A Practical Approach to Trauma: Empowering Interventions
Publication Year: 2007
Subject: Trauma, Violence & Abuse
A Practical Approach to Trauma: Empowering Interventions provides trauma counselors with effective guidelines that enhance skills and improve expertise in conducting empowering therapeutic interventions. Taking a practitioner’s perspective, author Priscilla Dass-Brailsford focuses on practical application and skill building in an effort to understand the impact of extreme stress and violence on the human psyche. She provides trauma counselors with effective guidelines that enhance skills and improve expertise in conducting empowering therapeutic interventions.
- Front Matter
- Back Matter
- Subject Index
- Chapter 1: Overview of Trauma
- Historical Overview
- Intergenerational and Multigenerational Trauma
- The Native American Genocide
- The Japanese American Internment
- Vietnam: A Special War
- Resources for Further Understanding
- Films on Native Americans
- Films on Slavery
- Films on the Japanese Internment
- Chapter 2: Assessment of PTSD, ASD, and DESNOS
- Assessment Challenges
- Factors That Influence Recovery from Trauma
- Common Responses to Traumatic Exposure
- Effect of Trauma on the Brain and Body
- Relationship between PTSD and ASD
- Complex Trauma
- Substance Abuse and Trauma
- Triggers and Retriggering: A Case Example
- Chapter 3: Models of Trauma Treatment
- Therapeutic Approaches
- Brief Psychodynamic Psychotherapy
- Cognitive-Behavioral Therapy
- Eye Movement Desensitization and Reprocessing
- A Stage-Specific Model
- A Self-Trauma Model
- Safety and Support
- Therapeutic Feedback
- Working Through
- A Stage-Oriented Treatment Model
- Early Stage Treatment
- Middle Stage Treatment
- Late Stage Treatment
- Determining Which Approach to Use
- Chapter 4: Empowering Interventions
- Empowerment as a Construct
- Important Principles of an Empowering Intervention
- Constructivist Perspective
- Ecological Perspective
- Needs-Based Perspective
- Multicultural Perspective
- Normalization Perspective
- Solution-Focused Perspective
- Strengths-Based Perspective
- An Empowering Model of Individual Intervention
- Initial Cognitive Phase
- Affective Processing
- Final Cognitive Phase
- Self-Care Techniques
- Chapter 5: Crisis Interventions
- Background on Crisis
- Why Crisis Work?
- Crisis Intervention Guidelines
- Multicultural Competence
- Factors Affecting Long-Term Recovery
- Crisis Phases
- Acute Phase
- Outward Adjustment Phase
- Integration Phase
- Models of Crisis Assessment and Intervention
- Gilliland's Six-Step Model
- Triage Assessment System
- Seven-Stage Model of Crisis Intervention
- An Empowering Model of Crisis Intervention
- Referral and Resource List
- Helping Children and Adolescents
- Suicide Assessment Issues
- Risk Factors
- Determining Suicidal Intent
- How to Help
- Outpatient Issues
- Working with Survivors of Suicide
- Resources for Further Understanding
- Chapter 6: Group Psychotherapy for Trauma Survivors
- Benefits of a Group Modality
- Models of Group Intervention
- Support Groups
- Interactive Psycho-Educational Groups
- Psychodynamic Trauma Groups
- Cognitive-Behavioral Groups
- Cultural Groups
- Group Therapy for Children and Adolescents
- A CBT Group with Adolescent Survivors of Sexual Assault
- Screening of Group Members
- Group Design and Content
- Sample of a Six-Session Group
- Chapter 7: Community Trauma and Working in the Schools
- Types of Community Trauma
- Community Reactions to Trauma
- Cultural Considerations in Community Responses
- Important Principles in Community Trauma
- Community Interventions after Trauma
- Guidelines for Conducting Community Meetings
- Structure of Meeting
- Working with Large Groups in a School Setting
- Planning Ahead in Schools
- Construction of Crisis Protocols
- Dealing with Parents
- Chapter 8: Traumatic Stress Debriefing With Adults
- Types of Traumatizing Situations in a Community
- Background on Debriefings
- Models of Debriefing
- The Debriefing Debate
- Community Trauma Debriefing
- Pre-Intervention Consultation
- Training Debriefers
- Psycho-Education and Self-Care
- Mechanics of Conducting a Community Trauma Debriefing
- Pre-Meeting Preparation
- Introducing the Debriefing
- Getting to the Facts and Thoughts
- Discussing Affective Reactions
- Psycho-Education: Reviewing Reactions
- Strategies for Self-Care
- Wrapping up the Debriefing
- Chapter 9: Children and Adolescents
- Background and Research Findings
- Effects of Chronic Stress
- Adolescent Responses to Trauma
- Children's Responses to Trauma
- Preschool (Ages 2–6)
- Early Childhood (Ages 6–10)
- Pre-Adolescence (Ages 11–14)
- Adolescence (Ages 15–18)
- Clinical Considerations and Guidelines for Helping
- Early Childhood
- Sexually Abused Children
- Chapter 10: Treating Interpersonal Violence
- Sociocultural Constructions of Rape
- Treatment Options for Rape Survivors
- Cognitive-Behavioral Therapy for Rape Survivors
- Rape Prevention Education
- Self-Defense and Resistance Training
- Social Organizing and Commonality
- Domestic Violence
- Intervention with Survivors of Domestic Violence
- Safety Planning
- Additional Resources for Battered Women
- Children Who Witness Domestic Violence
- Parental Stress
- An Ecological Approach to Helping Children Who Witness Violence
- Parents and Caregivers
- Schools and Teachers
- Programs for Men Who Batter
- Chapter 11: Treating Political Refugees
- Background and Research Evidence
- Common Reactions among Refugees
- Assessment Considerations
- Neurological Functioning and Traumatic Brain Injury
- Special Therapeutic Factors in Counseling Refugees
- An Ecological Approach
- The Role of Family
- The Role of Interpreters
- The Client as Authority
- Therapeutic Trust and Unconditional Acceptance
- Interventions with Political Refugees
- Refugee Treatment Centers
- Oregon Indochinese Psychiatric Program
- Additional Resources for Refugees
- Chapter 12: Terrorism
- Short-Term Reactions to Terrorism
- Steps in Crisis Intervention
- The Media: A Mixed Blessing
- Coping with Death
- Individual Counseling
- Family Therapy
- Community Responses
- National and International Responses
- Chapter 13: Natural Disasters
- Ecological and Cultural Considerations in Disaster Response
- Some Common Responses to Disasters
- Addressing the Psychological Needs of Survivors
- Disaster Counseling in the Acute Phase
- The First Step
- Providing Facts
- Focusing on the Here and Now
- Empathetic Understanding
- The Elderly
- Specific Disaster Interventions
- Crisis Intervention
- The Challenges of Disaster Mental Health
- Self-Care for Disaster Responders
- Additional Disaster Resources: Federal Government Organizations
- National Organizations
- Professional Organizations
- State and Local Government Agencies
- Chapter 14: Helping the Helper: Secondary Trauma
- A Matter of Definitions
- Supervision as a Self-Care Strategy
- How to Conduct a Secondary Trauma Workshop
- Introduction and Guidelines
- Getting Everyone on the Same Page
- Identifying Red Flags
- Common Response to Trauma
- Supportive Organizational Strategies
This book is dedicated to my dear husband, partner, and best friend, Keith W. Brailsford. His unconditional love, support, and encouragement empowered me to complete this daunting project.
Copyright © 2007 by Sage Publications, Inc.
All rights reserved. No part of this book may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher.
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Library of Congress Cataloging-in-Publication Data
A practical approach to trauma: Empowering interventions/Priscilla Dass-Brailsford.p. cm.
Includes bibliographical references and index.
ISBN-13: 978-1-4129-1637-0 (cloth)
ISBN-13: 978-1-4129-1638-7 (pbk.)
1. Psychic trauma. 2. Post-traumatic stress disorder. I. Title.
This book is printed on acid-free paper.
07 08 09 10 11 10 9 8 7 6 5 4 3 2 1
Acquiring Editor: Kassie Graves
Editorial Assistant: Veronica Novak
Production Editor: Beth A. Bernstein
Copy Editor: Diana Breti
Typesetter: C&M Digitals (P) Ltd.
Indexer: Sylvia Coates
Cover Designer: Candice Harman
Society, with unmitigated cruelty, has made the Negro's color anathema; every Negro child suffers a traumatic emotional burden when he encounters the reality of his black skin.—Martin Luther King, Jr. (1967)
The quote from Dr. King brings to life the cruel and harsh reality of the times in which he lived. Emotional trauma has affected the human experience since ancient times. The trauma counseling field exploded after the terrorist attacks of September 11, 2001. As a result, much attention has been devoted to understanding both adaptive and pathological responses to traumatic events. These efforts have generated important clinical advances in both counselor training and professional development programs.
This book captures the information I enjoy sharing with graduate counseling students as well as other professionals and colleagues in the field. In each chapter, I have compiled information based on intervention skills and strategies I have found useful in my work as a psychotherapist in many community and mental health settings. As a practicing counselor, I have used these concepts and skills in several work settings. The empowering model of intervention can be adapted to many situations, and its techniques can be generalized to serve the needs of diverse individuals and communities affected by trauma.
Although written for the beginning counselor, the material included is applicable to a broader audience. It can be used by counselors and para-professionals working in mental health agencies or by students taking a college course. When presenting workshops and seminars both nationally and internationally over the past 10 years, I have been struck by three things: First, the growing enthusiasm among counselors to become involved in [Page xiv]trauma work. Second, the strong desire of mental health professionals to learn how to conduct effective trauma therapy. Third, the misconceptions that trauma treatment involves an immediate disclosure of trauma details, that all trauma survivors initially present with trauma disorders, and that trauma therapy is vastly different from general psychotherapy. I believe this book will dispel these myths.
To present the material in an engaging format, I have chosen to include case vignettes and clinical material from clients I have encountered in my clinical practice. The case examples illustrate typical client presentations and help clarify diagnoses and different treatment interventions. Pseudonyms have been used to maintain confidentiality; identifying information has been changed to maintain the privacy of the special people I have worked with over the years.
The primary objectives of the book are to provide both a historical overview and theoretical perspectives on trauma; to review symptoms and the clinical picture; and to introduce treatment approaches that provide a stage-appropriate, culture-based paradigm that can be integrated into existing therapeutic orientations. This perspective comes from my belief that psychological and behavioral adaptations to trauma are expressions of pain and efforts to cope with unacceptable environmental demands or stressors. These adaptations are, therefore, not necessarily pathological and are often grounded in cultural systems of meaning-making. It is the counselor's responsibility to locate and use the strength and resilience inherent within individuals, families, and communities and to empower them toward healing and recovery. It is my hope that an understanding of this field will sharpen practice with both traumatized and nontraumatized people and will heighten understanding of the impact of extreme stress and violence while developing a self-reflective stance toward conceptual, ethical, and clinical approaches to trauma.
The book begins with an overview of the trauma field, focusing on intergenerational trauma among several neglected ethnic minority groups in the United States (Native Americans, African Americans, and Japanese Americans). Those readers who want to learn more about the struggles faced by these groups may find the resources offered at the end of Chapter 1 useful. The chapters that follow look at the diagnosis of trauma (Chapter 2) and the different approaches in trauma intervention (Chapter 3). Chapter 4, “Empowering Interventions,” describes the model I currently use in my own clinical practice. Although the therapeutic relationship assigns a level of power to the therapist, this chapter is not about the therapeutic power but the power inherent in all clients to change their lives and heal themselves.[Page xv]
An integral role of the therapist is identifying clients’ strengths, seeing their promise, and highlighting their power so that they can become independent keepers of their destiny. There is a significant overlap between trauma work and crisis work. Trauma therapists should be familiar with the principles of crisis intervention. Chapter 5 provides this information. Chapter 6 addresses group therapy, which is often used in trauma work either as a stand-alone or adjunctive modality. Trauma interventions with communities are inevitable when one works within an ecological model. Chapter 7 outlines the foundations of community intervention and describes how to conduct a community meeting. The efficacy of debriefing as a form of crisis intervention has been hotly debated in recent years. Chapter 8 reviews the background on debriefing, describes the various debriefing models, and introduces the community debriefing model that supports community empowerment.
In Chapter 9, the focus of the book turns to special populations and situations of trauma, beginning with children and adolescents; Chapter 10 addresses the interpersonal violence of rape and domestic violence as it specifically affects women and children. The chapters that follow look at those affected by political trauma, terrorism, and natural disasters. The book ends with an exploration of secondary trauma in Chapter 14, titled “Helping the Helper.”
I hope that this book holds your attention, adequately addresses your major questions, and enhances your ability to recognize, diagnose, and empower individuals, groups, and communities affected by traumatic events.
Acknowledgments[Page xvi][Page xvii]
This book would not have been possible without the courage of the many individuals and communities who have touched my life. I remain in awe of their resiliency, courage, and strength. I have been honored to bear witness to their pain as I have listened to their stories of survival in the intimate process of psychotherapy. In addition, a number of experienced, skilled, and devoted clinicians whom I have met in various mental health settings over the years helped inform my trauma practice. My family members cannot be thanked enough for their tremendous emotional support and encouragement: my husband for his undying cheerleading and my son and daughter for their stalwart belief that I could achieve whatever I set out to do.
Special thanks are due to Arthur Pomponio, who worked at Sage, for his acceptance of my initial proposal and his foresight that this book was timely (in the aftermath of September 11, 2001). He passed the baton of support to Kassie Graves, my editor at Sage, who, in her gentle way, has been supportive and critical at the same time. Her guidance and feedback is subtly evident in many aspects of this book. My heartfelt gratitude goes to her. Thanks, Kassie! Veronica Novak at Sage also helped in a multitude of ways. I thank her for her support. My sincere appreciation to production editor Beth Bernstein and copy editor Diana Breti, who both worked tirelessly and graciously to meet important deadlines. I would also like to acknowledge Lesley University for the time provided, through faculty development grants, to work on this book project. I have been able to put this precious time away from teaching to good use. My research assistant, Kimberly Cadden, was with me from the very beginning of this project. She always worked diligently and enthusiastically. Her commitment to the trauma field is evident in the quality of her work. I cannot thank her enough for her help and support. Susannah Buzard and Vanessa Brailsford helped with copyediting. Thank you both so much for doing stellar work under the severe time pressure I placed [Page xviii]on both of you. My sincere gratitude to the independent reviewers assigned by Sage for their constructive and critical feedback that helped sharpen the focus of this book.
Finally, my cat Speedy has stood unwaveringly by my side. He was often my morning wake-up call; his gentle nudge and purring was a reminder that it was time to write again. Late at night, he was still by my side, warming me and my laptop and serving as a steady source of both comfort and distraction.
Appendix I. Common Reactions to Trauma[Page 313]Physical Responses
Change in appetite Increased heart rate Change in sleep patterns Muscle tension Chest palpitations Nightmares/Night terrors Dizziness Shallow, rapid breathing Fatigue Stomach upset Headaches Sweating/rapid pulsePsychological/Emotional Responses
Anger toward others involved Feeling helpless/hopeless Anger/rage Feeling powerless/worthless Depression Feeling unsafe/vulnerable Emotional rollercoaster Guilt/Frustration Fear Loneliness Fear of ongoing victimization Sadness Fearing what others think Shock or numbnessCognitive Responses Confusion Intrusive images Difficulty concentrating Role-playing the event Difficulty making decisions Slowed thinking Difficulty remembering Thinking the world is unsafe Distorted thoughts Thoughts about dying Flashbacks Too many thoughts at onceBehavioral Responses Alienation from family/friends Doubts about relationships Angry outbursts False generalizations about others Changes in sexual activity Fear of being alone Clinging to people Inability to perform easy tasks Conflict in relationship Increased use of alcohol or medication Critical of others Irritability Crying Sense of aloneness Decreased energy Strong reactions to small change Difficulty trusting Withdrawal from others Disruption of daily routineSpiritual Responses
Despair Sense of the world being changed Feeling life is meaningless Spiritual doubts Loss of faith Withdrawal from church or community Questioning old beliefs
Appendix II. Coping with Trauma
- Care for yourself by eating well, exercising, and resting when necessary.
- Avoid stimulants such as caffeine, chocolate, and nicotine and depressants such as alcohol.
- Seek comfortable, familiar surroundings and avoid spending too much time alone.
- Share thoughts and feelings with those who are supportive and helpful—don't try to block recollections. It helps to talk. Feel free to set boundaries with people who have not been helpful in the past.
- Don't be anxious if reactions from past traumas re-emerge even though you felt those issues were resolved.
- Give yourself time to recover. Difficulties with concentration, memory, or decision-making are common; they are usually short-term reactions.
- Seek help if reactions are interfering with job responsibilities. Focus on concrete and achievable tasks.
- Remember that difficulty sleeping, nightmares, flashbacks, and hyper-alertness are common reactions and will diminish with time.
- Avoid personalizing or taking responsibility for how others respond to the traumatic event. Do not compare or measure your reactions to those of other people—each individual's experience is unique and personal.
- Communicate your feelings clearly. Others may not know how to respond to you appropriately. Let them know which responses are helpful and which are not.
- Know that anniversary dates or a specific holiday may trigger feelings related to the trauma.
- Seek help from a professional counselor if reactions persist.
Appendix III. Coping with Grief and Loss[Page 317]
Grief occurs in response to the loss of a loved one, a job, or a role (e.g., retirement, child leaves for college). It can be sudden or expected. However, each individual's experience of loss is unique. Grieving is a natural healing process. For most people, grieving proceeds through several stages, as outlined below. These stages are not hierarchical, and individuals may find themselves cycling through earlier stages as they attempt to come to terms with their loss.
Acknowledging and understanding grief reactions promotes the healing process and helps affected individuals know when to get additional support. Individuals respond to loss in many ways; some are healthy coping mechanisms and others hinder the grieving process.Stages of GriefDenial, Numbness, and Shock
- Denial protects the individual from experiencing the intensity of the loss.
- Numbness to experience is a normal reaction to loss and should not be viewed as a lack of care.
- Emotional paralysis causes the mind to exclude painful feelings of loss.
- Denial and disbelief will diminish as the individual slowly acknowledges the impact of loss and accompanying feelings.
- Individuals may ruminate about what they could have done to prevent the loss.
- Individuals may become preoccupied with the ways things could have been; they imagine all the things that will never happen.
- If not properly resolved, intense feelings of remorse or guilt may hinder the healing process.
- Once individuals realize the extent of their loss, they may experience depressive symptoms.
- Disturbances in sleep and appetite, lack of energy and concentration, and frequent crying and tearfulness are typical symptoms of this stage.
- Feelings of loneliness, emptiness, isolation, and self-pity may become prevalent.
- For some individuals, this phase must be experienced before they can begin reorganizing their lives.
- Feelings of anger surface when individuals feel helpless and powerless.
- Anger may also result from feelings of abandonment because of the loss.
- Feelings of resentment toward a higher power for the injustice of loss may surface.
- Once an individual acknowledges anger, feelings of guilt may surface.
- All feelings are natural and should be acknowledged and honored.
Guidelines to Help Resolve Grief
- Time helps individuals to resolve their feelings.
- Healing occurs when individuals integrate the loss into their lives.
- It is not unusual to return to earlier feelings of loss.
- The grieving process has no time limit; each individual's healing process is unique.
Further Reading[Page 320]1969). On death and dying. New York: MacMillan.(1975). The final stage of growth. Englewood Cliffs, NJ: Prentice Hall.(
- Give yourself time to express feelings openly. Crying offers a release; allow yourself to experience thoughts and feelings of loss.
- Acknowledge and accept both positive and negative feelings. Anger is an acceptable emotion, but how one deals with it is important.
- Try to maintain schedules and routines.
- Rest, sleep, and try to relax as much as possible.
- Journaling assists in the healing process. [Page 319]
- Confide in a trusted individual; telling the story of loss can promote recovery.
- Identify unresolved feelings and find ways to settle them.
- Bereavement groups provide opportunities to share grief with others who have similar experiences.
- Seek professional help when the grieving process becomes overwhelming or suicidal feelings emerge.
- Avoid minimization of one's emotions (e.g., by overworking).
- Avoid self-medicating with alcohol or drugs.
Appendix IV. Helping Children Cope with Loss and Grief[Page 321]
Death and loss can be quite confusing to children. The following guidelines can help make this challenging task a little easier.
Tell your child about a death or loss as soon as possible to prevent the child from hearing about it from someone else.
Some Children's Books on Death and Loss
- Choose a quiet, familiar setting with few distractions.
- Be direct and accurate in your communication and avoid words that could be misinterpreted (e.g., “We lost Uncle David” could be interpreted literally by your child that Uncle David could be found). Depending on their age, children may see death as reversible.
- Listen carefully, ask your child if he or she has any questions, and allow for silence.
- Talk about your own feelings without burdening the child. Expressing your own grief and sadness is appropriate.
- Offer your child reassurance and show your love. The recent loss may engender fears of losing you as well.
- Children may ask the same questions repeatedly as they struggle to come to terms with their loss; try to be patient.
- Children may question whether they are to blame for the loss of a loved one and may need reassurance in this area.
- For the first time, children may realize they could also die and may need reassurance that people usually die when they are older. [Page 322]
- Funerals can help children accept the reality of death, but children's attendance at a funeral should only occur if they appear ready for it; they should always be given a choice.
- If children attend a funeral, they should be informed about what to expect. Explain the purposes of a service and prepare some activities (e.g., coloring book and crayons) to occupy them should they get bored.
- Monitor the child carefully for behavioral changes and seek professional help if necessary.
Thomas, P., & Harker, L. (2000). I miss you: A first look at death. Hauppauge, NY: Barron's Educational Series.
Helps children understand that death is a natural part of life and that grief and a sense of loss are normal feelings. The story is direct and simple and easy to understand. Full-color illustrations attract children's attention (Ages 4–7).
Eldon, A. (2002). Angel catcher for kids: A journal to help you remember the person you love who died. San Francisco, CA: Chronicle Books.
Angel Catcher for Kids helps children cope with the painful and confusing process of grieving. This book helps children overcome the loss of a loved one by recording their special memories of the person who has died (Ages 7–12).
Kidd, D. (1993). Onion tears. New York: Orchard Books.
Through this tale of Nam-Huong, a refugee child who wants to adjust to her new life in Australia, children learn how to deal with the loss of home and familiar people. Nam-Huong slowly develops trust and is able to love again with the help of her foster mother and her teacher (Ages 5–8).
Palmer, P., & O'Quinn Burke, D. (2000). I wish I could hold your hand: A child's guide to grief and loss. Atascadero, CA: Impact.
This book helps grieving children identify and express feelings of loss. Uplifting and cheerful illustrations and accessible writing helps children accept that loss is a natural part of life (Ages 9–12).
Schriver, M., & Speidel, S. (1999). What's heaven? New York: Golden Books.
In this touching tale, a young girl tries to understand the loss of her great-grandmother. Reassuring explanations help children understand that death and grieving are a normal part of life (Pre-K).[Page 323]
Buscaglia L., & Buscaglia L. F. (2000). The fall of Freddie the leaf: A story of life for all ages. New York: Holt, Rinehart & Winston.
In this story, Freddie experiences the changing seasons along with his companion leaves who change with the passing seasons, finally falling to the ground with a winter's snow. This inspiring story illustrates the delicate balance between life and death (Ages 4–8).
Alley, R. W. (1998). Sad isn't bad: A good-grief guidebook for kids dealing with loss. St. Meinrad, IN: Abbey Press.
This guidebook teaches children how to deal with loss. It is filled with positive, life-affirming advice on how to cope with loss as a child; the world is seen as safe, life is seen as good, and hurt hearts are able to recover (Ages 4–8).[Page 324]
Appendix VI. Deep/Diaphragmatic Breathing[Page 327]
Diaphragmatic breathing makes use of the muscles of the diaphragm (a strong dome-shaped muscle) located under the ribs and above the stomach. When we breathe in, we push the muscle down, and our tummy moves forward. When we breathe out, the diaphragmatic muscle moves back to resting position and our tummy moves back in. There is little or no upper chest movement during diaphragmatic breathing.
When you first learn the diaphragmatic breathing technique, it may be easier to follow the instructions while lying down. As you gain more practice, you can try the diaphragmatic breathing technique while sitting in a chair (described below). To begin this exercise, lie on your back on a flat surface or in bed with your knees bent and your head supported. You can use a pillow under your knees to support your legs. Place one hand on your upper chest and the other just below your rib cage. This will allow you to feel your diaphragm move as you breathe.
Breathe in slowly through your nose so that your stomach moves out against your hand. The hand on your chest should remain as still as possible. Tighten your stomach muscles, letting them fall inward as you exhale through pursed lips. The hand on your upper chest remains as still as possible.
To perform this exercise while sitting in a chair,
- Sit comfortably, with your knees bent and your shoulders, head, and neck relaxed.
- Place one hand on your upper chest and the other just below your rib cage. This will allow you to feel your diaphragm move as you breathe. [Page 328]
- Tighten your stomach muscles, letting them fall inward as you exhale through pursed lips. The hand on your upper chest remains as still as possible.
You may notice an increased effort is needed to practice diaphragmatic breathing correctly. At first, the exercise may be exhausting. With continued practice, however, diaphragmatic breathing will become easy and automatic.
Practice this exercise for 5 to 10 minutes about 3 or 4 times per day in the beginning. Gradually increase the amount of time you spend doing this exercise; the effort of doing the exercise can be increased by placing a book on your abdomen.
Appendix VII. Progressive Muscle Relaxation[Page 329]
Progressive muscle relaxation (PMR) is a simple, easy-to-learn technique for relaxation. In PMR, the client is taught to relax his or her muscles through a two-step process: first deliberately applying tension to certain muscle groups and then releasing the tension and noticing how the muscles relax and the tension dissipates. With practice, clients quickly learn to distinguish between tense muscles and relaxed muscles. With this simple knowledge, they can induce physical muscular relaxation at the first signs of tension and anxiety. Mental calmness usually follows physical relaxation.Suggestions for Practice
PMR (Short Form)
- Practice PMR twice a day for about a week before moving on to the shortened form (also outlined below).
- Begin practicing full PMR in a quiet place, without distractions or background sounds (music).
- Remove shoes and wear loose clothing.
- Sit in a comfortable chair, if possible. You may practice lying down, but this increases the likelihood of falling asleep.
- Begin by focusing on the muscles of your right foot; inhale and squeeze the muscles as hard as you can for about eight seconds. This may feel slightly uncomfortable. After eight seconds, quickly release the muscles and let the tightness flow out as you simultaneously exhale. Feel the muscles relax and become limp while the tension flows away. Allow yourself to notice the difference between tension and relaxation.
- Systematically repeat this process with the lower right leg and the entire right leg before moving to the left foot, lower left leg, and entire left leg. Tense and [Page 330]relax the right hand, forearm, and entire arm; then do the same with the left side. Next, tense and relax muscles in the abdomen, chest, shoulders, neck, and face. This is a full PMR procedure, which provides a deep sense of relaxation.
- When you finish a session, relax and sit with your eyes closed for a few seconds before getting up slowly. Some people count backwards from five while breathing deeply before allowing themselves to become fully alert.
The shortened form of PMR is often used in therapy sessions after clients have practiced the full PMR at home or on their own time. The focus is on a group of muscles rather than individual muscles:
- Lower limbs
- Abdomen and chest
- Arms, shoulders, and neck
The individual focuses on both legs and feet at once, rather than each individually. The shortened form should be practiced under similar environmental conditions to full PMR, twice daily for a week, to gain proficiency.
Finally, as a word of caution, individuals with a history of serious injuries, muscle spasms, or back problems should consult a physician. Deliberate tensing of muscles, as is required in PMR, can exacerbate pre-existing conditions.
Appendix VIII. Stages of Burnout[Page 331]Stress Arousal Stage (Evidenced by Two of the Following)
Conservation Stage (Evidenced by Two of the Following)
- Persistent irritability
- Persistent anxiety
- Heart palpitations
- Inability to concentrate
- Bruxism (grinding teeth in sleep)
Fatigue Stage (Evidenced by Two of the Following)
- Frequent clock watching at work
- Difficulty going to work/showing up late for work
- Decreased sexual desire
- Tiredness in mornings
- Social withdrawal
- Cynical attitudes
- Increased alcohol consumption
- Increased tea, coffee, and soda consumption
- Loss of interest in work
- Need for three-day weekends
- Chronic sadness/depression
- Stomach or bowel problems; frequent colds and flu [Page 332]
- Chronic mental fatigue
- Migraines and headaches
- Extreme physical fatigue at end of workday
- Social withdrawal and loss of interest
- Isolation and withdrawal from friends, family, and co-workers
- Desire to commit suicide
- Decrease in compassion for victims
- High absenteeism
- Excessive drug use
Appendix IX. Counselor Self-Care, Beliefs, Conflicts, and Rewards[Page 333]
- Identify all the ways you are caring and providing services for others:
- At work:
- In your family:
- For colleagues:
- For friends:
- For your community:
- Any other ways:
- How long have you been doing this?
- What did your family of origin teach you about altruism and caring?
- What are your beliefs about caring for others?
- What are your difficulties/conflicts/challenges in caring?
- What are the rewards of being a caregiver?
- Who/what are your sources of inspiration?
- What was your original purpose for becoming a volunteer/human service provider?
Appendix X. Trauma Assessment Tools for Adults[Page 335]
Several tools have been developed to assess a trauma survivor's level of functioning. These tools are briefly outlined below. Before using any assessment tool, Kulka et al. (1991) cautions the counselor to keep in mind the following variables:
- What can be accomplished by using an assessment tool?
- What evidence supports its use?
- How long does it take to complete?
- How might gender, ethnicity, and cross-cultural differences influence the results?
- How might translations, which are not always psychometrically equivalent to the original instruments, impact assessment?
- How are multiple measures incorporated, given that their use is strongly recommended in assessing PTSD?
The counselor should always remember the goal of assessment is not to simply acquire a test score, but rather to improve a practitioner's understanding of how a trauma has affected a client. All assessment measures are fallible to some degree; combining methods helps reduce diagnostic errors (Weathers & Keane, 1999).[Page 336]Trauma Symptom Inventory
The Trauma Symptom Inventory (TSI) is a test containing 100 items that measures post-traumatic stress and psychological sequelae of traumatic events. The TSI was devised to assess symptoms of acute and chronic traumas such as rape, physical assault, spouse abuse, major accidents, combat trauma, and natural disasters. Additionally, the TSI assesses the enduring effects of abuse and trauma that may have occurred in childhood (Briere, 1995).Clinician-Administered PTSD Scale
The Clinician-Administered PTSD Scale (CAPS) is a structured, comprehensive interview designed to assess PTSD among adults. The CAPS scale evaluates 17 symptoms of PTSD listed in DSM-IV. Additionally, the CAPS includes the following five features associated with PTSD: guilt, dissociation, derealization, depersonalization, and reduction in awareness of surroundings. Initially developed by the National Center for PTSD (Blake et al., 1990), the CAPS scale evaluates
Impact of Events Scale
- self-reports of exposure to potential Criterion A events.
- current and/or lifetime DSM-IV diagnoses of PTSD,
- the frequency and intensity of each symptom,
- the impact of the 17 PTSD symptoms on social and occupational functioning,
- the overall severity of PTSD.
The Impact of Events Scale (IES) is a 15-item questionnaire devised by Horowitz, Wilner, and Alvarez (1979) to measure subjective distress as it relates to a specific event. The IES is one of the earliest self-report measures of post-traumatic disturbance, and it has displayed the ability to discriminate a variety of traumatized groups from nontraumatized groups (Briere, 1997). This scale's sensitivity to change renders it useful for monitoring a client's progress in therapy (Corcoran & Fischer, 1994).
Measured by the IES, the intrusion and avoidance scales are two major response sets that show good internal consistency. However, Briere (1997) found that the IES is racially sensitive; he recommends that interpretations of results from the IES should include a consideration of racial factors.[Page 337]Dissociative Experience Scale
The Dissociative Experience Scale (DES; Bernstein & Putnam, 1986) is a 28-item self-report instrument that can be completed in 10 minutes and scored in less than 5 minutes. The questionnaire is easy to understand, and the questions are framed in a manner that does not stigmatize the respondent who responds positively. A typical DES question reads, “Some people have the experience of finding new things among their belongings that they do not remember buying. Mark the line to show what percentage of the time this happens to you.” The DES outlines a variety of dissociative experiences, many of which can be considered normal.References[Page 338]1986). Development, reliability and validity of a dissociation scale. Journal of Nervous and Mental Disease, 174 (12), 727–735. http://dx.doi.org/10.1097/00005053-198612000-00004, & (1990). A clinician rating scale for assessing current and lifetime PTSD: The CAPS-1. Behavior Therapist, 13, 187–188., , , , , , et al. (1995). Trauma symptom inventory: Professional manual. Odessa, FL: Psychological Assessment Resources.(1997). Psychological assessment of adult posttraumatic states. Washington, DC: American Psychological Association. http://dx.doi.org/10.1037/10267-000(1994). Measures for clinical practice: A sourcebook (, & (3rd ed., Vol. 2). New York: The Free Press.1979). Impact of event scale: A measure of subjective stress. Psychosomatic Medicine, 41, 209–218., , & (1991). Assessment of posttraumatic stress disorder in the community prospects and pitfalls from recent studies of Vietnam veterans. Psychological Assessment, 3, 547–560. http://dx.doi.org/10.1037/1040-35126.96.36.1997, , , , , , et al. (1999). Psychological assessment of traumatized adults. In P. A.Saigh & J. D.Bremner (Eds.), Posttraumatic stress disorder: A comprehensive text. Boston: Allyn & Bacon., & (
Appendix XI. Trauma Assessment Tools for Children and Adolescents[Page 339]Trauma Symptom Checklist for Children
Although several multi-scale tests exist that assess childhood post-traumatic symptoms, none were standardized on a large sample of children in the general population. This deficit was addressed in 1996 when Briere designed the Trauma Symptom Checklist for Children (TSCC). The TSCC evaluates children's responses to unspecified traumatic events in different symptom domains. Additionally, the TSCC is standardized on a large sample of racially and economically diverse children from a variety of living conditions. This checklist also includes norms for age and gender; it is suitable for both individual and group administration (Briere, 1996).Child and Adolescent Version of the Clinician-Administered PTSD Scale
The Child and Adolescent version of the Clinician-Administered PTSD Scale (CAPS-CA) is a structured clinical interview that can be developmentally adjusted for use with children and adolescents. The CAPS-CA evaluates self-reports of exposure to potential Criterion A events; current and/or lifetime diagnosis of PTSD; the frequency and intensity of each symptom; the impact of the 17 PTSD symptoms on developmental, social, and scholastic functioning; and the overall severity of PTSD.[Page 340]
To increase the utility of this assessment tool with children, there are additional features of the CAPS-CA:
Traumatic Events Screening Inventory—Child
- Iconic representations of the rating scales
- Opportunities to practice the format prior to questioning
- A standard procedure for identification of the critical one-month time frame for current symptoms
The Traumatic Events Screening Inventory—Child (TESI-C) is a guide for clinical and/or research interviewing that screens for children's history of exposure to potentially traumatic experiences. The protocol is designed to help clinicians systematically focus on the primary domains of child trauma. These primary domains include direct exposure/witness to severe accidents, illness, or disaster; family or community conflict or violence; and sexual molestation.
The questions gradually lead up to the most intimate traumatic experiences; this assists children to tolerate the distress of disclosing a trauma. As a result, sexual trauma is only discussed at the end of the interview. Furthermore, the inventory is structured to foster the child's recollection not only of physical harm or violence but also threats of harm and the witnessing of trauma. Since this protocol merely provides hypotheses, findings should be corroborated with information gained from other independent sources (Ribbe, 1996).Child Dissociative Checklist
The Child Dissociative Checklist (CDC) is an easily administered scale designed to assess dissociative symptoms in sexually abused children. There are 20 items, which assess the following symptoms:
References1996). Trauma symptom checklist for children: Professional manual. Odessa, FL: Psychological Assessment Resources.(1988). Child dissociative checklist. Bethesda, MD: Author.(1996). Psychometric review of traumatic event screening instrument for children (TESI-C). In Stamm, B. H. (Ed.), Measurement of stress, trauma and adaptations (pp. 386–387). Lutherville, MD: Sidran Press.(
- Spontaneous trance states
- Alterations in identity
- Aggressive and sexual behavior
- Rapid shifts in mood and cognition (Putnam, 1988)
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