Tag Archives: trauma

Helping clients navigate religious trauma

By Diane Walsh and Gillian Koch November 15, 2023

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As counselors, we seek to support others in their search for meaning, wholeness and healing. This journey can lead us to work with clients who have had various experiences — both positive and negative — with religion and spirituality. Therefore, we must be prepared to address issues of religion and spirituality when appropriate, especially for those who have survived religious and spiritual trauma.

Many researchers in the social sciences describe religion as a shared set of practices and beliefs and spirituality as a personal relationship with God(s) or a Higher Power. Based on this understanding, an individual could experience spirituality through organized religion, be spiritual but not religious, or participate in religion but not be spiritual. According to the Pew Research Center, 63% of individuals in the United States identified as Christian, 9% identified as a member of a non-Christian religion and 29% identified with no religious tradition in 2021. An increasing number of individuals are leaving the religion they were raised in or not identifying with any religious tradition due to changing beliefs or finding community elsewhere.

Significant life events can shape a person’s spiritual and religious identity. In a recent study on religious trauma, published in the Socio-Historical Examination of Religious and Ministry in 2023, Darren Slade and colleagues found that “likely that around one-third (27-33%) of U.S. adults (conservatively) have experienced religious trauma.” Although no known studies have been done to determine the number of individuals who leave a religious tradition after experiencing religious/spiritual trauma, religious/spiritual trauma can deeply affect how individuals identify with and experience their own religion and spirituality. Understanding clients’ spiritual experiences is a critical part of engaging in multiculturally competent care, especially as research indicates that religion and spirituality can impact meaning making, worldview, social connections, physical and emotional health, and more.

The Association for Spiritual, Ethical and Religious Values in Counseling (ASERVIC), a division of the American Counseling Association, identified 14 competencies across six areas for addressing religion and spirituality in counseling. These competencies are a helpful framework for understanding ethical ways to address religion and spirituality in counseling when appropriate. The competencies include standards related to basic knowledge of religion and spirituality, awareness of how they may impact a client’s worldview, self-awareness on the part of the counselor and use of appropriate treatment methods in counseling. These competencies are of particular importance when working with survivors of religious/spiritual trauma to avoid further traumatization or inappropriate care.

The impact of religious/spiritual trauma

Religion and spirituality can have a positive impact on overall well-being, but they can also be harmful, damaging or traumatic. Lisa Ruth Oakley and Kathryn Susan Kinmond conducted a study on spiritual abuse and Christian adults in the United Kingdom and found that almost 75% of individuals felt “damaged by a church experience.” (Their findings were published in the Journal of Adult Protection in 2014.)

Religious/spiritual trauma is similar to other types of trauma, and it can overlap or co-occur with physical, sexual or emotional trauma. However, religious/spiritual trauma can be a particularly life-altering experience because religion and spirituality are often lenses through which people view the world. Religious/spiritual trauma can thus impact a person’s sense of identity, their core beliefs and values, and their perception of safety in the world. Moreover, it can deeply alter or damage an individual’s relationship and previous understanding of that which they consider to be sacred.

In a 2022 systemic review published in Spirituality in Clinical Practice, Heidi Ellis and colleagues reviewed 25 studies on religious/spiritual abuse. They identified three common elements of religious/spiritual trauma: misuse of power by religious/spiritual leaders, psychological harm and spiritual harm. Religious/spiritual trauma can be particularly painful when it desecrates core values or co-occurs with other types of trauma, such as sexual or physical trauma. It can also severely impact an individual’s sense of community and relationship with others.

The review found high rates of religious/spiritual trauma across many populations and locations, including the United States, Canada and the United Kingdom, but it indicated that certain populations may be more at risk for experiencing this type of trauma. For example, the review included a doctoral dissertation by Brian Simmons that analyzed data from almost 300 individuals who identified as LGBTQ+ and were either current or former members of The Church of Jesus Christ of Latter-day Saints. Simmons’ study found that almost 90% of participants met components of the diagnostic criteria for posttraumatic stress disorder due to spiritual trauma. This finding contrasts sharply with Slade and colleagues’ 2023 study that suggested 1 in 3 adults experience religious trauma.

Although the Diagnostic and Statistical Manual of Mental Disorders does not distinguish diagnoses based on the type of trauma a client experienced, conversations about religious/spiritual trauma have been occurring in the larger community of mental health professionals. For instance, Marlene Winell, a licensed psychologist, used the term “religious trauma syndrome” to describe the various symptoms that might emerge when an individual leaves a fundamentalist or manipulative religious tradition. Individuals who leave such religious traditions may have to navigate situations and their beliefs in new ways, including their understanding of the Transcendent and personal salvation or even deciding how to dress or talk to others.

The concept of deconstruction (the process of breaking down and exploring underlying previously held beliefs, understandings and practices) can also help provide insight into the unique characteristics of religious/spiritual trauma. Through deconstruction, individuals may leave their faith tradition entirely or emerge with a newfound strength and religious conviction, but the process itself can be highly challenging and requires reconstruction of personal identity and beliefs.

Many common symptoms occur across types and experiences of trauma, including psychological distress, intrusive memories of the trauma and heightened levels of arousal. Religious/spiritual trauma not only affects individuals’ physical, mental and emotional well-being but also their spiritual well-being. Because religious/spiritual trauma can deeply impact clients’ mental health, counselors have a responsibility to develop the knowledge, skills and awareness to support clients who have experienced this type of trauma.

Working with clients experiencing religious/spiritual trauma

Like with other forms of trauma, individuals who experience religious/spiritual trauma vary in their responses and reactions. Some clients may try to preserve their previously held religious/spiritual beliefs, while others may change or abandon their beliefs. As counselors, we may see clients who are conflicted or who do not know how they want to respond to the religious/spiritual trauma.

As with any traumatic experience, we first work collaboratively with clients to establish safety and healing. But there are a few other ways we can ensure we are providing effective care for clients who have experienced religious/spiritual trauma. In the following sections, we highlight key components of care for clients who have experienced religious/spiritual trauma. We also offer examples of specific language counselors can use in session with clients.

Cultivate safety through a trauma-informed approach. When clients have experienced religious/spiritual trauma, they often have a natural and automatic instinct toward self-protection and preservation that may be expressed as guardedness within the therapeutic space. Counselors must carefully consider how they build the therapeutic relationship and create safety with this population. Seemingly small considerations such as asking permission and allowing clients a sense of control can have a significant impact.

For example, counselors can get a client’s permission before asking questions about the trauma: “I’m curious about how that experience felt to you. Would you feel comfortable sharing more about it?” They can also allow clients to decide where to sit in session: “It’s great to see you today. Feel free to sit wherever feels most comfortable.” Or they can validate and let clients have a sense of control and ownership over their experiences: “That experience sounds really heavy. Where are you now emotionally?”

Perform an initial and ongoing assessment of risk. It is extremely important for counselors to assess the client for risk of suicide, self-harm and other safety concerns. This risk assessment should be conducted during intake and accompanied by appropriate follow-up assessments, including assessing if the client is at risk for further religious/spiritual trauma. The client may not be ready to dive into the details of the religious/spiritual trauma, but it is helpful to get a broad sense of what the trauma is, how the client understands the religious/spiritual trauma and where they currently are regarding their personal religion or spirituality.

For example, if a client has experienced trauma perpetuated within a specific religious community, a counselor can assess the client’s current level of engagement in that community by saying, “I hear how important that community was to you at that time. What’s your involvement like now — and how do you feel about it?” Then, it may be helpful to explore with the client the impact of their engagement, including if continued engagement may lead to increased risk of religious/spiritual trauma.

Other areas of assessment include the client’s symptoms such as emotional or physiological experiences, feeling of shame or detachment, and levels of reactivity. Counselors can broach these topics by saying, “How does it feel to talk about what happened? When you talk about the experience, does it feel like you’re telling a story or like you’re reliving the story?” or “That experience sounds so challenging. Which part of the story is the hardest for you to hold right now?”

Remember, regulation before intervention. Clients who have experienced any trauma (including religious/spiritual trauma) may experience symptoms of nervous system dysregulation throughout their daily lives. These symptoms may intensify during the therapy session, especially when discussing the trauma(s) they have experienced. Thus, it is important to make sure clients are not experiencing overwhelm or flooding in the therapy space because this will inhibit the client’s ability to experience the clinical interventions as intended. Grounding and mindfulness interventions (such as progressive muscle relaxation, 5-4-3-2-1 sensation naming activities or gentle stretching) can be helpful when working with this population. It can also be useful to develop a common language with your client so that you can remain attuned to their level of distress throughout the session. This can take the form of hand gestures, a subjective units of distress scale or code words — anything that allows the client to quickly and accurately communicate their level of distress so that the counselor can adjust the clinical intervention as needed.

For example, the counselor may tell the client, “I want to support you as much as possible as we talk about your past experiences. Let’s imagine a 10-point scale, with 1 being the least distressed (e.g., peaceful, at ease, relaxed) and 10 being the most distressed (e.g., angry, anxious, upset). We’ll use this scale throughout our work together so that I can stay attuned to how you’re feeling; I really care about that. Using that scale, where is your level of distress right now?”

If the client shares something about the traumatic experience in session, the clinician could say, “What you just said felt really impactful. Can I check in with you quickly? Where’s your distress level right now on a scale of 1-10?” If the client says they are at a 7, then the counselor could respond, “Thanks for letting me know you’re at a 7. Would it help to pause the story and do some grounding exercises? I can give you a few options to pick from if that’s helpful.”

Considerations for counselors

Working with clients with religious/spiritual trauma requires counselors to develop specialized skills and self-awareness as well as be trauma informed. To provide the best care for these clients, practitioners should not overlook the following four clinical considerations:

Learn trauma modalities. There are many trauma theories and techniques available for counselors to learn. Most evidenced-based trauma therapies share two primary common factors: First, they provide a corrective emotional experience for clients through a supportive, genuine and boundaried therapeutic relationship. Second, they include an exposure component while remaining respectful of the client’s pace. In some modalities, the exposure component takes a narrative form, and in others, it is conducted via an exposure hierarchy that includes imagined or in vivo exposure to triggers. As with any trauma treatment, it is crucial that pacing be closely monitored by the clinician to ensure that the client is receiving a level of treatment that is challenging but not overwhelming to prevent accidental traumatization. There may be some situations in which exposure work is not appropriate for clients, so counselors need to engage in critical case conceptualization, collaborative decision-making and consultation when determining treatment options. It is imperative that counselors receive thorough and complete training as well as ongoing support for the trauma modalities they practice.
Understand personal worldview and religious/spiritual experiences. Throughout the process of working with clients who have experienced religious/spiritual trauma, counselors may also experience different feelings, emotions and expectations. It is crucial that counselors manage and identify potential areas of countertransference. This is especially true when considering how the counselor’s own experiences of religion and spirituality could impact their work with the client. Bracketing is one tool counselors can use to manage their own experiences; Michael Kocet and Barbara Herlihy, in a 2014 article on ethical decision-making published in the Journal of Counseling & Development, defined ethical bracketing as a practice in which a counselor intentionally sets aside their beliefs and personal views when working with a client. In alignment with the ASERVIC competencies, counselors also need to understand different religious/spiritual traditions and perspectives outside of their own to avoid assumptions or generalizations. Clients experiencing religious/spiritual trauma may not be able (or ready) to leave the environment in which they experienced trauma. In these situations, taking a harm reduction approach can help clients explore ways to increase their safety while feeling understood and supported by the counselor.
Foster resilience. Burnout, compassion fatigue and vicarious trauma are risks for counselors engaging in trauma work. However, an emerging body of research also suggests that counselors may experience vicarious resilience and other positive impacts from witnessing posttraumatic growth and resilience in clients. Using a wellness-focused and strengths-based model can help build resilience in both the survivors we work with and in our own personal lives.
Take care of yourself. Because trauma work can be challenging, we encourage counselors engaging in this work to actively care for themselves. Supervision and consultation are vital, especially when working with clients experiencing religious/spiritual trauma. These spaces can facilitate growth in clinical skills as well as the development of professional support networks. In addition to supervision and consultation, self-care is key to preventing compassion fatigue, vicarious trauma or burnout. When a counselor is grounded in their own life’s peace and meaning, they are better able to create a space for clients to cultivate these in their own lives.

Religious/spiritual trauma is unique in its ability to uproot even the most deeply held beliefs in a person’s life, including those related to self, identity, religion, spirituality and the world. Working with clients who are navigating through religious/spiritual trauma can be challenging, but if counselors take the time to gain awareness and develop the clinical skills needed to help this population, then the work can be a profound and meaningful experience for both the client and the counselor.

Diane Walsh is an assistant professor of counseling at McDaniel College in Maryland. She is a licensed graduate professional counselor who maintains a small caseload of clients. Her research areas of interest include religion, spirituality, social class and counselor education.

Gillian Koch is a licensed professional clinical counselor in Minnesota. She served as president of the Minnesota Counseling Association for two years and is currently serving as the board’s past president. She works in private practice and specializes in supporting health care professionals as well as folks experiencing grief and loss.

Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Prioritizing trauma-informed care

By Lisa R. Rhodes October 4, 2023

wooden block figure that is broken in the middle; standing against a blue background

Andrii Yalanskyi/Shutterstock.com

Trauma is pervasive and its roots can take hold from an early age. According to the Centers for Disease Control and Prevention (CDC), about 64% of adults reported they had experienced at least one type of adverse childhood experience before age 18, and nearly 17.3% reported they had experienced four or more types of adverse childhood experiences.

Cathy Lounsbury, a licensed clinical professional counselor in Maine who specializes in trauma and trauma-informed care, says that most clients seeking mental health services have experienced some traumatic events in their lives that continue to affect their current functioning. Therefore, it’s important that counselors understand the role trauma plays to effectively address the root of some presenting symptoms, she adds.

Concerns about the prevalence of trauma and its impact on the individual and society led to the development of trauma-informed care. This foundational framework ensures that health care and other social service organizations recognize and respond to signs, symptoms and risks of trauma and work to reduce the likelihood of retraumatization.

A growing awareness of trauma-informed care

“Over the past few years, we’ve seen a big shift in counseling when it comes to trauma-informed care,” says Allison Dukes, an assistant professor of clinical mental health counseling at Saint Joseph’s University. “More people are recognizing the prevalence of trauma within our lives and the lives of our clients.”

In 2014, the Substance Abuse and Mental Health Services Administration (SAMHSA) established six guiding principles for trauma-informed care. These principles provide a framework for how providers can work to reduce the possibility of retraumatization and increase a person’s sense of power and safety. The six guiding principles are:

Safety
Trustworthiness and transparency
Peer support
Collaboration and mutuality
Empowerment, voice and choice
Cultural, historical and gender issues

The guiding principles stress the need for organizations inside and outside of mental health to ensure the safety of clients and staff, promote transparency in decision-making and encourage the sharing of lived experiences between clients and staff. They also call on organizations to foster collaborative relationships, validate the strengths of client and staff, and recognize and address societal biases and stereotypes.

Dukes says studying SAMHSA’s principles is a good start for counselors who are new to trauma-informed care and for counselor educators who want to talk about it with their students. Incorporating trauma-informed care in organizations and private practice also requires an understanding and the practice of the Multicultural and Social Justice Counseling Competencies, she adds.

“When planning for sessions or considering the effectiveness of interventions, we have to consider the ways in which our clients’ identities and past experiences are impacting their worldview, which is likely impacting their time in therapy and the therapeutic relationship,” Dukes says.

Lounsbury, a professor of counseling and dean of the counseling department at Antioch University, says she is not sure how a mental health professional could effectively treat a client who has experienced trauma without integrating a trauma-informed approach.

“Since trauma can impact a person physically, emotionally, socially, spiritually and behaviorally, trauma symptomatology is likely to be expressed during a counseling session,” she says. “It is imperative that the counselor understands it as such and responds in a way that is not retraumatizing to the client.”

Lounsbury and Dukes both agree that trauma-informed care is becoming the standard in the counseling profession because, as Dukes points out, “it aligns with our profession’s ethical standards and encourages us to look at the deeper reasons for [clients’] presenting concerns.”

Jenny L. Cureton, a licensed professional counselor (LPC) and owner of Evolutions Counseling and Consultation in North Canton, Ohio, has also seen growing evidence that counseling is becoming more trauma informed. “We are finally beginning to shift from seeing trauma solely as a niche to also considering it as foundational knowledge and a skill that counselors across specializations should develop and use in collaboration with each other to be responsive to clients, students and ourselves,” she says.

Seeing the whole person

Both clients and counselors benefit from agencies and organizations implementing trauma-informed care practices. For example, a trauma-informed lens can help counselors gain a deeper understanding of the client and see them more fully, says Cureton, an associate professor of counselor education and supervision at Kent State University who specializes in trauma-informed care and education.

Trauma-informed care “calls us to depathologize,” she explains. “We make the compassionate and realistic assumption that the problems someone presents are their body’s, brain’s and heart’s best attempts to live through something awful; this broadly helps us maintain unconditional regard and empathy.”

Taking a trauma-informed approach helps counselors be more discerning, especially with differential diagnosis and comorbidity of traumatic stress and disorders, Cureton continues. For example, without understanding trauma, a counselor might inadvertently attribute a client’s stress-related symptoms to an anxiety disorder when it might in fact be a traumatic stress response instead, she says.

“A key component to engaging in trauma-informed care principles is to be a safe, trustworthy and empowering counselor [and] to transparently and collaboratively understand the client holistically and in cultural contexts,” she adds.

A trauma-informed lens also helps practitioners build a more effective relationship with clients. “Past and ongoing trauma makes trusting deeply uncomfortable,” Cureton says. “When you’ve experienced trauma, it can feel too dangerous to trust others and even to trust yourself. Without being trauma informed, a counselor might misjudge a client’s reticence to share or even their no-show behavior as ‘resistant’ and even give up on providing truly quality care.”

Cureton finds that counselors who are trauma-informed are better able to gauge the status of the counseling relationship, timing for interventions and their own state in the moment of providing care. “Establishing and maintaining trust is not just an ideal counselors aim for. Decades of research on the common factors of counseling show that the counselor-client relationship is crucial for successful counseling,” she notes.

Jessica Meléndez Tyler, an LPC-supervisor and partner and clinical therapist at The Wandering Mind, a private practice in Columbus, Georgia, says a trauma-informed approach recognizes and respects the impact of trauma on clients’ lives, bodies, community and even their descendants.

“Trauma-informed care cultivates a sense of safety and empowerment that extends past the therapeutic relationship [and moves] away from approaches that put counselors as the expert and providers of therapeutic interventions,” she explains. “Counselors can co-create an environment of understanding, sensitivity and collaboration that has been absent for survivors of trauma.”

Challenges implementing trauma-informed care

Despite the benefits associated with trauma-informed care, efforts to fully implement this foundational framework across mental health agencies have resulted in a mix of successes and challenges. Some mental health organizations have successfully enacted trauma-informed policies that benefit both clients and staff, but others have not yet addressed the issue.

“In reality, the implementation of trauma-informed care still varies by the work setting,” says Cureton, president of the Ohio Association for Resiliency and Trauma Counseling.

She’s noticed that more agencies and nonprofit organizations have enacted trauma-informed care to align with funding initiatives from the grant and government entities that support them. For example, Cureton says some organizations that have been practicing trauma-informed care have been able to apply for funding to support its evaluation or enhancement. In other cases, trauma-informed initiatives did not exist within the organization until it became a requirement to qualify or keep funding.

“[I think] the push from some funding sources for interprofessional and cross-institutional work has supported the growth in trauma-informed care,” she says. “For instance, states that have received and distributed federal funding involving trauma-informed care often have more trauma-informed care across their systems, such as foster care, substance use treatment and K-12 education.”

Cureton says some school and school districts, as well as colleges and universities, have “truly stepped forward as leaders on creating a trauma-informed culture,” whether at the level of the counseling center, department or institution. However, she notes that counselors who work in settings such as the criminal justice system or serve resource-strapped communities such as refugees or immigrants often feel they are still waiting for the trauma-informed approach to be acknowledged and supported.

“It comes down to the readiness to change to address trauma among leaders in the immediate setting and beyond (e.g., organizational headquarters, county or state boards and legislatures),” Cureton explains. “Counseling settings with leaders who are aware of and responsive to reports of trauma from those they serve and employ are simply more likely to work to prioritize trauma-informed care funding and implementation. However, when society and leaders of counseling settings devalue some lives (e.g., BIPOC [Black, Indigenous and people of color] communities, people with offenses, people from other countries), we give them fewer resources for trauma-informed care and other needs.”

Melissa Youngblood, an LPC and certified clinical trauma professional at Therapeia, a group practice in Royal Oak, Michigan, says trauma and trauma-informed care are often not given the attention they deserve.

“I think there is a lack of emphasis on trauma in our training programs and clinical internships,” she says. “There is often a general approach in outpatient clinics that overlooks having staff trainings and psychoeducation about trauma-informed care for our clients.”

The general approach in most clinics is to develop basic skills in diagnostics and treatment planning, but trainings often overlook the need to have staff develop advanced capabilities in trauma modalities and trauma-informed care, Youngblood explains.

Work settings and institutional factors also play a role in the success of implementing trauma-informed care principles. Agencies working with mandated or incarcerated populations, for example, often do not have the support or buy-in to incorporate this type of care because the administrations and staff do not understand how these principles promote rehabilitation, says Tyler, an associate professor of the practice in the Department of Human and Organizational Development at Vanderbilt University.

Adapting existing practices and policies to align with trauma-informed care principles can also be met with logistical challenges and institutional resistance to change, she adds. “This requires education and collaboration with colleagues, administrators and stakeholders to foster a culture that supports trauma-informed approaches,” she says.

According to Lounsbury, some of the challenges facing mental health counseling systems that want to adopt trauma-informed care include the mental health worker shortage, a lack of funding for mental health services and disparities in funding for mental health treatment.

“Because some agencies do not have enough counselors to meet the need, resulting in waiting lists in services for clients, and because these agencies are reliant upon billable hours to keep their doors open, it can be challenging to take clinical staff ‘offline’ for training and supervision,” she says.

Another pressing factor is the fact that counselors often do not have the space to support their own wellness at some mental health agencies, which can result in secondary traumatic stress and burnout. So Lounsbury stresses that a trauma-informed care approach must acknowledge the impact the work has on counselors.

Counselors sometimes struggle to enact trauma-informed care because their work setting has procedures that conflict with its principles. For example, Cureton says a school or college counselor who works in an educational setting or state that requires them to avoid specific topics or words (such as “gay”) or to report specific details about a student’s identity are faced with potentially compromising the client’s safety, retraumatizing the client and essentially withholding trauma-informed care.

“Sometimes this is the nature of any work in systems — policies aimed at fairness, which then overly restrict counselors from making informed decisions customized to specific clients,” she adds. “Other times, it is structures that enact values centered more on money and power than on care and human dignity.”

Advocates for trauma-informed care

Despite these obstacles, clinicians can play a pivotal role in helping to ensure that trauma-informed care is the standard for treatment and workplace development in mental health. In fact, Tyler says counselors’ clinical expertise and understanding of the impact of trauma on the micro and macro levels help position them as advocates for change regarding trauma-informed care.

Counselors can educate public agencies on the effects of trauma and guide institutional and agency staff in recognizing signs of trauma, she notes.

“They can collaborate with interdisciplinary teams to develop policies and practices that prioritize safety, choice and empowerment for clients,” Tyler continues. “Furthermore, counselors can champion a culture of continuous learning and sensitivity, ensuring that staff are equipped to provide trauma-informed care effectively.”

Working to ensure that trauma-informed care is the prevailing mindset in mental health and that all clients are viewed through a trauma-informed lens is a valuable goal for counselors, particularly after COVID-19.

“I think that post COVID-19, there is a shared trauma that we experienced as a community enduring a pandemic,” Youngblood says. “We can no longer say ‘this client has no history of trauma,’ and we must begin to assess the impact of COVID on their mental health. We must acknowledge and support our clients in processing the impact for years to come.”

Dukes agrees. “Every client we work with for the next 10 or so years will have been impacted in some way,” she says. “Practicing trauma-informed care will allow us to discuss not only the trauma of the pandemic but also how our identities and histories impacted our understanding and overall experience of the pandemic.”

Lisa R. Rhodes is a senior writer for Counseling Today. Contact her at lrhodes@counseling.org.

Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Essential skill development for meaningful social connection

By Lisa Compton and Taylor Patterson September 18, 2023

A group of adults sitting around a table drinking coffee and smiling

Geber86/Shutterstock.com

Research has identified the important role social connectivity plays in mental wellness. As trauma experts, we also recognize how attachment deficits and trauma wounds can impact components of making and maintaining relationships.

Attachment deficits may cause people to seek friends and partners who possess similar characteristics to their insecure attachment figures (such as partnering with abusive or emotionally unavailable individuals). These deficits may also result in people prioritizing their own attachment needs above the needs of others (as in the case of narcissistic relationships), or they may cause people to disregard their own boundaries to maintain relationships at any cost (such as in codependent relationships).

Unresolved trauma wounds can interfere with healthy connectivity when our survival defense systems are in overdrive trying to protect us from pain. We may react with hypervigilance and misinterpret interactions as potential threats, have difficulty trusting others, maintain rigid boundaries to avoid intimacy, or simply overreact or underreact emotionally to situations. Past trauma can cause both emotional and physiological changes that interfere with social connection. The survival reactions of fight, flight or freeze direct bodily resources to respond to the crisis and move away from activities unnecessary for immediate survival, such as digestion and higher-order functions of the prefrontal cortex. The limited operation of the prefrontal cortex reduces our capacity for executive functions such as reasoning and communication, which are important components in navigating relationships. This reduction in executive function can happen during an actual trauma or may be triggered by a sensation associated with the trauma.

Counselors play a significant role in clients’ social skill development, increasing their potential to interact intentionally and not reactively from defensive responses. To help facilitate these discussions, we created the meaningful connection skills pyramid, a clinical tool counselors can use with clients who have insecure attachment and trauma histories (see Figure 1). This tool identifies six developmental skills that function in a progressive, developmental path toward meaningful connection and aid in intentional interactions: self-awareness and assessment, self-soothing to calm nervous system arousal, connection of past events to current triggers, reciprocal interactions, boundary enforcement, and rupture and repair.

Figure 1: Meaningful connection skills pyramid by Lisa Compton and Taylor Patterson

In the following sections, we illustrate how counselors can use this tool with a hypothetical example: Alicia comes to counseling after she has a significant argument with one of her close friends. When she was scrolling through social media, she discovered that her friend attended a party without her. Alicia was so upset that she called her friend and accused her friend of not caring about her or their friendship. Then Alicia blocked the friend’s phone number and social media accounts. Alicia’s history of trauma has disrupted her ability to reason, communicate with her friend, hear other possible explanations for why she wasn’t invited or work through the relational rupture.

Increasing self-awareness

Self-awareness is a foundational skill in social connection. Socially intuitive individuals can remain aware of internal cues (i.e., awareness of internal states) and external cues (i.e., awareness of how they come across to others). Clients may be interoceptive, the internal awareness of what is happening in the body (e.g., heart racing, feeling a “pit” in the stomach), or neuroceptive, the ability to assess external cues of safety or threat in the context of relationships. For example, an employee may notice that their chest is tight as they approach an important performance review at work (interoception). When they enter the conference room, the boss provides cues of warmth and approachability by smiling, leaning back in their chair and greeting the employee in a friendly manner (neuroception); these cues enable the employee to intentionally engage in calming behaviors and remain grounded throughout the meeting. By increasing our internal and external awareness and recognizing when we are in a threat response mode, we can work toward feeling safe and changing our defensive reactions.

Counselors can use assessment tools to help clients notice, evaluate and describe their level of distress and social connection. Here are three self-assessments we recommend using with clients:

Subjective Units of Distress Scale: This self-assessment tool allows clients to quantify their level of distress on a scale from zero to 10.
Body scans: This method asks clients to pay attention to parts of their body and bodily sensations, starting with their feet and moving up to their head. Body scanning helps strengthen clients’ ability to practice interoception.

Zipper screening tool description of zipper images

Figure 2: Zipper screening (a self-assessment tool created by Lisa Compton)

Zipper screen: I (Lisa) created this tool to help clients quickly assess and describe their current perceptions of social connection (see Figure 2). Counselors ask clients, “How ‘zipped’ or connected to others do you feel right now?” Clients then respond using the metaphor of a zipper to describe how connect they feel: zipper broken (disconnected), zipper functional but unzipped (lonely but hopeful), partially zipped (interacting but unsatisfied) and fully zipped (connected and fulfilled). Clients can also create their own metaphors such as “zipper stuck in the fabric lining” to represent feelings of enmeshment and other distressful forms of connection.
Window of tolerance: Clients can use this tool to evaluate their current arousal levels. The window of tolerance describes the optimal arousal zone (also considered “equilibrium”) between hyperarousal and hypoarousal, where clients remain regulated and the prefrontal cortex is active and functioning optimally. We recommend counselors use a color code to simplify the use of this tool: red for hyperarousal, green for optimal zone and gray for hypoarousal. With this method, clients do not need to remember the terminology; instead, they can respond using colors to indicate how they feel: green (“go” or move forward with treatment), red (too hot and need to cool down) or gray (lethargic and need to be energized). Counselors can teach clients how to expand their window of tolerance through emotion regulation activities and early identification of triggers.

We can help our hypothetical client, Alicia, increase her awareness of physiological cues of distress (interoception) and external cues of safety or danger (neuroception) using these tools. For example, the counselor could have Alicia take the Subjective Units of Distress Scale and reflect on the intensity of her distress at various points in her conflict with her friend (e.g., before seeing the social media post, during the phone call, after blocking her). In addition, the counselor could ask Alicia to identify what sensations she was feeling in her body at each of these points (e.g., stomach felt nauseous, chest was tight, face felt warm). Alicia could also consider what external cues contributed to her distress (e.g., the social media post, her friend’s tone of voice).

Calming the nervous system

It is common for clients with a history of insecure attachment or trauma to try to restore emotional and physiological equilibrium through maladaptive emotion regulation strategies. This can often prompt unhelpful oscillation between hyperarousal and hypoarousal.

For example, because of her traumatic experiences, Alicia finds herself constantly scanning her friendships for perceived rejection. This creates a state of hyperarousal and often intense symptoms of anxiety. To manage her hypervigilance, she drinks heavily in social situations in an attempt to calm her anxiety. The counselor can work with Alicia to help her identify her reactivity. Then she will be able to consider more adaptive emotion regulation strategies, including regulated breathing, progressive muscle relaxation and grounding exercises.

Connecting past events to present triggers

When clients have an emotional response that seems disproportionate to the present circumstances, they are likely reacting to past trauma wounds or attachment deficits. As clients learn to regulate their nervous system arousal, they can begin to cognitively connect their reactivity to specific triggers related to past events.

It’s understandable that Alicia would feel disappointed or confused when she discovered she was not invited to a party, but an amygdala-initiated survival response of fight, flight or freeze does not seem to correspond with the present threat. Once Alicia identifies her reactivity, she can explore past events potentially connected to her current trigger. For example, maybe past experiences of rejection led to negative core beliefs about Alicia’s self-worth, such as “I’m unlovable,” “I’m defective” or “I’m invisible.” In this case, modalities such as eye movement desensitization and reprocessing and cognitive behavior therapy can help clients such as Alicia identify origins of triggers, examine negative core beliefs associated with these memories, and instill more adaptive beliefs to promote healing from past trauma wounds and decrease reactivity to present triggers.

Engaging in reciprocal relationships

Insecure attachment can become trauma responses if the person has unmet needs in infancy and early childhood. Parental responses to infant distress create relational structures that affect how the infant learns to relate to their caregivers and others. Insecure attachment is characterized by chronic misattunement to a child’s needs or emotional experience and can be experienced by the child’s nervous system as a threat to survival. The child learns to adapt to this chronic misattunement through relational patterns such as attention seeking or overattending to the needs of others.

Attachment science has been helpful not only in understanding child-caregiver relationships but also in conceptualizing adult relational patterns. Without intervention, children with anxious, avoidant and disorganized attachment styles can continue to exhibit these patterns in their adult relationships, creating enmeshed, detached or volatile relationship dynamics. But with therapeutic intervention, clients can learn to build and maintain reciprocal relationships, which allows both the client’s needs and the needs of others to be honored and respected. Counseling can also help clients discern safe and unsafe relationships, decreasing the likelihood of repeating unhealthy relationship dynamics established in childhood.

Alicia can now identify her reactivity, practice adaptive self-soothing reactions and connect her triggers to past wounds so that she can begin to practice reciprocal relationships with others. For example, the counselor might suggest Alicia take the risk of planning a social event and inviting others to attend, rather than expecting that her peers will anticipate and act on her desire for connection.

Enforcing boundaries

Reciprocal relationships establish an environment in which boundaries can be set and maintained. Boundaries provide personal guidelines for multiple areas of our life, including our commitments, how we want to be treated by others and how we care for ourselves. Communicating boundaries effectively requires assertiveness, or the ability to clearly communicate one’s needs while respecting the needs and dignity of others. Practicing this skill often requires people to be brave because others may not be receptive to or respect one’s boundaries.

For example, Alicia’s desire for her friends’ approval often caused her to stay out too late, which disrupted her sleep and her ability to arrive at work on time. A personal boundary for Alicia may involve setting a curfew for herself and communicating this to her friends. By keeping her own arousal levels in check and assertively communicating her needs, Alicia creates an environment with less potential for relational harm and higher potential for resolution to relational conflicts.

Managing and repairing ruptures

Every long-term relationship will experience a rupture of connection because of conflict, miscommunication or simply a difference of opinion. How we manage the ruptures determines the level of intimacy and longevity of the relationship. Many people did not have healthy role models in childhood for managing relational conflict. Maybe they watched their parents engage in volatile disagreements or passively avoid conflict; both extremes can make conflict feel threatening and prompt people’s defense mechanisms to engage quickly. It is tempting to avoid conflict and detach from individuals at the first sign of relational difficulties.

Once Alicia has managed her reactivity, moved toward reciprocal relationships and practiced boundary enforcement, she can resist the urge to lash out or withdraw in response to conflict and tolerate the uncomfortable feelings that come from confrontation. Ideally, Alicia would be able to communicate her sadness and disappointment about being excluded from a social event to a safe and trustworthy friend and work toward repairing the relationship. The skills of distress tolerance and active communication enable clients to stay engaged long enough to make genuine repair attempts and invite them to use effective conflict resolution with their partner, friend or colleague. The ability to successfully navigate relational ruptures and repairs builds trust and increases the potential for long-term intimacy in relationships.

Counselors can also model this skill for clients within the therapeutic relationship. In the book Preparing for Trauma Work in Clinical Mental Health, I (Lisa) and Corie Schoeneberg discuss how to have difficult conversations with clients and how to repair the relationship when therapeutic ruptures occur. Regardless of the type of relationship, remaining in the window of tolerance enables us to repair ruptures without defensive reactivity so that we can protect the integrity of the relationship and foster relational intimacy.

Conclusion

The meaningful connection skills pyramid provides a treatment plan for helping clients improve their social skills by progressing along a developmental path. Improving client self-awareness and emotion regulation and their understanding of the connection between past events and current triggers are all foundational interventions for trauma work and other presenting issues, such as marital distress and workplace conflict. Higher-level skills such as reciprocity, boundary work and conflict resolution are invaluable for all relationships and settings. Regardless of trauma history or childhood attachment security, all clients can increase their well-being through improved ability to maintain social connection.

Lisa Compton is a professional counselor with over 25 years of experience. She holds a doctorate in counselor education and is a certified trauma treatment specialist. She is a full-time faculty member in the master’s and doctorate counseling programs at Regent University, an author and a conference speaker.

Taylor Patterson is a doctoral student in counselor education and supervision at Regent University. She is a licensed professional counselor who works primarily with adults with a history of childhood trauma.

Counseling Today reviews unsolicited articles written by American Counseling Association members. Learn more about our writing guidelines and submission process at ct.counseling.org/author-guidelines.

Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Conceptualizing and assessing race-based traumatic stress

By Portia Allie-Turco July 6, 2023

melitas/Shutterstock.com

Counselors have a responsibility to promote and provide equitable care and treatment as outlined in the ACA Advocacy Competencies and the Multicultural and Social Justice Counseling Competencies. To do so, counselors require awareness, knowledge and skills to work effectively with Black American clients. Clinicians seeking to treat Black American clients must understand that racial trauma is deeply rooted in historical, generational and ongoing systemic oppression and has a pervasive impact on the well-being of Black individuals and communities. The toll of racism is implicated in health and mental health disparities that can be addressed only through knowledge, awareness and a commitment to culturally responsive care. Culturally competent counseling requires specialized conceptualization, assessment and treatment of racial trauma.

A foundational understanding is that racism is embedded in all aspects of daily life and is a common and frequent experience for Black Americans. Racial inequity has profound economic, health and mental health impacts. Racial disparities contribute to unequal access to employment, education, housing and other material resources. Black families are more likely to live in dangerous neighborhoods and areas of concentrated poverty, have limited employment and poor access to quality health care, and experience food deserts, all of which exacerbate the effects of poverty and impede access to opportunity. Racism contributes to mental health issues such as anxiety, depression and posttraumatic stress. Racism is implicated in the phenomenon of weathering — a trauma response related to repeated exposure to chronic stress and adversity — resulting in myriad chronic health issues including hypertension, obesity, heart disease and early death.

The effects of racism extend to the counseling realm. Historically, racial trauma in Black American slaves was attributed to mental health conditions not believed to exist in other people. In 1851, Dr. Samuel Cartwright, who had apprenticed under Dr. Benjamin Rush, the “father of American psychiatry,” diagnosed two slave disorders he labeled “drapetomania” and “dysaesthesia aethiopica” (or “rascality”). Supposedly, drapetomania caused slaves to escape plantations; rascality was understood as an inherent trait of laziness and carelessness. Unfortunately, the idea of rascality continues to permeate views of Black Americans in relation to poor work ethic and criminality. The recommended treatment for both drapetomania and dysaesthesia aethiopica was physical torture. Today, these false diagnoses are associated with justifying police brutality and the harsh treatment of Black Americans facing legal authorities.

In counseling, Black Americans face an increased risk of retraumatization because of inappropriate assessment, misdiagnosis and poor treatment. Given this reality, and the resulting cultural mistrust of health care professionals, it is not surprising that rates of unilateral termination in counseling are much higher among Black American clients.

Conceptualizing historical trauma and slavery’s lasting effects

Historical racial trauma reflects the unresolved collective grief and cultural wounding that are passed down generationally. The field of epigenetics highlights that negative environmental conditions and stressors affect human beings down to the cellular level. For Black Americans, the racial trauma of slavery underpins a soul injury of unresolved grief that affects the whole being. In this context, the social-cultural wound is a collective experience of an internalized racial injury so pervasive that it impacts Black American culture in distinct racialized ways.

Anti-Black racism is rooted in the belief that people of darker skin tones are uncivilized, savage and prone to violence, regardless of how much status, achievement and standing a Black person may attain. This manifests in the phenomenon of colorism — the preference for lighter skin tone and Eurocentric features. Counselors need to know that colorism affects all aspects of a Black person’s life and influences their life chances, both within and outside of the Black American community. Black Americans face greater likelihood of poverty, more restricted access to education, and higher rates of imprisonment, underemployment and health inequity the further removed they are from the white ideal.

Posttraumatic slave syndrome (PTSS) is a theory of historical trauma that highlights the multifaceted impact of the violence of slavery, institutionalized segregation and oppression, and ongoing struggles for racial justice on the lives of Black Americans who are descendants of enslaved Africans. Counselors need to know the theory of PTSS, which was developed by researcher and educator Joy DeGruy-Leary to describe the survival strategies that were necessary for enduring the hostile conditions of slavery. PTSS accounts for both negative responses and positive adaptations and can explain some of the behavioral patterns of present-day Black Americans.

Controlling images and stereotypes

When Black American clients come to therapy, counselors should be aware of the controlling images and racial stereotypes these clients face.

The labeling starts early. In school, Black children are disciplined at higher rates than other children, with severe consequences that can include out-of-school suspensions, law enforcement involvement and, ultimately, even imprisonment for some Black children. Black boys are disciplined for being too “aggressive.” Black girls are disciplined for being “too loud” or dressing in a sexually provocative way. This reflects “adultification bias,” wherein school authorities hold Black girls to excruciatingly high standards because the girls are perceived to be more developed than they actually are. These responses stem from broader toxic stereotypes against Black Americans, deriving from slavery.

Controlling images underlie many of the mental health and stress-related concerns among Black women. One controlling image, the “Jezebel,” originated during slavery to justify the raping of Black women by white slave owners. It continues to have repercussions today in the increased risk of violent sexual assault against Black women due to the perception that they possess voracious sexual appetites and welcome aggression. The media also exploits the Jezebel trope and reinforces it in music videos, social media, television and movies, where Black women are often hypersexualized projections.

When counselors buy into the Jezebel myth, they risk misdiagnosing and mistreating sexually related concerns in therapy. Therefore, it is important to explore healthy sexual identity development and to challenge traumatic internalization of this controlling image. To further support and advocate for Black clients effectively, counselors need to be aware of these controlling images that discourage women from reporting sexual crimes and make it less likely they will be believed or find justice in court.

Another trope is the “Angry Black Woman.” This is routinely applied to Black women who are assertive and stand up in defiance of expectations of being demure and submissive. When they challenge injustice, they are labeled as domineering, masculine and emasculating. This combines racialized and gendered oppression and encourages the self-silencing of Black American women.

In response to these damaging stereotypes, Black American culture sought to reclaim the dignity of Black femininity. This was done in part by cultivating virtues of a Black matriarch who embodied strength, self-reliance, care of others and emotional containment while being a pillar of the community. In internalizing this “Strong Black Woman” schema, however, Black women are under enormous pressure to achieve excellence, block their emotions and care for others to the exclusion of their own needs. If counselors are unaware of this schema, they may not recognize the self-silencing, emotional dysregulation and fatigue that are the result of an endless demand on Black women for strength and voiceless endurance. Counselors should know that Black women who internalize this schema are most at risk for pain-numbing behaviors such as binge eating disorder, which is not about image or dieting, but rather an emotional regulation strategy.

Microaggressions and racial trauma in daily life

Psychiatrist and Harvard University professor Chester M. Pierce first proposed the term “racial microaggressions” to describe brief, commonplace verbal or behavioral racial slights, whether intentional or unintentional, that communicate hostile, derogatory or negative insults toward Black Americans. Microaggressions are often veiled and ambiguous; for example, complimenting a Black person about how well-spoken they are. The implication is that the listener is surprised because they did not expect the Black person to be articulate.

The subtle nature of microaggressions makes them especially frustrating for victims, who may be unsure of the intention behind the slight and unclear about whether or how to respond. This distress is damaging to a person’s well-being, especially when accumulated over time. Microaggressions result in increased stress, anxiety, depression and other trauma-related conditions. They can also lead to anger, voicelessness, internalized self-devaluation and an assaulted sense of self.

Race-based traumatic stress

Experiences with discrimination and oppression can result in race-based traumatic stress (RBTS), a term coined by researcher Robert Carter and colleagues to describe the significant stress Black Americans experience because of cultural, individual and institutional encounters with racism. Much like posttraumatic stress disorder (PTSD), RBTS carries psychological and physiological effects such as avoidance, hypervigilance, flashbacks, nightmares and somatic expressions (e.g., headaches, stomachaches, heart palpitations). At the same time, racial trauma differs from PTSD in significant ways. For instance, racial trauma involves ongoing cumulative injuries due to exposure, both direct (such as physical assault) and indirect (such as vicarious injury when other Black people are racially harmed or when witnessing racist incidents in person or in the media).

RBTS also includes reexposure to race-based stressors. Criteria include exposure to a racist event that is experienced as painful and uncontrollable. The traumatic reaction of avoidance, intrusion or arousal can manifest in several ways, including emotionally, cognitively, behaviorally and physiologically. Unfortunately, most of these wounds are easily overlooked if counselors do not understand race-based trauma symptomatology. Black American clients may need help in understanding and managing their strong reactions to these events. It is incumbent on counselors to have this awareness because Black American clients may not know that these exposures are considered traumatic.

The fact that racism is a stressor that can harm or injure its targets is still not recognized as an official diagnosis in the most recent iteration of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR). This decreases the chances that counselors can identify, assess and treat RBTS, even though researchers have reported higher rates of traumatic experiences among Black Americans when compared with the general population.

Although the current diagnostic criteria for PTSD in the DSM-5-TR is more expansive with respect to trauma generally, it does not account for the symptoms of RBTS due to its limiting of the types of experiences that lead to trauma. For instance, Criterion A specifies “exposure to actual or threatened death, serious injury or sexual violence” as the main diagnostic criteria, even though other types of stressful experiences, such as racism, have been linked to negative mental health outcomes.

Criterion A also contains a specific notification, under Criterion A4, that explicitly states “experiencing repeated or extreme exposure to aversive details of the traumatic event(s) does not apply to exposure through electronic media, television, movies or pictures, unless this exposure is work-related.” This is concerning because advancements in technology and the ubiquitous reach of media have increased the exposure of Black Americans to heightened images of racial injustice and trauma, such as the gruesome images, in real time, of the murder of George Floyd.

Similarly, newer forms of hate crimes have emerged in social media networks as a convenient means of transmitting hate. All of this can have the effect of retriggering and retraumatizing previous racialized experiences. Black American clients might present to counseling with trauma stirred up by these media exposures to racism, but it may not be apparent because of the everyday nature of these incidences. In addition, diagnosis is difficult because of the electronic media exclusion note in Criterion A4.

The current definition of PTSD in the DSM-5-TR is problematic. It contributes to potential misdiagnosis and the pathologizing of racial stress symptoms, and it limits the ability of Black American clients to receive adequate racial trauma treatment. Additionally, without an official diagnosis, health care insurance coverage and reimbursement can be restricted.

RBTS assessment measures

Despite the limitations of the DSM-5-TR diagnostic criteria, counselors can still offer an appropriate assessment of RBTS, if they have the necessary knowledge and awareness and the proper tools. Experts in the racial trauma field have developed several scientifically validated instruments that accurately assess trauma symptomatology. Counselors can choose any of these instruments during a scheduled intake or following a session when a client presents with symptoms that may be indicative of racial trauma. These tools can help counselors assess Black American clients and develop treatment strategies for healing their traumatic experiences.

The University of Connecticut Racial/Ethnic Stress & Trauma Scale (UnRESTS) uses an interview format to facilitate communication regarding clients’ experiences with racism. UnRESTS uses a two-column format: one column with instructions for the counselor to prepare the interview and the other column describing questions to ask the client. This measure is helpful for counselors who are inexperienced in identifying racial trauma or those who are hesitant to broach racially charged topics in counseling. It provides clinicians with a structure to conduct the interview, starting with identifying racial or ethnic identity development and moving through experiences of covert and overt racism, including vicarious racism. This provides counselors with the confidence that they have elicited the greatest input from their clients on these issues and can make a treatment plan based on this comprehensive review.
The Race-Based Traumatic Stress Symptom Scale (RBTSSS) evaluates a client’s exposure to racist experiences and the symptoms that can result, including emotional and physiological reactivity. The measure includes 52 items in seven categories that explore self-esteem, physical reactions, anger, avoidance, depression, intrusion and hypervigilance or arousal, all associated with racial trauma. When using the RBTSSS, the clinician begins with open-ended questions to obtain information from the client about racist experiences. This is followed by closed-ended questions about the client’s reactions. A clinician can assist in administering this assessment, or it can be administered as a self-report measure.
The General Ethnic Discrimination Scale (GEDS) is an instrument specially designed for measuring clients’ frequency of exposure to racism. It is appropriate to use with most ethnic groups affected by racial trauma. GEDS consists of 18 self-reported items that measure the client’s personal perception of racial discrimination. This tool is similarly structured to other existing stress inventories currently in use. Because this is a self-reporting tool, instructions have been simplified for participants whose first language is not English. It is also specifically useful when faced with time constraints because it is a relatively quick measure for assessing racial trauma.
The Racial Microaggressions Scale (RMAS) is a tool measuring racial slights and the resulting distress of microaggressions. It specifically explores six types of microaggressions using a 32-item questionnaire in a Likert scale format. The distress subscales include criminality distress, low achieving/undesirable culture distress, sexualization distress, invisibility distress, foreigner distress and environmental distress. Counselors might choose this assessment when Black American clients report experiencing insults and invalidations that undermine their sense of self.

Because racial trauma is so deeply rooted in historical and generational oppression going back to slavery, Black Americans continue to experience the devastating toll. Counselors who work with Black Americans must understand the conceptualization of this experience and be competent in evaluating its impact on their clients.

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Learn how to treat race-based traumatic stress in July’s Knowledge Share article “Treatment strategies for race-based traumatic stress.”

Portia Allie-Turco is an assistant professor, clinic director and program coordinator in the Counselor Education Department at the State University of New York at Plattsburgh. She is also a licensed mental health counselor who specializes in healing racial, generational and complex trauma. Contact her at p.allieturco@gmail.com.

Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

A cultural framework for generational trauma

By Jyotsana Sharma, Carolyn Shivers and Cadence Bolinger June 20, 2023

A father hugs his son while standing outside. Both are looking down.

Ruslana lurchenko/Shutterstock.com

Intergenerational trauma, much like the definition of trauma, is often subjective and complex. Trauma can be broadly defined as an event or recurring event that can overwhelm the body and its ability to cope in a variety of different ways. Based on an individual’s capacity, trauma may be met by resilience or growth with the help of positive support systems and adaptive coping mechanisms, or it may overwhelm the survivor’s mind and body and lead to traumatic stress reactions or other debilitating effects. The traumatic experience may then directly or indirectly impact descendants, resulting in intergenerational trauma or the transmission of trauma between generations. Because intergenerational trauma, like all experiences, is highly subjective, each person may experience it differently. In this article, we define intergenerational trauma as any traumatic experiences survived or actions perpetrated on communities or individuals that contribute to enduring biopsychosocial changes, including adverse repercussions for survivors or abusers, and direct, indirect or vicarious implications for their children and grandchildren, both within a culture and across cultures.

Intergenerational trauma is often understood in the context of historical or cultural violence. Children and grandchildren of Jewish survivors of the Holocaust, Native American and First Nation survivors of residential schools, and other survivors of ethnic genocide have described feelings of unease, anxiety and fear, despite having never directly experienced a traumatic event themselves. In many cases, traumatic experiences were never shared with these descendants, and it is only through exploration of their ancestors’ lives that these individuals could begin to understand and start working through their own struggles.

More recently, clinicians and researchers have recognized that individual traumas such as interpersonal violence (IPV), domestic violence, sexual violence, emotional abuse/neglect or deprivation can also contribute to the intergenerational transmission of trauma. In other words, trauma does not have to be experienced at a community level to affect later generations. Any individual trauma can disrupt a generational system in ways that travel through time.

Although research and practice acknowledge the variety of possible events that lead to intergenerational trauma, there are few theories on how such trauma is transmitted. Some modern studies have found genetic underpinnings of trauma (i.e., transmission through changes in the genetic code of survivors who experienced the trauma). However, as with most psychological phenomena, it is equally important to consider the role of nurture. It is possible that trauma survivors may consciously or unconsciously develop behaviors and reactions that transfer fear, avoidance, anxiety or hopelessness to their offspring, thus unintentionally passing on distorted core beliefs, values, thought processes or emotions.

Although intergenerational trauma may affect many of our clients, it often goes unnoticed. In addition, the complexity of generational trauma is difficult to assess, so we developed a framework — the cultural framework of generational trauma (CFGT) — to help support practitioners when working with complex, intergenerational traumatic experiences. The framework can be used in a culturally diverse society, and it can be adapted to all individuals, regardless of the nature and origin of the traumatic events.

A bioecological approach

As counselors, we need to broaden the way we view trauma, especially trauma that emerges from experiences of interpersonal violence, and consider how it can affect multiple generations and, most importantly, how these processes may differ across social and cultural realms. To do this, we propose counselors use a targeted bioecological framework when addressing the impact of social and cultural contexts on the experience of individual trauma(s), especially as it relates to the intergenerational transmission of trauma. Mental health practitioners can adapt this macro approach to understand clients’ worldviews and the implications that the intersections of the individual, the trauma, and the social and cultural contexts might have on advertently or inadvertently transmitting patterns of trauma intergenerationally.

The CFGT integrates the Bowen family systems theory, Yael Danieli’s Trauma and the Continuity of Self: A Multidimensional, Multidisciplinary, Integrative (TCMI) framework and Bronfenbrenner’s bioecological model. The CFGT uses the macro lens of Bronfenbrenner’s bioecological model, which helps us understand the multiple layers of disruption that trauma causes and the capacity of this disruption to travel across generations within family systems through a set of complex interconnected processes. In our framework, trauma and violence exist not only within the individual or between the person who carried out the abuse and the survivor but also within surrounding familial, social and cultural contexts. For example, our framework includes children who have witnessed abuse toward someone else, been on the receiving end of the abuse, or been manipulated or used as a means for carrying out violence or abuse.

The Bowen family systems theory helps us understand interpersonal dynamics within family systems, and the TCMI helps explain how trauma and violence cause ruptures that travel from the survivor to their social and cultural contexts and vice versa. It’s important to note that the influence between survivors and sociocultural systems is reciprocal, which can lead to various trajectories of traumatic stressors, recovery or growth.

The CFGT consists of the following four components, which we adapted from Bronfenbrenner’s bioecological model:

Person. Our framework is centered on the victimized individual or survivor who is in conflict internally or with another individual. The individual’s unique worldview has been influenced by their genetics, family, and social, political and cultural contexts. Any trauma the individual faces has the capacity to transform the entire family system, starting with the individual and rippling out toward the family system and components of that individual’s sociocultural contexts.

Context. The individual affected by trauma or violence is surrounded by social, political, economic and cultural contexts, which form their environment. They are also influenced by various systems in their environment such as family members, friends, colleagues, community, religious organizations, neighborhood, society (e.g., U.S. society, Midwestern society), socioeconomic status, political trends and culture as it relates to race, ethnicity and country of origin, as well as the beliefs and biases held by the survivor and individuals in each system. These systems influence the survivor and are influenced by the survivor. By specifying multiple aspects of the environment, our framework helps encourage counselors to explicitly consider spheres of influence that might be affecting the individual’s trauma and vice versa. For example, if there has been a pattern of triangulation in a client’s family system, then maybe the client and counselor need to explore how triangulation has carried across the generations and whether it plays a role in their current family life.

Process. Most of the disruption happens within the family (chosen or otherwise) because it is the closest system to the individual. Family members who try to help or support the person affected by trauma or violence are often also affected themselves. Similar processes could then exist for traumatic transfer to other members of the survivor’s environment. If a child survivor, for example, shares their trauma with a school counselor, then that counselor may now be affected by the trauma vicariously. Religious/spiritual leaders who provide support or guidance to the survivor and family and law enforcement officials who are called to assist during or after a trauma or violence occurs can also be influenced by the survivor and the survivor’s family unit.

In addition, with the passage of time, the survivor may experience healing, which can also transfer to others and lead to healing within the family and the social and cultural context surrounding the survivor. But if healing does not occur or it does not fully occur, the patterns of coping, the altered values or beliefs, and the ways in which the survivor or the family unit has changed can transition from the survivor’s generation to the next. Bowen family systems theory refers to this process as multigenerational transmission and defines it as a process through which behaviors, attitudes, skills, values, ideas or assumptions directly or indirectly transfer from one generation to the next via patterns of coping.

Drawing on Bowen’s concept of family projection, which refers to how parental figures transmit or project their own personal anxieties or interpersonal relationship issues onto the children within that family system, it is possible that the survivor’s generation transfers biopsychosocial patterns (e.g., fears, anxieties, defensiveness, depression, relational dissatisfaction, unhealthy coping after trauma or violence). Survivors may also transfer patterns of being or existing or even meaning making onto descendant generations.

Time. Like Bronfenbrenner’s chronosystem, our framework includes the factor of time — both throughout an individual’s life span and across generations. We propose that the factor of time be considered not only continuous but also repetitive: Processes, interactions and complex intersectionalities occur in small yet recurring ways. With the passage of time, efforts toward recovery or growth might result in healing for the survivor and their social and cultural contexts. On the other hand, if the survivor struggles with traumatic stressors, there is also the possibility that these patterns of trauma or violence will influence, transition or transfer to another generation by seeping into the life of this survivor’s descendants.

Once the descendant’s biopsychosocial patterns are disrupted, that adverse experience becomes an essential part of the child’s lived experiences. Therefore, this aspect of time represents multiple ways in which experiences of trauma and violence repeat over the course of several lifetimes through social interactions, genetics, behavioral patterns, values or attitudes, sneaking from one generation to the next like a soul wound without the survivor’s or their descendants’ awareness.

Applying the framework

One advantage of our cultural framework is that it can be used across generations (i.e., for the survivors of trauma and violence and for the survivor’s descendants or extended families). A key element of the CFGT is the passage of time, which is important with intergenerational trauma. To illustrate how our framework could be used with a survivor and someone in later generations affected by their parents’ trauma experiences, we apply the CFGT framework to a case example; the data for the case study came from the first author’s dissertation study, which used semi-structured interviews to examine the impact of culture on trauma recovery and posttraumatic growth among survivors of IPV. Our survivor, JJ (pseudonym), was a 40-year-old Mexican woman who had experienced IPV between the ages of 30 and 37.

Person. JJ was married to her abuser, who exhibited escalating patterns of emotional abuse such as manipulation, isolation, gaslighting and physical violence (including shoving, hitting and choking).

Context. JJ’s abuse included intersectional social, political, cultural, economic and community factors, all of which contributed to her experience of IPV and attempts to seek support. JJ described her upbringing as a Mexican woman and discussed how divorce was frowned upon for women in her culture. Although her mother was a divorced, single parent, her grandmother, who also lived with them, was very traditional.

The community where her abuser forced her to move after marriage was isolating for JJ. She felt alone because she didn’t know anyone in this place, and her friends and support system were all back in the city that she had left. JJ’s then husband was gaslighting her and isolated her from her church community in an attempt to manipulate her and reduce her credibility. For example, after JJ suffered injuries from physical abuse, he would refuse to take her to church; instead, he would go by himself and tell the church community that she was struggling with mental health issues, which was not true. This facilitated even more isolation for JJ because now the church community not only thought she was unwell but also didn’t believe her when she told them about the abuse. She also described how police officers did not believe her when she reported the abuse. According to her, the officers sided with her husband, who was manipulative but maintained positive social relationships with the officers.

JJ also reported that social influences played a role in both preventing and encouraging her to leave her abuser. Some of JJ’s neighbors encouraged her to pray and work to “be a better wife” because JJ’s husband had again manipulated the narrative of the abuse and told them she was struggling with her home life and kids, but the neighbors didn’t realize the full extent of what was happening. But she also had friends from before her marriage who, after learning about the abuse, encouraged her to seek individual counseling. After JJ decided to leave her husband and move to a domestic violence shelter in another town, her friends supported her through the process of establishing an independent life for herself and her children.

Process. JJ experienced domestic violence for more than seven years, and the abuse escalated over time. Her abuser was not physically violent with her at the beginning of their relationship. JJ described how the emotional and psychological abuse began shortly after they got engaged, and her spouse became increasingly controlling when she was pregnant — putting her on a diet and demanding that he attend all her medical appointments. The spouse’s need for control was a common theme throughout the process and affected her socially and financially. His controlling nature was the underlying reason behind their move to a small town where JJ was cut off from all cultural and social support. Her spouse would prevent her from talking to anyone he believed was “on her side.” He also sold her car and took control of the finances, which limited her freedom and increased her dependence on him.

The CFGT allows counselors to see how the process of interpersonal violence is deeply embedded within the sociocultural context in which the violent relationship exists and how it can change and evolve over time. In JJ’s case, the contexts she was in at various times both perpetuated the violence (e.g., law enforcement officers refusing to believe her) and helped her escape (e.g., finding social support and legal assistance at a domestic violence shelter a few miles away from where she lived). Because the CFGT explicitly incorporates change over time throughout the entire framework, it allows counselors and clients to work through the complexity of the process as it exists within a person’s sociocultural context and vice versa.

Time. The time aspect of JJ’s case is particularly illustrative because she described both how her ancestors’ experiences affected her (looking backward) and how she could see her own experiences affecting her children (looking forward). JJ’s mother was divorced, and JJ recognized the stigma her mother faced as a divorcee in Mexican culture. This stigma influenced JJ’s opinion of her own marriage and contributed to a cultural pressure to “find a man” and stay married no matter what, which was largely influenced by her grandmother’s views on marriage.

JJ also described how her son received a temporary detention order in school when he was 5 because of behavior problems stemming from his mother’s abuse by his father and subsequent divorce. JJ and her abuser shared custody of their children, which resulted in her abuser trying to triangulate the children against JJ. He was also physically abusive toward the children. Although JJ did not fully describe how much her children knew about her abuse, she said that the children did witness some of the violence directed toward her and they were also victimized by the father. Using the CFGT can help counselors understand the intergenerational impact of JJ’s trauma, independent of and in conjunction with the children’s own trauma.

Time also shaped and changed the context of JJ’s story. When JJ was living in a small, isolated community where people knew and believed only what JJ’s abuser was telling them, she was stuck. Moving to the domestic violence shelter, however, allowed her to find support from people in this new community and from friends she had known before the marriage. In the CFGT framework, time applies to both influences across generations and changes across time for an individual during their lifetime and journey toward recovery.

Conclusion

JJ’s story is particularly apt because she worked for years with a team of counselors (both her own and her children’s), attorneys, support staff and friends to free herself from her abusive relationship. She eventually established her independence, gained custody of her children, provided them with a safe environment and worked on her own trauma recovery. Through counseling and the recognition of her experience (person), the influences of her environment and culture (context), and the impact of both the past and future on the experience (time and process), JJ was able to develop strength, resilience, self-acceptance and confidence and grow from her experiences.

I (Jyotsana) met JJ while conducting interviews for a research study. One of my fondest memories of her was when she was in her art studio on a video call with me. After she shared her story with me, I asked her, “How are you going to move forward from here?” She spun her camera across the room and said, “Just for starters … I’m in my studio … my own studio.”

In cases such as JJ’s, the CFGT could help provide mental health professionals with insight into key psychoeducational interventions, advocacy related to policy changes, and social justice-focused approaches for survivors of trauma and violence and those affected by generational trauma. The CFGT may provide the groundwork on which holistic treatment modalities can be developed or formulated. We believe the CFGT is a comprehensive and culturally sensitive approach, and we are confident that focused research efforts will be able to provide evidence that this framework is a useful foundation for the treatment of clients affected by trauma and violence.

It’s also important to highlight that, like trauma, recovery and growth can also transfer from one generation to the next. Recent research on protective factors has acknowledged the potential for healing to be transferred through generations just as trauma from adverse experiences can be. Now it is up to counselors to be open-minded and adopt the CFGT as a holistic framework for education, research and practice. We are confident that by adopting this framework, mental health professionals can better assess, conceptualize and treat clients who display patterns of unresolved generational trauma.

Jyotsana Sharma is an assistant professor in the Counseling and Counseling Psychology Department at Oklahoma State University-Tulsa. She is also a licensed clinical mental health counselor in New Hampshire, national certified counselor and approved clinical supervisor. Her research focuses on trauma recovery and posttraumatic growth, with a particular emphasis on the sociocultural factors affecting these processes. Contact her at jyotsana.sharma@okstate.edu.

Carolyn Shivers is an associate professor of psychology at Niagara University. Her work involves understanding and eliminating barriers to inclusion for people with physical, cognitive and psychiatric disabilities.

Cadence Bolinger is a doctoral student in the Counseling and Counseling Psychology Department at Oklahoma State University-Stillwater.

Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.