2013)" (474). However, although these techniques can be helpful as an adjunct to other strategies for CTS clients in particular, they "are not sufficient in themselves because post-traumatic symptoms are only one aspect of the total symptomatology for CTSs (Courtois & Ford, 2009)" (474).

Mindfulness

Although Christian counselors may hesitate to incorporate a practice associated with the Buddhist worldview, Gingrich makes clear that mindfulness as a therapy technique is not dependent on adherence to Buddhism. As she explains:

The application of mindfulness to CTSs is related to the overwhelmingly intense emotions of guilt, shame, anger, hatred, depression, and the like that are so commonly experienced . . . Being mindful of emotions means to be aware of them and examine them, but from an emotional distance, without judging whether they are right or wrong (Segal, Williams, & Teasdale, 2013) or, in biblical terms, sinful or not. (474–475)

Becoming mindful and aware of their emotions allows CTS clients to make choices as to what to do with them.

Strategies that make therapeutic use of dissociation

"Simply put, dissociation is compartmentalization, or disconnection among aspects of self and experience” (475). Since, "CTSs tend to dissociate more than individuals who do not have a history of CT . . . their increased ability to dissociate can be put to good use in therapy" (475).

She offers four strategies that may be helpful for CT clients:

• Use 'parts of self' language. Gingrich has found this language "fits their experience of themselves in that they often feel fragmented, as though there are different 'parts' that make up their sense of self and identity." (476).
• View symptoms as attempts at coping. While CTSs often interpret their symptoms as all bad, "If, however, symptoms are viewed as attempts at coping with the horror of their trauma, or as warning signals that something needs attention, the destructive power of the symptoms is greatly reduced" (476).
• Make contact with disassociated parts of self. "Counselors can facilitate such connections by helping CTSs to listen inside and pay attention to thoughts, internal voices, or impressions that could signal that a part of them is attempting to communicate" (477).
• Use ideomotor signaling. "Ideomotor signaling uses finger signals as a way to communicate with parts of self of which the CTS may not be aware. The technique originally comes from hypnotherapy, but because dissociative states have some similarities to hypnotic states, the technique works well with CTSs" (478).

Phase Two: Processing of Traumatic Memories

To move on from phase one to phase two, CTSs need to have developed good coping strategies that they can also use between memory processing sessions. "Indicators that it may be appropriate to begin phase two work are (a) when you sense that the client is able to ground herself both within and outside of sessions with minimal help from you, and (b) when the client is able to manage post-traumatic symptoms between sessions" (480).

Gingrich offers several strategies to help your clients process and manage particular traumatic memories.

Ask the client where to begin

Dissociated parts of the self often have information that can be helpful in making a wise decision about where to start the trauma processing. "Ideomotor signaling or another way of connecting with other parts of self can be helpful here. Some memories are obviously more difficult for a client to deal with than other memories" (480), such as sexual abuse at the hands of the client's father or mother.

Invite the part of the self that holds the memory to allow access to it

"Accessing dissociated memories is similar to asking for a key to a locked room; once the key is available, retrieving the traumatic material is a matter of opening the door behind which it has been hiding. Having CTSs verbalize what they are seeing/experiencing helps them develop a trauma narrative. This is necessary for the integration of the emotional material that is stored in the amygdala of the brain with the cognitive content that involves the hippocampus" (480).

Ask open questions

Gingrich highlights the difference between asking open questions ("What is happening now?") and closed questions ("Is it your uncle?"). It is important to ask open questions. She explains how she guided one client:

After we agreed to look at what was behind the incidents of Helen waking up terrified, I simply asked Helen to go “inside” and to tell me what was happening. She described startling awake and hearing the door to her bedroom open. I let her continue her narrative of seeing a dark figure enter her room and approach the bed until she paused, at which point I asked, "What’s happening now?" and she continued. (481)

Keep the CTS connected to the here-and-now

"There is no value in reexperiencing the trauma to this extent; it merely becomes retraumatizing. The goal is to allow for various dissociated components of the memory (i.e., cognitive, affective, physical sensation, and behavior) to become reintegrated by having the CTS reexperience all of the components, at least to a minimal degree, while verbalizing what is happening" (481).

Counselors facilitate this goal by creating space to help clients "have one foot in the past and one foot in the present while narrating what happened . . ." (481).

Grounding techniques

Counselors enable this process through grounding techniques, which is any sensory experience that helps CTSs keep them in the present. "Asking clients to listen to your voice, open their eyes and look at various things in the room, drink cold water, suck a sour candy, or rub bare feet on a carpet are all examples of helpful grounding techniques" (481). These techniques are vital both while processing trauma as well as at the end of a session so that the CTS can get home safely.

Pace the trauma processing

"There is nothing gained by overwhelming CTSs by pushing through with trauma processing despite indicators that the client is in distress. The concept of pacing is applicable to how frequently trauma processing is entered into as well as to the speed with which a particular incident is processed within a session" (482).

Process the emotions

"Intense affective work is an essential aspect of phase two. Grief and loss, anger, depression, guilt, shame, hatred, self-hatred, fear, and anxiety are all common emotions experienced by CTSs. Be prepared to help your clients face and get through such strong feelings" (482).

Christian clients in particular can experience a lot of guilt about some of these emotions. However, "Letting CTSs know that their emotional reactions are normal given what was done to them, and that God already knows what is there and loves them regardless can be very freeing" (482).

Phase Three: Consolidation and Resolution

The third phase in this model of care for survivors of complex trauma focuses on building on existing changes and helping clients integrate their lives. Often techniques used in this final phase are similar to what counselors would use with other clients. For this reason, Gingrich briefly outlines the areas of focus that are important in this phase.

First, CTSs need to develop new coping strategies. After the previous phases, CTSs are now aware of the details of their trauma and they need to cope differently. "No longer relying on dissociation as their primary defense mechanism…they can no longer as easily compartmentalize an overwhelming feeling" (483). 

Second, the relationships of CTSs will be impacted. "While there is the potential for some relationships to become healthier, others will not survive" (483). In order to grow, CTS clients need to grieve this and establish new, healthy relationships—often with the help of counselors.

Third, while the topic of forgiveness may have arisen earlier in counseling, here it often is primary. Gingrich sees the work of Sells and Hervey (2011) for sexual abuse survivors dealing with forgiveness as being applicable to CTSs more broadly. During this phase, questions about whether, how, and when to confront perpetrator(s) is often the focus.

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This article is not short, but it still just scratches the surface. Delve deeper in Counseling Techniques, which will equip therapists and students to help victims of trauma and other frequent clinical issues that arise in all forms of counseling.

A brief recap of what Counseling Techniques offers:

• a variety of the most effective and commonly-used techniques associated with (a) various client issues and diagnoses, (b) theoretical bases, and (c) client populations
• topics are addressed by a lineup of top-notch, experienced counselors whose approaches are deeply integrated with a Christian worldview
• an excellent balance of reliable clinical insight and readability

If you are involved in any sort of counseling profession, add this comprehensive resource to your library for guidance and reference during the course of your calling.

Article References

Briere, J. N., & Scott, C. (2013). Principles of trauma therapy: A guide to symptoms, evaluation, and treatment (2nd ed.). Los Angeles, CA: Sage.

Courtois, C. A., & Ford, J. D. (Eds.). (2009). Treating complex traumatic stress disorders: An evidence-based guide. New York, NY: Guilford Press.

Sells, J., & Hervey, E. G. (2011). Forgiveness in sexual abuse: Defining our identity in the journey toward wholeness. In A. J. Schmutzer (Ed.), The long journey home: Understanding and ministering to the sexually abused (pp. 169–185). Eugene, OR: Wipf and Stock.