2015 Oregon Counseling Association Conference presentation by Lori Daniels, PhD, LCSW about trauma processing and veterans.

1. TRAUMA
PROCESSING
Revealing
the Healing
Lori Daniels, Ph.D., LCSW; former Counselor, Portland Vet Center

2. disclosure
• All statements made are strictly the presenter’s and
do not reflect the thoughts, opinions, nor policies of
the Dept. of Veterans Affairs.
• Acknowledgements: R. Scurfield, S. Tice, D. Smith;
Readjustment Counseling Service (Vet Centers); all
my clients

3. O, my good lord, why are you thus alone?
For what offence have I this fortnight been
A banish'd woman from my Harry's bed?
Tell me, sweet lord, what is't that takes from
thee
Thy stomach, pleasure and thy golden
sleep?
Why dost thou bend thine eyes upon the
earth,
And start so often when thou sit'st alone?
Why hast thou lost the fresh blood in thy
cheeks;
And given my treasures and my rights of
thee
To thick-eyed musing and cursed
melancholy?
In thy faint slumbers I by thee have
watch'd,
And heard thee murmur tales of iron wars;
Speak terms of manage to thy bounding
steed;
Cry 'Courage! to the field!' And thou hast
talk'd
Of sallies and retires, of trenches, tents,
Of palisadoes, frontiers, parapets,
Of basilisks, of cannon, culverin,
Of prisoners' ransom and of soldiers
slain,
And all the currents of a heady fight.
Thy spirit within thee hath been so at
war
And thus hath so bestirr'd thee in thy
sleep,
That beads of sweat have stood upon thy
brow
Like bubbles in a late-disturbed stream;
And in thy face strange motions have
appear'd,
Such as we see when men restrain their
breath
On some great sudden hest. O, what
portents are these?
Some heavy business hath my lord in
hand,
And I must know it, else he loves me not.Shakespeare, W. (1594); Lady Hotspur Verse
Henry IV, Act II

4. Agenda:
1. What trauma survivors have encountered.
2. A model of trauma processing & PTSD
3. Preparing the client for trauma disclosure
4. Questions for data-gathering in sessions
5. Tenacious Curiosity and the Ability to Not Bail
(Early)
– Case examples: guilt/grief; guilt & % of responsibility;
helplessness in nightmares
6. Goals of trauma processing & PTSD intervention

5. What many trauma survivor clients have
encountered prior to coming into counseling –
and even within counseling programs
Expectations: that
their story is not going to
be shared (“speak no evil”
AND/OR that the provider
doesn’t want to hear it
(“hear no evil”) =
COLLUSION OF SILENCE
REGARDING TRAUMATIC
EVENT...
Client’s minimization of
trauma impact (“see no
evil”)

6. TRIGGERS:
subtle/
obvious
Intrusive
Recollections:
Memories,
nightmares, flashes
AVOIDANCE: quest for
mood shift
American Psychiatric Association, DSM-V; 2013
Distorted &
distressing
thoughts and
mood

7. TRIGGERS:
subtle/
obvious
Intrusive
Recollections:
Memories,
nightmares, flashes
Detachment: quest for
mood shift Distorted &
distressing
thoughts and
mood
American Psychiatric Association, DSM-V; 2013

8. TRIGGERS:
subtle/
obvious
Intrusive
Recollections:
Memories,
nightmares, flashes
AVOIDANCE: quest for
mood shift Distorted &
distressing
thoughts and
mood
American Psychiatric Association, DSM-V; 2013

9. • Cognitive Processing
• Dialectical &
Behavioral
• Acceptance &
Commitment
• Eye-Movement
Desensitization
• Medication Mgt.
• Coming in for help
• Psychoeducation
• Social & vocational
• Medication
• INTEGRATIVE
INTERVENTIONS
• Merging multiple
methods
• Includes emotional
focus processing of
dilemmas & conflicts
BUT, what about the emotions &
feelings one had during the
trauma? And still has post-trauma
when triggered?
Distorted &
distressing
thoughts and
mood

10. Hearing about
trauma =
10

11. Trauma history is protected information.
Trauma healing can
occur if allowed to
be revealed.

12. Trauma
Processing
Safe Place
Strong
Rapport
Cognitions
(distorted)
Allow for
emotional
expression
Provide
feedback
re: reality
Eventual Goal:
INTEGRATIVE
METHODS

13. Trauma
Processing
Safe Place
Strong
Rapport
Cognitions
(distorted)
Allow for
emotional
expression
Provide
feedback
re: reality
Eventual Goal:
INTEGRATIVE
METHODS
Safe
Place

14. SAFE PLACE 
Provides a healing context
 Creating a space to build trust/ where
survivors can allow themselves to be
vulnerable:
• To disclose and process changes since traumatic
event
• To feel comfortable and not judged
• Provide opportunity to fully express
grief/loss/sadness
–Clients are questioning whether they are
safe with therapist.

15. Trauma
Processing
Safe Place
Strong
Rapport
Cognitions
(distorted)
Allow for
emotional
expression
Provide
feedback
re: reality
Eventual Goal:
INTEGRATIVE
METHODS

16. Trauma
Processing
Safe Place
Strong
Rapport
Cognitions
(distorted)
Allow for
emotional
expression
Provide
feedback
re: reality
Eventual Goal:
INTEGRATIVE
METHODS
Strong
Rapport

17. A bit about RAPPORT...
• How can a therapist “soften” the
tension?
– Know that clients are watching closely
(for reasons to discontinue; “Is this
provider wanting to help me? Able to
help me?”)
– Informal vs. formal approach: first
name vs. Mr., Mrs., Dr., etc.
• Depends on program, care provider
context
– Standardized assessments vs. open
interview (first impressions)
– Flexibility with first few appointments:
interaction

18. • Part of rapport-building:
– Friendly, non-judgmental tone, welcoming to your office,
explanation of how 1st interview, and subsequent
conversations will “look”
– Ask early: “What kind of things are you looking to work on
through (me/us/______(name of agency)?”
– Listen closely to specific problem areas
– Share that you’re listening for whether you/program will
“match” with the needs stated by the client
– Ask at the end of interview if the client has any questions;
ask also if they feel like they’d like to come back
– Offer to share with them during next visit about what
PTSD diagnoses looks like, and the therapy role within
PTSD.

19. Trauma
Processing
Safe Place
Strong
Rapport
Cognitions
(distorted)
Allow for
emotional
expression
Provide
feedback
re: reality
Eventual Goal:
INTEGRATIVE
METHODS

20. Remembering and telling the truth about
terrible events are prerequisites both for
the restoration of the social order and for
the healing of individual victims. Herman (1992)

21. Without thorough assessment and rapport
building: PROTECTED INFORMATION regarding a
traumatic incident may never be disclosed by a
client to their provider.

22. Setting the foundation for trauma processing
• Education about PTSD diagnoses
• Share about the goal of therapy
and counselor’s role
– Discuss compressed/overly
controlled emotions
• Consistency and no surprises.

23. Trauma
Processing
Safe Place
Strong
Rapport
Cognitions
(distorted)
Allow for
emotional
expression
Provide
feedback
re: reality
Eventual Goal:
INTEGRATIVE
METHODS

24. Trauma
Processing
Safe Place
Strong
Rapport
Cognitions
(distorted)
Allow for
emotional
expression
Provide
feedback
re: reality
Eventual Goal:
INTEGRATIVE
METHODS
Trauma
Processing

25. Hearing about
trauma =
25

26. One approach does not appear to fit for all clients

27. What is
there to
process?
GUILT
Helpless
GRIE
F

28. Dilemmas After Trauma
• Unpredictability of life and death
• Unexpected Losses (multiple levels of grief)
• Moral Complexities (incl. guilt)
• Feelings of low self-worth
Boehnlein, JK (2000). Psychiatry and Religion: The Convergence of
Mind and Spirit. Washington, DC: American Psychiatric Press

29. Preparing the client for trauma
disclosure
• Provide basic information (use visual diagram) to share about
PTSD symptoms: fill out specifics together
• Explain how you plan to intervene with current pattern
– “Why I do what I do.”
• Share diagram of emotions and truncated feelings
– “Why I do what I do... Toward feelings.”
• Watch their responses, reassess their understanding, are they
on-board? Have they had this before? Validate discomfort.
Clarify their goals for therapy. Reassure that doing heavy work
too soon will not occur, but avoidance won’t either.

30. TRAUMATIC EVENT OCCURS  No resources to help survivor put that experience (share, feel)- left to
own methods of coping
YEARS LATER  Survivor is probably experiencing increased trauma reactions due to TRIGGERS NOT BEING
IDENTIFIED
TRAUMA TRIGGERS:
Thoughts
about self,
danger, old-
script;
EMOTIONS.

31. Despondent
Despair
Helpless
Grief
Sadness
Depressed
Low
Disappointed
Fear
Loneliness
Hurt, Solemn
Anger Irritated
Agitated
Frustrated
Numb "Okay"
"Fine" No
Feeling
Satisfied
Confident
Optimistic
Excited
Thrilled
Enthusiastic
Ecstatic Joyful
Acceptable range
VICE GRIP ON EMOTIONS
AFTER TRAUMATIC EVENTS
© Daniels, 2012

32. Where the rubber meets the road
• Once you have safe place, rapport,
and context, how to distill out
underlying issues
• Listen: very closely to language
used by client while sharing
• Watch: affect as client shares
• Use: Probing, summary, reflecting,
neutral affect, supportive body-
language

33. QUESTIONS TO ASK THE CLIENT (assessing
for context):
• “How long have you had
____(symptom)?”
• “How often do you have these
thoughts?” (frequency)
• “When was the first time you felt like
this in your life?” (duration)
• “How old were you when ___(incident)
occurred?”
• “What emotions (feelings) are you
experiencing right now as you are
sharing this?”
Where the rubber meets the road

34. QUESTIONS TO ASK THE CLIENT
(assessing for current response pattern):
• “What do you usually do when
___(memory) arises?”
• “Does ___ (behavior) work?” What
effect does that have for you? What
function?”
• “What emotions are you trying to
change?”
• “Have you ever allowed yourself to feel
the emotions connected to your
trauma?” (If so, what was that like?)
Where the rubber meets the road

35. SIMULTANEOUSLY, QUESTIONS TO ASK
YOURSELF: (gathering data via
“watching” and “listening”)
• “What is their affect/body-
posture/gaze?”
• “Do I hear statements suggesting loss,
guilt, unresolved grief?”
• “What statements of ‘I am’ can I infer
from what I’m hearing?”
• “How old would I guess the client is
as they are talking with me now?
(how they present themselves)?”
Where the rubber meets the road

36. QUESTIONS/STATEMENTS TO THE
CLIENT:
• “What emotions are you aware of
right now? Where in your body are
your feeling them?”
• “I notice that you are hunched over
and looking down... What’s going
on?” (wait wait wait for the answer)
• Combining assessment and
observing: more information.
Where the rubber meets the road

37. So many options: clinical intuition

38. So many options: clinical intuition
Watch/Listen:
• Body posture, eyes
• Statement about self
• Specifics about
traumatic incident
– Decisions made
– Full context of
situation
– Use of outcome to
flavor decisions made
during crisis
Therapist options:
(just like they taught us in school –
just mix it up)
• Summary
• Reflection
• Deeper level questions
• Extra information/educ
• Focus on emotions
• Listen... listen, watch,
wait, listen more.
– The whole time thinking

39. Tenacious curiosity + don’t bail
too early.
What is the narrative I’m
hearing? How is this being
shared? First time? Details?
Context? Triggers? Resistance:
verbal, emotional?
Emotions: Fear? Guilt? Grief?
Helpless? How to get
“unstuck?”
TRAUMA STORY REVEALED
More details shared
Context assessed
Emotions identified
“I -- statements” identified

40. Case: Mr. B - VN Vet
(processing guilt and grief)
• Benjamin is a war veteran (65 y.o.) from VN; helicopter door-
gunner; guilt about not retrieving the body of his friend (who
was KIA during training mission in dangerous area).
– His narrative: “I should have gotten him... I have not allowed myself to
grieve him yet b/c we didn’t get his body... I’m still angry about it... The
Capt. Should have let me go – I’ve been on dangerous missions
before... “
“What kind of person am I to leave someone behind?... Who did I become?”
– Prior to processing – a lot more information gathered (tenacious
curiosity – full picture); all aspects of what he recalled were explored
and assessed
• Example: He shared that he had been part of intelligence meetings, which were
often accurate; his commander left for several minutes before telling the vet
“no” about going to get his friend; reasoning for not being allowed to go
changed (wider perspective).
– Processing using all information he provided

41. Case: Ms. M - VN Vet female w/MST
(processing guilt)
• Marianne (63 y.o.) states that her decision to sign-up her ex-
boyfriend on a helicopter for a base air-show resulted in him being
killed
– Her narrative: “I got him killed...and I’ve never forgiven myself for that “
– Prior to processing – more information gathered (tenacious curiosity – full
picture)
– Percentages of Responsibility questions asked
• “What have you been saying about yourself given this incident?” “How often have
you told people that you feel this way?” “How has this effected your life?”
• (Gestalt) “Choose three people in this room and tell them how you’ve been holding
yourself responsible all these years and the impact it’s had on your life”.
• Diagram produced: Processing using all information she provided

42. Diagram: before & after processing
degrees of responsibility
“I’m 100% responsible, he’s dead
because of me.”
Veteran who
was isolated
after the
tragedy; told
that she was at
fault by officers.
“I wasn’t the only one making decisions
that day that caused him to get killed.”
The officers who
arranged the air
show
The politicians who
visited
The helicopter
mechanics
The other pilot of
the other
helicopter
The ex-boyfriend
who coerced the
vet to put him on
the manifest
The Veteran
The designers of
the Cobra

43. Case study:
(processing disempowerment, helplessness)
Mr. L, MST client with recurrent, traumatically-based
nightmares, and lots of triggers
• Larry (61 y.o.), former Air Force, was on special duty at another
base; took a nap in the barracks and was assaulted by another
service-member who came into the room while he slept. Was
threatened 2-3x during assault.
– His narrative: “I didn’t move… and then I didn’t tell anyone what
happened… there was no one to tell…and I really thought he was going
to kill me…”
– Prior to processing: identified more triggers (wood smells, larger men,
being visible, feelings of out of control
– Original target symptom: recurrent nightmare 3x/week
– Client completed CPT and PE at VAMC prior to Vet Ctr.
– Nightmare therapy, action (Wii) therapy, sandplay with new nightmare

44. Case study:
(processing disempowerment, helplessness)
Mr. L, MST client with recurrent, traumatically-based
nightmares, and lots of triggers

46. Emotionally processing traumatic events:
Goals
• Increased understanding of one’s own
unique PTSD symptoms & triggers
• Reduction of hyperarousal &
reexperiencing symptoms
• Reduction of distorted beliefs
• Gain insight
• Reduction of dysfunctional coping
• Permission to have all emotions
• Increased self-worth
• Ability to control PTSD response
(automatic) toward reduced
time/intensity of reaction.

47. NATIONAL CENTER FOR PTSD
PILOTS Database
www.ptsd.va.gov