TRANSCRIPT AND LEADER GUIDE
Crisis Counseling: The A B C Model
And live demonstration with two PTSD clients
A training Video for Beginning Counselors
Kristi Kanel, Ph.D
California State University, Fullerton
Special Acknowledgement is given to Joseph Chang and Desiree
McCune who were willing to share their stories so that others may
learn how to help those in need and to Glennda Gilmour for her
feedback and observations.
OUTLINE OF THE VIDEO AND REVIEW QUESTIONS
CHAPTER ONE
A. Overview of video and introductions
B. Brief historical background of crisis intervention
C. Caplan’s characteristics of effective coping people
D. Definition of a crisis
E. General Goal of Crisis Counseling
F. General Consideration
Pause for review questions
1. How does crisis counseling differ from more traditional forms of mental health
interventions?
2. What are some situations that often create crisis states?
3. Why should counselors be direct and structured when conducting crisis
intervention?
CHAPTER TWO
A. Outline of the ABC Model
B. Cognitive Tree
CHAPTER THREE
A: Basic Attending Skills
Paraphrasing
Open-ended questions
Reflection of emotions
Summarization
CHAPTER FOUR
Begin session with Desiree
Pause for review questions pertaining to Basic Attending Skills
1. How does the counselor show she is paying attention to the client?
2. What were some examples of open-ended questions used by the counselor?
3. What effect did the counselor’s paraphrasing have on the client?
4. When and why did the counselor reflect emotions? What effect did reflections
have on the client?
5. What was included in the summarization?
CHAPTER FIVE
B: Identify the nature of the crisis
Precipitating Event
Cognitions
Subjective Distress
Functioning
Ethical issues
ALTER COGNITIONS
Support and validation statements
Educational statements
Empowerment statements
Reframes
CHAPTER SIX
Continue session with Desiree
Pause for review questions pertaining to identifying the nature of the crisis and offering
therapeutic interactions
1. What was the precipitating event? When did it occur?
2. What are the client’s feelings about the precipitating event?
3. What are the client’s thoughts about the precipitating event?
4. How has the client’s functioning been affected by the crisis?
5. Is this client suicidal?
6. Are there any ethical issues that were addressed?
7. What was said by the counselor to let the client feel understood and validated?
8. How did the counselor educate and help the client see her situation more
realistically?
9. What did the counselor say that might help the client feel more powerful and in
control?
10. What did the counselor say to help reframe the problem?
CHAPTER SEVEN
C: Coping
Getting client to ponder own ideas
Offering referrals
Offering other ideas
Getting a commitment
CHAPTER EIGHT
Conclude session with Desiree
Pause for review questions pertaining to coping
1. How does the client believe that she can start to resolve the problem?
2. What ideas did the counselor give the client?
3. How did the counselor use the client’s frame of reference to provide alternative
ways of coping?
4. How were Caplan’s characteristics of effective coping people shown in the video?
CHAPTER NINE
Debriefing with Desiree, Glennda, and Kristi
CHAPTER TEN
Session with Joseph
Chapter review questions: Go over all of the questions from chapters 4, 6, and 8
CHAPTER ELEVEN
Debriefing with Joseph, Glennda and Kristi
FOLLOWING IS A WRITTEN TRANSCRIPT OF THE VIDEO.
Phrases in bold print will also be shown for a brief moment on the video to
indicate when a specific aspect of the ABC model is being demonstrated during
the session with a client as will a some PowerPoint slides.
K refers to Dr. Kanel
D refers to Desiree
G refers to Glennda
J refers to Joseph
CHAPTER 1
(Tape 3)
Overview of the video and introductions
(PowerPoint slide #1)
K: Hi, I’m Dr. Kristi Kanel in this video I will be discussing the ABC Model of
Crisis Intervention which I have been developing and working on over the past 20
years and which can be found and described in detail in my book, A Guide to Crisis
Intervention which is in its 3rd edition now. In the following video, I will begin with a
brief presentation of the development of crisis intervention, the definition of crisis,
and the goal of crisis intervention. Following that presentation, there will be a
discussion of the ABC model of crisis intervention. Following that there will be two
sessions with two different clients in which I will demonstrate the ABC model of
crisis intervention. After each session there will be a debriefing period with my
colleague Glennda Gilmour, a Licensed Marriage and Family Therapist who has also
been teaching this course for over 20 years.
Historical background
Crisis intervention really began after the 1942 Coconut Grove Fire. (01.45 show
PowerPoint slide #2)Gerald Caplan and Eric Lindemann who were two psychiatrists
in that area, begun something called the Wellesley project where survivors of this
nightclub fire were treated and the families of them. This was probably the biggest
up to date in U. S. history where almost 500 people were killed overnight. And at
that point in history, there really wasn’t any trauma response teams or brief therapy
models. Pretty much everybody was trained in long term psychiatry, and what they
learned to use back then were nonprofessionals. They gathered up teachers,
housewives, clergy, anybody who was interested to help. And they did some brief
training and studied the reactions and coping behaviors of these survivors and their
families. Based on what they learned, they coined the term “Preventive Psychiatry”
because they came to believe that if you could get to these people after a trauma quick
enough, you could prevent them from having psychiatric symptoms later on. Later on
the term “Crisis Intervention” came to be used for the same kind of processes. (end
slide #2 02.41)Caplan and Lindemann in this Wellesley project, after they studied
people, came up with Characteristics of Effective Coping People. Based on these 7
characteristics, he came up with a model that could be utilized in terms of the goals of
crisis intervention.
The first thing he came up with is seeking information and reality. (03.11 PowerPoint
slide 3) It’s very important that when somebody is going through a crisis that they are
provided with accurate and realistic details and information about what they are going
through. And how to be helped and how to get resources.
Another characteristic is freely expressing feelings and tolerating frustration. It’s
very important for people to have their feelings in session with you that and in that
way they can master them.
Another thing he found helpful was actively invoking help from others. When in a
crisis it’s good not to try to handle it alone and so crisis intervention attempts to hook
people up with helpers.
Another thing he found that was effective was breaking things down into manageable
bits and work them through one at a time so a person doesn’t feel overwhelmed by
the trauma that they are experiencing.
(04.06 show PowerPoint slide #4)Along with that is being aware of fatigue and pace
their efforts to cope while trying to maintain control and function in as many areas as
possible. You don’t want somebody just giving up and not participating in regular life
activities during a crisis period but you also need to let them know you can slow
down.
You also want them to learn that to master feelings, be flexible and be willing to
change is very important in learning to deal with a crisis.
Lastly, people who can trust in themselves and others and have an optimistic attitude
about the outcome tend to do better in a crisis.(04.47 end PowerPoint slide #4)
So as we do crisis intervention we always want to keep these characteristics in mind
as we help people through their crisis process.
I’d like to give now a working definition of a crisis. Some people think of crisis and
they think of panic and people freaking out and being out of control. That’s not
always the case. Basically there are certain parts of a crisis that we need to
understand because as we do crisis intervention part of what we’re going to do is
identify the components of a person’s crisis state Once we know these components
and identify it, we understand what their problem is and we do some other things to
help them through it.
(05.32 show PowerPoint slide #5) The first thing we want to understand is the
precipitating event. This is something that has actually happened in their life. It
usually has occurred within the last month before they come in for some kind of help.
It’s important to get that precipitating event because that has triggered the crisis state.
Now many people would think that the precipitating event is what causes the crisis. In
fact, it’s more about how the event is perceived by the particular person, how they
interpret it, and it’s often interpreted in a negative or threatening way. And that’s
what leads to feelings that are unpleasant. What we often call subjective distress or
emotional disequilibrium. Now, if this was all that a person experienced we might
just call it stress because things happen in our life, we experience them as negative
and we have unpleasant feelings. But in order for it to really be a crisis, the next two
characteristics must exist, (06.34 show PowerPoint slide #6) that the subjective
distress or the emotional impairment leads to impairment in functioning. Somehow
their daily living, their work functioning, their academic functioning or perhaps social
functioning is impaired and lastly, their attempts to cope and manage the situation
have failed.(06.57 end slide #6). That is when we have the true definition of a crisis.
So one of the things we’re going to do in the ABC model is identify all aspects of
this crisis for the person.
The general goal of crisis counseling (-7.09, show slide #7) is to increase functioning
and decrease the subjective distress. We take a two-prong approach in doing this.
The first thing we want to do is alter or change the perceptions create the negative
feelings in the first place. It’s really difficult to go in and just change someone’s
feelings, but if we think back and realize that those feelings were caused by the
person’s perception and the way they think about the event, it makes sense that if we
change the way they think that will change the way they feel about the event. The
other thing we want to do is provide coping strategies that will help them cope in
general with the crisis state.(07.51 end slide #7)
Some general considerations in doing crisis work (07.59 Slide #8) is to realize that it
can be useful and modified for most situations. It can be used on hotlines in a 10
minute phone call, it can be used in an outpatient counseling center of some type, at
nonprofit agencies where people might stay for 45 days for a residential facility,
managed care companies and HMOs often use the short term crisis model. And it’s
often used by community trauma response and critical incident debriefing teams.
(08.26end slide #8) In fact if you look up critical incident debriefing, you’ll see that
many of the things they recommend are exactly in this crisis model.
(Cut/delete all video from 08.32-11.53.)
Before I begin the presentation of the ABC Model, I’d like to give your class an
opportunity discuss some of the questions on the study guide that’s provided for you.
(Pause at 12.08 for review questions)
CHAPTER TWO
(Begin video again at 12.10)
The ABC Model is a very structured approach that directly focuses on the
precipitating event, that which brought the client in now. (12.18 show slide # 9) It’s
very important to develop a strong personal rapport quickly and gather information
quickly, yet smoothly. You don’t want it to look like an interrogation. (12.27 end
slide 9)
In general, the A part refers to developing and maintaining rapport (12.33 show slide
#10). This is something you want to do throughout B and C. In the B part, the focus
is on identifying the nature of the crisis and altering cognitions. The C part is a way to
rap up the session and provide coping strategies and referrals. (12.49 end slide #10)
But throughout B and C you want to continue to do A, which are basic attending
skills.
One of the ways in which we change cognitions in the B section, is to identify
cognitions. This seems to be one of the most effective components of this ABC
model. If we can think of a cognitive tree where we start with what the client
presents (13.15-13.19 show slide 11 and 12) identify all aspects of the crisis and
understand how they think about the crisis we are like climbing a cognitive tree
(13.21-13.29 end slide #12)to understand the real essence of what’s causing their
distress.
So this is the whole purpose of the B section. We can’t do any of our altering of
cognitions until we know what the cognitions are in the first place.
CHAPTER THREE
I’d like to now do a brief presentation of the A part which is the Basic Attending
Skills. Basic attending skills include (13.50 show slide #13) basic attending behavior
such as good eye contact, verbal following, minimal encouragers like nodding of the
head, and a very interested posture. (end slide #13 at 14.00) Body language says a lot
and can make the person want to talk or close up. (show # 13 again at 14.06)
Paraphrasing and clarifying are two other basic attending skills, open-ended questions
that begin with how and what, reflection of emotions, and summarizations(end slide
13 at 14.16). I’ll now cover each one of those individually.
Paraphrasing. (14.23 show slide 14) Paraphrasing is a way of restating in the
counselors own words what the client just said. It shows the client that the counselor
understands the basic facts and thoughts. It establishes empathy and a nonjudgmental
stance. It can be done in a questioning form when you’re clarifying a fact that maybe
wasn’t quite understood by the counselor.(14.44 end slide #14)
Open ended questions are best done when related to what the client just said (show
slide #15 at 14.48) We should use a word or a phrase that the client just said when
asking an open ended question so it relates to what the client is thinking about. It
allows the client to explore more of what was just said without leading the client into
territory that may be irrelevant to the client. And it does not make the client feel
defensive like why questions often do. And it doesn’t lead to dead end as does do you
and are you questions often do because those can be answered with yes or no and you
don’t really get much information from closed ended questions. (15.27 end slide #
15)
Another basic attending skill is reflection of emotions. (15.32 show slide #16) These
are best done immediately following a display of nonverbal feelings by a client. They
can be done after a client expresses a feeling verbally as well. You want to keep it
simple. The shorter the better as this allows the client to stay with the feeling. If you
add too much facts and thoughts to it, then the reflection of feeling could get lost and
they lose contact with their emotion at the time. (end slide # 16 at 15.52).
Sometimes you can reflect by pointing out that “I notice you have tears in your eyes
as you talk about this. At other times you could say “you seem sad when you talk
about this”.
Summarization. This is a statement that ties (16.16 show slide #17) together most of
the facts, thoughts, and feelings presented in the interview. It’s very useful when
transitioning from B to C. Beginning counselors might want to summarize, often
they go blank and don’t know what else to do, so a summarization can help a client
talk about what is relevant to them at that moment.(16.34 end slide #17).
At this point we’re going to begin our session with Desiree. You can look for basic
attending skills and you begin this opening segment. After the segment, take time in
your class to discuss some of the basic attending skills that you observed going on.
CHAPTER FOUR
(16.55 Pause tape 3 for insertion of video with Desiree.)
(Tape 1)
Start at 1.03
K: Hi Desiree, I’m just interested today to find out what you’d like to talk about, so
anything you feel is on your mind that you’d like to go over with me I’d be happy to
hear from you.
D: Well Dr.Kanel, I was on campus just a couple of days ago and I had a little
incident where I had a panic attack and I was walking into one of the buildings on
campus and I had seen someone that pretty much had given me bad episodic event
where I saw them and they, I don’t know, something about them just gave me a very
eerie feeling and started to bring up bad feelings and I just had a really bad reaction to
seeing them and I ran into the locker room and started hyperventilating. And good
thing it was at the end of my day where I was going to go to work but I ended up
going back to my car but I couldn’t drive, I was still hyperventilating and I started
crying.
K; That sounds like that was really a traumatic event for you. (insert flashing
subscript Paraphrase at 2.14)
This happened two days ago?
D: Yes,
K: Ok, it’s just that you saw somebody and all of a sudden you went into this panic
mode, and ran to your car, and you were stuck there? (Insert flashing subscript
Clarification at 2.25)
D: I was stuck there for two hours, two and a half hours and I had to call my dad and
I was crying and I told him I can’t drive, I can’t drive, come and get me, I can’t drive,
and he basically, luckily that we didn’t live too far away from campus but he
basically had to sit in the car with me. I couldn’t move. And I was sitting..
K: So for two and a half hours you were crying and panicked and paralyzed (Insert
flashing subscript Paraphrase at 3.03)
K: What were some of the thoughts going through your head at the time? (Insert
flashing subscript Open-ended question at 3.05)
D: Just a lot of memories coming and flooding into me where I could not see straight
and I pretty much was just doubled over my steering wheel saying to myself, It will
go away, it’ll go away, it was just a flood of images just different images of different
periods of time in my life and I just got flooded.
K: Sounds like they were so terrifying that it immobilized you, you just somehow
couldn’t deal with the images (Insert flashing subscript Reflection at 3.34)
D: yeah, I couldn’t deal, I was just crying and my dad couldn’t do anything or say
anything to console me and he was very worried, he’d never seen me have that bad of
a reaction. He’s seen me in public places have reactions, but this was the worst where
I couldn’t drive to another location or make it home.
K: What do you think made this one so much worse than other times? (Insert flashing
subscript Open ended question at 4.09)
D: I’m not, I think it’s just what having a bad experience in the first place I think it’s
just that person didn’t make me feel good in the first place and you just have a gut
instinct, they have this emanation of just badness and it doesn’t mesh with how you
are. And you have a reaction and it just brings bad things up that you don’t want to
have come up It’s the only way I can explain it, I just didn’t mesh with that person.
It’s not as though I have hung out with that person, it’s just intermittent meetings
because you know it’s campus, and you meet a lot of people, you see a lot of people,
and it’s just intermittent meetings for one reason or another you can’t get away from
that person. It’s just bad, bad feelings, bad energies, just bad feelings and I just
couldn’t get away from that person fast enough before that bad feeling began to flood
out of me. It was just an enormous flood where I literally ran out of the locker room.
(cut delete video from 5.52-6.33)
Start again at 6.34
K: So let me make sure I understand, you knew this person that you saw that day, a
couple of days ago, was it a male or female? (Insert flashing subscript Clarification
at 6.35)
D: It was a female
K: So you’ve known this female and you’re saying in the past you always felt some
upset or bad every time you would have an interaction with her. And then this
particular time you saw her the reaction was so bad you run and basically were in
tears, terrified and couldn’t function and so you called your dad. (Insert flashing
subscript Summarization at 6.44)
D: That’s correct
K: You also said it brought up a flood of memories
D: That is correct
The memories were just past experiences from my earlier younger life. I mean, I was
raped consecutively, numerous times,
K: I’m sorry to hear that
When you were a child you say?
D: The last time I was raped I was 17, 18. And they were also sexually abusing me
from a very young age,
( fade out tape 1 at 7.54 and continue with tape 3 below)
CHAPTER FIVE
(tape 3 continued 17.01 Begin again with lecture video)
Before we continue our session with Desiree, I’d like to discuss the B section which
is by far, the meat of any therapy session. This is where we’re identifying the nature
of the crisis, and offering different ways to think about it. Now it doesn’t necessarily
have to be done in the order in which I’m presenting it. Conversations don’t usually
work that way. So what the smooth counselor does is listen to their client and as you
hear something that relates to some of the material, you identify the material as it
seems natural to the client. We want to identify the precipitating event (17.38 show
slide #18) What brought the client in now? (end slide #18 at 17.45)There has to be
something in the past 2 weeks or month that really triggered them to be in a crisis
state. We want to be very direct when we ask these questions. The more direct you
are the easier for the client. When a client is in crisis they need directness. So if you
can help them organize their thoughts, this will help the client present to you the
material you need to help them. (18.13 show slide #18 again) You also want to
identify perceptions, thoughts and meanings about the situation. (18.19 end slide
18)This is not usually done in normal conversations. But this is really important in
crisis intervention. You can’t begin to help them think differently if you do not
understand what thoughts are making them feel bad in the first place. (18.34 show
slide #18 again) You also need to identify emotions and any other subjective distress.
You want to identify their current functioning level and impairments in functioning
(18.41 end slide #18).
There are also a few other ethical concerns that are important to assess whether you
need to do a thorough assessment or not. (18.53 show slide #19) One of these is
suicide. Many people in crisis have suicidal feelings.(end slide #19 at 18.57) They
feel there is no hope, that life is not worth living, and we need to conduct a good
thorough suicide assessment if we get any indication that the depression is severe, or
they might say things like I feel helpless, hopeless, life is not worth living. So a good
suicide assessment is very important.
Also, we might need to assess whether it might be a danger to others (19.21 show
slide #19 again). Additionally, any abuse issues such as child abuse, elder abuse,
disabled adult abuse. These are mandated areas in which crisis worker have to report
to officials. The last ethical issues has to do with medical concerns such as serious
mental illness, any type of dementia or neurological issues, also substance
dependence. (19.49 end slide #19) When somebody is addicted to alcohol or drugs
they need medical referrals to help them work through that physiologically. These are
all ethical issues because there are laws or ethical standards about all of these issues.
Some, we’re mandated to report, others we’re permitted to break confidentiality, and
some require that we have physician involvement. And you know to know the limits
of your qualifications.
Also in the B section is something I call Altering Cognitions (20.18 show slide
#20)There are four therapeutic interactional processes that I have observed over the
years that therapists tend to use during therapy. The first one is called support and
validation statements. These statements let the client know that what he or she is
feeling and experiencing is understandable and difficult and that they are entitled to
their feeling.(20.46 end slide #20) This is not to tell them that “it’s ok to have this
feeling,” or “I totally understand” it’s to say, “it’s understandable” “sure people going
through this feel like this” just to normalize the experience for them.
(21.00 show slide #21) Educational statements are something else we want to offer.
These are comments from the counselor that provide the client information about the
crisis.
(cutdelete video from 21.07-21.30)
They are often used when a client presents with myths or false information about the
crisis. Sometimes just knowing that something is normal reduces subjective distress.
(21.43 end slide #21)
Empowerment statements (21.44 start slide #22) are something else we offer clients.
These are statements that show the clients that they have choices and areas where
they have power. These are particularly useful for client who feel helpless and who
have been victims (21.57 end slide #22)
Reframes. These comments are extremely effective when done properly. They
utilize the client’s frame of reference regarding the crisis. (22.09 show slide #23).
The counselor must slightly change the frame by helping the client see the situation
differently but using the client’s original frame. (22.22 end slide #23) They’re
usually difficult to explain and teach, they usually just occur to the counselor
intuitively, and I’m hoping in our sessions you’ll see a few reframes.
At this point we’re going to continue the session with Desiree after which there will
be a slight pause in the video for you to discuss some of the questions on your study
guide.
CHAPTER SIX
(22.38 pause tape 3 for insertion of session with Desiree)
(start tape 1 again at 7.57)
K: And you’re saying seeing this woman triggered you to remember these events,
these rapes that you experienced? (Insert flashing subscript Identify Precipitating
Event at 7.59)
D: Yeah, they were my father’s co-workers and I just had a flood of energies come
through me and all these memories and
K: When you had those memories what were some of the thoughts you had? I think I
know the feelings, panic, terror. What were some of the thoughts that were going on
in your mind when the memories started to come to you?(Insert flashing subscript
Begin exploring Cognitions at 8.32)
D: Hatred, anger, helplessness.
K: What do you mean hatred? How was that though evolving in your head at that
time? (Insert flashing subscript Climbing Cognitive Tree at 8.54)
D: Hatred just toward the individuals that did me harm because I didn’t I just I didn’t
like what they were doing to me. Helplessness because no one would listen to me.
Because I would be screaming saying help me help me. And anger because of what
they had done to me
K; An anger completely justified.(Insert flashing subscript Validation statement at
9.33)
D: uh uh
K: And hatred because… What exactly about being violated like that brings up so
much hatred in you? (Insert flashing subscript Climbing cognitive tree at 9.42)
D: The hatred is because of having an enormous amount of distrust toward people.
People are not something individuals that I can have a normal relationship. It takes
me a long time to have a normal relationship regardless of it being a friendship or an
intimate relationship. It takes me a long time. I don’t trust people. I have a very
difficult time just outwardly trusting someone and taking someone for their face
value.
K: So what you’re saying is that you hate the people that raped you because that
experience has made it difficult for you now to trust people and have fulfilling
relationship or open relationships. Something like that? That’s why you hate them.
What about what they did to you creates this inability to trust people?
D: The inability to trust people is because I don’t want people to hurt me. I just put
up a very thick wall and make sure that people have an understanding that these are
my boundaries. And don’t cross them
K: So one of your thoughts about having been violated is that everyone’s going to
hurt you or potentially everyone’s going to hurt you.
D: correct
K; Desiree, that’s not true though. Part of you knows that’s not true.
D: It’s not true, but it’s not something that I can say Oh, you’re not going to hurt me.
I’ll let you in. It’s something that I
K: It’s almost like you can’t control that though
D: Correct. It’s just an immediate feeling an immediate emotion, it’s something
that’s continuous when I meet people. I try to make it as open and receptive as
possible except with boundaries. That I’m the one that’s in control of how far the
introductory period is going to go or whether or not I want to go any further, create a
friendship or a professional relationship with that person.
K: You just triggered a thought in me because one of the things you said earlier was
about feeling helpless. No one would help you, and so it almost sounds like by not
trusting people, this is a way you have found to feel in control. Since you can’t, based
on what your experience was, you don’t think you can trust other people to help you
so now you’ll be in control of things and yet what are some of the implications in
that? How has that affected you since the rapes happened and particularly this last
event? What are some of the ramifications or consequences of that kind of way of
being?
D: I don’t’ have very many friends, I have a very secure number of people that are
around me that I know won’t do anything to me/ I keep them I just kind of keep them
separate from other people. I don’t introduce them to anybody. You have, I pretty
much have acquaintances, then professional, then intimate relationships. I kind of
keep them separated.
K: Do you know we call that? Compartmentalizing.
D: uh uh
K; You have heard that term before?
D: yeah
K: It sounds like that’s a way you have managed to control things.(Insert flashing
subscript reframe at 14.11) What do you think about using compartmentalization for
functioning and being in this world?(Insert flashing subscript Cognitive Exploration
at 14.18)
D: I don’t think people understand it. I think people think I’ve actually been told, I
don’t just think it, I’ve been told that I’m very standoffish. And that I’m very rigid
and disruptive
K: So it has some negative implications for you, doesn’t it?
D: Yes
K: And while I can admire and understand you want to be in control because you
were horrifically traumatized, that should have never happened to you, nobody is
prepared and nobody should be ever expected to cope easily with rape(insert flashing
subscript validation statement at 14.49) and you said repeated sexual abuses and
then not being believed. That’s really beyond anybody’s capacity and it leads to Post
Traumatic Stress Disorder. Sometimes we call it Rape Trauma Syndrome.(Insert
flashing subscript Begin Education statement at 15.16) You’ve probably heard of
PTSD.
D: Correct
K: And so sometimes, what happens is until we work it through, until you work this
through completely, you still manifest some of these symptoms and I think the other
day when you saw this woman, you had the flashback, ok that’s all part of Post
Traumatic Stress Disorder. Having flashback, it triggers the same feelings, and so
what that indicates to me and maybe you can see this is that you haven’t completely
worked through the rapes that occurred to you over time earlier on. Because it’s still
triggering events now. And although you’ve tried to take control through
compartmentalization and for some periods of time you feel safe and together, when
things like this happen,(insert subscript reframe at 16.08) it maybe can serve as a
reminder. And maybe it’s not so bad because it kind of presses the point that you
have some more work to do.
D: uh uh
K: And it’s not anything about you being weak or you can’t handle it, nobody should
be expected to handle those kinds of horrific traumas.(Insert subscript validation
statement at 16.20)
D: uh uh
K: And so it’s normal and it makes sense that you would have struggled and continue
to struggle especially in relationships.(insert subscript validation statement at 16.32)
Because your perception about the event is I can’t trust people now.
D: correct
K: And so that in a sense, although you feel in control, the fact that it’s still affecting
you kind of indicates that you’re not quite in control. My preference would be to
move you into being a survivor of this. And not still a victim of it. Insert subscript
reframe at 16.54) But as I see it, the fact that you’re still trying so hard to be in
control and having these functioning problems you’re still somewhat victimized by
this. And to gain power it means taking a look at some of these thoughts you’re
having that because these people hurt you and certain people didn’t believe you
maybe you’re thinking that no one will believe you, almost anyone can hurt me. And
that kind of keeps you trapped in that victim role.
D: uh uh. I’ve actually been working on myself, I’ve been just kind of when I get the
opportunity I just look at the memories, I write them down in a journal and I just say
OK, you know, those people are not in my world anymore, but I have to
acknowledge what it is that is in the back of my head. And I have to ..
K: When you say what’s in the back of your head what are you talking about?
D: Well it’s just residual memories, the flashbacks that I have are just residual
memories and I have to say to myself that I have to take control and I have to
understand and I have to just go into a quietness and just acknowledge what it is that
has happened. So through my journaling I am able to just write down everything and
just read through a period of time and just say this happened, this happened, this
happened, but having an understanding that nobody’s going to be able to do this to
me again I’m just older, I’m stronger, I have an understanding. I’ve also got involved
with yoga so that’s allowed me to open up and be more pay more attention to myself
and give myself more what I need instead of trying to you know as you say
compartmentalize everything. And try to be more loose.
K: Well I’m impressed with how much you’re doing that’s a lot of work you’ve been
doing as you acknowledge that still is problem, can we say that,
D: yes
K; the thing that concerns me is this thing the other day that just by seeing somebody
you got yourself in such a state you weren’t able to drive and in terms of safety and
things like that. (insert subscript Identify impairments in functioning at 20.10) Is
there other ways in which, since that event how have you been functioning? How
have you managed since that event?
D: I’ve just been talking more to my parents. My parents have been more receptive
to the way I am.
K: How’s school? How are you doing in school?
D: School’s OK. School’s good. I have a good gpa considering I’ve been working
long hard hours. So my gpa is very good and I’m happy with the way school is, but I
notice that I’ve been using school as a crutch. It’s kind of been pay attention to
school, pay attention to school and then everything else will kind of line up and you
can deal with what you need to deal with later, but right now school’s more
important, school’s more important. Emotions are not so important.
K: What do you think about that last statement you made? Emotions aren’t that
important.
D: I have to pay attention to what’s in front of me because my past has held me back
for so long. I want new and improved and better things. But I understand that I have
to work through my past but I can only do so much at one time. I can’t say I can do
all this at the same time
K: I’m glad to hear that (insert subscript Caplan’s characteristic #2 at 21.59)you’re
tolerating that, that you’re not trying to fix it all at once. That’s important that you
kind of (insert subscript Caplan’s characteristic #4 at 22.09)let yourself work
through it slowly, step by step and acknowledge it and I hope that you can kind of see
that you have a process of working towards becoming a survivor of this, because you
did survive it. Like you said, it’s not happening again, it’s not going to happen again
probably and you made it through and I wonder if you can turn that into a positive for
yourself.
D: uh uh
K: That which does not kill you makes you stronger. And by the fact that you
survived it, and you looking at it can be a strengthening thing for you (insert subscript
Empowerment statement at 22.41)
D: I’m looking at it as a strengthening effort because everything that I’m doing. I
mean my studies help me go into an area that I never would before. So
K: What do you mean by that?
D: Well my studies are within the psychological venue and so I’m picking up books,
that are saying well, how to heal and how to be more full of courage and look at
yourself from the inside out. And I’ve been reading books on how to document my
feelings and how to document my emotions and putting it on paper and putting it
where I can read it and putting some place that’s in front of me instead of putting it in
back of me. So as long as everything is in front of me I feel that yes, I’m going to say
it’s an important role of control, but maybe it wouldn’t be so rigid form of control,
maybe an aspect of control where I can look at it and see it instead of running away
from it. I think that’s really what it is that I’m working on. Instead of running away
because running into a locker room is running away and not facing it. If it’s in front
of me and I can see and I can read it, then I can understand it and it won’t be so
fearful.
K: That’s brave of you. It really is. To face it. I agree with you. I think that’s
what’s going to make a turn for you. To see yourself as a survivor. (insert subscript
Empowerment statement at 24.29)This way you don’t let those guys, that attacked
you, you don’t continue to let them violate you. You know you said you had hatred
because you’re thoughts were that because of them I can’t trust people
D: right
K: So one way you can let go of that or at least not give them the power over you
anymore is to continue to face it so that you could trust. Because my imagination
tells me that you’d probably want to trust people and not have those, you said that
there were some social issues and some major personal problems because of this.
D: right
K: So continue the bravery in facing it is important.
D: I feel that’s the only way that I’m going to be able to go forward and I don’t want
to go backward because my schooling has been really good, I’ve got a good gpa, and
I want to continue and I want to go to grad school. That’s the only, that’s pretty much
what I’m looking at as far as my healing is concerned. And if I continue on this path,
and I know I’ll be a stronger person.
K: Surviving something like this can only make you stronger. It can actually make
you stronger and develop stronger coping skills then maybe people who have never
gone through traumas. I always think about the people who maybe survived the Nazi
concentration camps or who lived in war torn countries. How much strength they
must have inside them to have endured that. (insert subscript reframe at 25.42) And
this is just something that unfortunately happened to you and it can actually be a
strength producing situation for you
D: uh uh
That’s my goal.
(Fade out tape 1 at 26.10)
Review questions
CHAPTER SEVEN
(Begin tape 3 again at 22.47) Before we conclude the session with Desiree, I’d like
to cover a little bit about the C part of the model, the coping part. The most important
thing to remember about moving into this section is to have the clients think about
what they would like to do to begin to resolve their situation. And you want to do
this before the counselor starts to offer their own ideas. (23.14 show slide #24)By
having the client ponder their own ideas and then using these ideas as a starting point
for the counselor to brainstorm, then you can offer referrals and other coping
strategies that the client is not likely to resist because it came from them in the first
place.(end slide #24 at 23.31) So you want to ask the client about any ideas about
what he or she would like to do. (23.35 show slide #25) Then ask the client to think of
other ideas. Maybe things that have worked in the past maybe things they would tell
a friend to do. And you want to encourage clients to do those things and then you start
offering alternative ideas (23.44 end slide #25).
Some of the things you might offer them to do (23.48 show slide #26) might be a
referral to a support group. These are groups usually run by a professional or a
paraprofessional but it is run by a counselor usually for people that have gone through
the same situation. You might refer them to a 12 step group. These are done by
nonprofessionals, usually not run by a professional, things like Alcoholic’s
Anonymous, Gambler’s Anonymous. These usually follow the 12 step traditions and
are pretty well known. They’re wonderful interventions because you can go 3 times a
day 7 days a week and they’re free so they’re ideal for many people.
You might refer somebody for a medication evaluation if they seem to be suffering
from a severe mental illness or their symptoms are so severe that they cannot
function. Sometimes it’s a temporary medication regime that they’ll be put on. A
physical examination might be recommended so that’s an option and you might offer
a physician referral. Legal assistance is something that is sometimes necessary, as are
referrals to various agencies, shelters, or other clinicians.(24.55 end slide #26)
Sometimes, you, the crisis worker will just continue to work with a particular client but
you might offer them homework assignments. (25.00 show slide #27) Maybe you’ll have
them journal and write about something specific. You might do assertion training and
recommend them to go through an assertion training class. Reading books related to the
crisis is often helpful as is watching films. Stress management classes are often very
helpful as well as are college classes.(25.20 end slide #27)
One thing you want to do before you end the session is get commitment from that client
that they’re going to do something. (25.26 show slide #28). You want to have a definite
plan of action and a commitment that they will follow through. (25.30 end slide #28)
We’ll now finish our session with Desiree, and afterwards, there will be a slight pause in
the video for you to discuss the chapter questions.
CHAPTER EIGHT
Conclude session with Desiree
(Continue tape 1 at 26.10)
K: What do you think specifically now that this event happened a couple of days ago,
what do you think would be some things that you can do more specifically to ensure that
maybe that doesn’t happen again?(insert subscript Start having client brainstorm
coping strategies at 26.11)
D: Well I avoided the location a while,
K; What do you think about that?
D: I don’t think it’s , I don’t that’s really doing me any good by avoiding the situation. I
think it’s creating more tension inside of me where if I avoid it then I’m not facing it.
And it’s animosity within myself because I’m not saying, Ok this situation happened, but
you can’t avoid the situation, you have to face it , you have to acknowledge it, and so
therefore I haven’t acknowledged it, I’ve kind of hidden it away from me so that’s not
really a good
K: Are you saying you don’t really want to keep avoiding that location?
D: No
K: So what do you think you could do to get yourself to that location?
D: By just going, just being there, just making my presence known, by being more
assertive and just saying I own this situation, I own this location. Everything here belongs
to me just as much it belongs to somebody else. I’m a student here, I have just as much
right to be here
K: And how could you inoculate yourself, like what if you ran into that woman again?
What are some things you think you could do?
D: I would hope not to run away, I would hope to just stand my ground. I and just if I do
have emotions come flooding to my head again, I would just stand there and count on my
inner strength to just take the bearing. Just be able to take the burden just let it be.
K: What are some things that you could maybe say to yourself if you were to run into
this woman that could help manage and master those feelings?
D: She’s not them, she’s not them That’s basically
K: And she’s not going to hurt me.
D: And I won’t allow her to hurt me.
K: Ok, that works better for you.
D: Yes, I mean that would be something that would be verbally and mentally said to
myself.
K: That’s something you could remember to do?
D: yeah, definitely
K: Anything else you could think of that you could do to master your feelings and work
on issues like trust issues
D: I try to spend as much time with people as possible by giving them an opportunity
and chance but if I feel discomfort I try to work through it but if it’s discomfort that I
can’t bear, I just walk away. Because it did not make me feel good
K: When you feel the discomfort, what’s that discomfort like?
D: Nausea
K: Nausea, so what’s something that you could do maybe to overcome that feeling?
D: I really don’t know
K: You said you take yoga and they talk about take deep cleansing breaths (insert
subscript using client’s previous ideas at 30.00)
D: Well it’s sort of like a meditation
K: There’s training in breathing though?
D: yes, they have different style of breathing where you just calm yourself down but I
would definitely have to walk away.
K: Could you walk away temporarily, take some cleansing breaths and then go back?
Excuse yourself, take some deep breaths and then get back.(insert subscript offer coping
at 30.20)
D: That would be a possibility, I have not yet done that,
K: Would you be willing to try that?
D: I would definitely be willing to try that.
K: Same thing if you ran into that woman. You might as well use your yoga for other
situations it would be beneficial. It actually,(insert subscript education at 30.50) taking
in breaths like that and slowly breathing in and out it reduces your pulse it reduces your
blood pressure, it does increase relaxation response in general. And because a lot of what
you’re experiencing is PTSD symptoms of anxiety, it’s almost an ideal thing for you to
contain the physiological symptoms that happen to you.
D: right
K: That’s something that I hope you really will practice doing on a regular basis. When
you’re around people and start feeling a little anxiety, catch when it first starts, it’s
probably the best way though
D: yes
K: So maybe something you can do is pay attention to the beginning symptoms, a little
bit of nausea, when you get that oh oh feeling, that little sense, maybe that’s when you
can do the deep breathing and contain yourself physiologically and that can help you and
then you can do your cognitive messages to yourself. Would you like to try those things?
D: yeah, I definitely, I mean, I can say that I will definitely (insert subscript Got
commitment at 31.45) try that but it always depends on the moment. Like oh, oh oh,
breathe. Because sometimes,
K: that’s why I was asking you to recognize and identify the potential beginnings of a
panic attack or the potential beginnings of needing to run away or get away from people.
And force yourself to be reexposed cuz there is a creation of a little bit of a phobia and
that’s kind of conditioned because of the original trauma so is this something you can
begin to do is identify and pay attention to yourself so that in the end what I’d like to see
happen is you can strengthen and enhance your relationships with people.
D: I do want to enhance my relationships. I do want more friendships, I do want more
intimate relationships but that’s something that it’s going to be slow, it’s not going to just
happen.
K: But this is just one extra thing to offer you that you can maybe try. Ok?
D: Ok
(End video at 32.55)
Chapter review questions
(cut delete video from 32.56-33.09)
CHAPTER NINE
Debriefing
(start video tape 1 at 33.10)
K: Now that we’ve completed the session, I’ve brought my colleague, Glennda Gilmour,
who’s been teaching crisis intervention courses for the past 20 years, and she is going to
give some of her comments about the session which she has been observing. I wanted to
kind of structure it in terms of the ABC components. Glennda, did you observe anything
in particular during the A part which we know A actually covers B and C. So can you
make some comments and observations about the use of basic attending skills?
G: Well besides looking at your client, and nodding and letting her know through
nonverbal you were paying attention, you also paraphrased and reflected constantly
throughout the model, clarifying what was going on and just opening your client to talk
more.
K: So that’s the effect. Can you think of a reason to keep these basic attending skills
running throughout?
G: Well, it makes it more personal, it’s easier for the client to not feel that they’re being
drilled, that you want to know what they’re saying. You want to be with them.
K: Now as a client were you aware of what she’s talking about? The use of paraphrasing
and reflection. Not just a bunch of questions at you. Did you sense that as the client?
D: Yes I did.
K: And what effect do you think that had on you as a client?
D: I think it’s very soothing, I think that when you are paraphrasing what somebody has
said you are more understanding and more personable with the individual you are
speaking with.
K: So you feel that I understood what you were saying
D: correct
K: Now Glennda, when we moved into the B, what did you notice going on in the B
section in terms of cognitive exploration and the kinds of therapeutic interaction
comments?
G: Well you were constantly, one thing you said was What do you mean by hatred? You
were clarifying exactly what that meant for her. What her meaning was behind the
thought. Because we can’t just assume we know what the client says. You were
clarifying the feelings, you were talking about how her not being able to drive affected
her currently since this happened. Exploring her whole world. And how it affects her
relationships, her driving, her physical body,
K: So trying to tie in the precipitating event and how that is affecting her functioning.
G: right
K; And why do you think that might be important?
G: Well I don’t think clients normally think about how this is affecting them. And by
clarifying that, in a sense gives them control. It shows what is working, what isn’t
working and what they can do.
K: Ok and did you notice the use of any educational statements, validation,
empowerment statements reframes?
G: A lot. Educational about what PTSD is for example, what specifically are
flashbacks?
K: I was wondering what effect that had on you Desiree to be educated about PTSD?
D: I think that when educating, being educated about what a person is experiencing I
think that also gives a manifestation of control where the client, being me would have the
opportunity to have an understanding of what it is that the emotional experiences are.
K: Ok, anything else you noted Glennda?
G: You talked about how she puts things into compartments and I noticed later she was
using the words. And she had literally taken in what you had taught her and was applying
it.
K: And how do you think that could be effective or helpful?
G: Sometimes it helps to actually know the words, of what you’re doing. It gives you
control. And you now know how to work with it.
K: Anything else you noticed about empowerment statements, validation comments in
particular?
G: Support statements, how difficult this must be that she’s talking to you
(cut delete 37.28-39.18)
(pick up again at 39.19)
K: So Desiree how did you feel with me pointing out to you that it must be difficult, it
must be terrifying, me pretty much validating how difficult that is?
D: When you’re asking me the questions, well not really asking me, but you’re asking
me the question of how difficult it is for me, I feel you’re more compassionate with how
you are interested in how you are trying to get more feelings and emotions I feel that it’s
an opener where I will just give you and release what it is that I am experiencing.
K: I found that many times beginning counselors are afraid to mention to a client how
difficult it must be or terrifying because they might be afraid that it would make you feel
bad. But it sounds like that’s not the case with you. That it actually makes you feel more
open and understood.
D: It’s an open release for me, it’s something that you are opening the door to my
understanding and my experiences. You truly want to hear what it is that I have to say.
K: Now you noticed some empowerment statements or any other forms of reframes?
G: One reframe was that flashbacks can show you where you need to work instead of
being terrified it can be something good.
K: What did you think about that, the idea that instead of flashbacks being a negative,
they can be a positive because they’re communicating to you, something’s not right
inside and I need to work on this? How did hearing that make you feel?
D: The incidents with the flashbacks is definitely communicating where my weaknesses
lie in myself
K: So you didn’t mind hearing that way
D: no
K: That could be a helpful thing for you
K: And were there any empowerment statements that you noticed?
G: Yeah, you showed how she could take control of what she’s going through. By
seeing someone, she survived this. She gets her body back.
K: Did you feel empowered at all during this session?
D: yes I did, I did feel empowered
(cut delete video from 41.49-42.00)
K: What do you think made you feel empowered?
D: I feel the empowerment stemming from the understanding of taking the flashback
incident and having control over that and just and letting it occur, letting it happen,
looking at the visions, and just acknowledging that they’re there. Taking the time instead
of running away.
K: Ok, now the last thing I wanted to comment a little about was the movement into the
termination the C part, the coping strategies. Glennda, did you notice how that was done
in particular, where you saw that moving towards we’re going to finish this session?
G: Basically talked about what she is doing right now how she’s thinking about how in a
sense that is a sense of control of the situation. She mentions she’s journaling, breathing
yoga and then you continually explored that with her that what she’s doing can actually
be a strength for her, how she can use it to cope, to survive. You didn’t just stick on that
but you explored among other things.
K: Yeah, often in order to come up with a good coping strategy, I listen to what they’ve
talked about earlier on and then I try to make sure that I get it from them that might be
useful for them so it makes more sense to them rather than me just throwing that on there
to her.
G: you took we she offered and you expanded it. Yoga is also learning how to breathe.
Plus how you think.
K: And I really meant what I said about the physiological aspects of PTSD and how deep
breathing can really reduce a lot of that and it can be a great benefit. Do you think that
you will follow through with that?
D: Yes
K: Ok, so it was realistic to offer that as a coping strategy?
D: Yes
G: it was realistic because she was already doing it.
K: But it had to come from her first. Ok, is there anything more either of you ladies
would like to say?
G: Well you talked about how could she prepare herself if this happened again and
basically if this precipitating event happened again, she’ll have some ideas on how to
handle it
K: That’s one of our goals for crisis work is to learn a coping strategy should a future
precipitating event or trauma occur.
Anything else? Is that it for now
G: Probably for now.
K: Ok thanks
D: Thank you.
(end video tape 1 at 44.51)
(Cutdelete video tape 3 from 25.42-26.11)
(26.12 tape 3 continue) I’m now going to conduct another session with a different client,
Joseph. He’s an Iraq war veteran and this time we’re not going to interrupt the session
for review questions. So they’ll be no pauses. But I do want you to watch and assess and
see if you can find the ABC model in usage with Joseph.
(End video tape 3 at 26.34)
CHAPTER TEN
Session with Joseph
(Begin tape 2 at .46)
K: Hi Joseph, today I thought we’d spend a little bit of time and I know there’s been
something that’s been troubling you so please feel free to tell me a little bit about
what’s been going on
J: Yes, I am involved with the student veteran’s association on campus and we’re
preparing this veteran’s appreciation event and I got to interview with this journalist.
And his question about my experience during deployment kind of made me think
about..
K: Deployment where?
J: Deployment to Iraq
K: Oh, Ok
J: Made me think again, it’s been already 2 years and I had a flashback of some of
the incidents and the journalist asked me the names of the soldiers that got killed
during the operations, and I was trying to give him a correct name but that also
triggered me to think about the details of the deployment which gave me some of the
PTSD symptoms.
K: When you say PTSD symptoms, what are you referring to?
J: It’s been 2 years after coming back home from the deployment to Iraq, within
about 6-8 months I was going through some sensitive anger issues and nightmares
K: When you say sensitive anger issues, what do you mean? (insert subscript
Cognitive Exploration at 2.23)
J: I’ll say it’s 2 different issues I guess. I’d be very sensitive to the noises and
surroundings and also the conversations. I was very sensitive the topic of war and
government and it triggers me to be angry, resentful, and sad
K: Did these just stay feelings inside, or did you act out the angry feelings or sad
feelings at all?
J: No I didn’t get to act out. My personality is pretty calm and I’m very empathic, I
try to understand where other people are coming from. So I don’t act out like that, but
usually go inward. So I’ve been kind of repressing that feeling
K: Mostly the anger? What about the sadness you mentioned?
J; Yes, I’ve been kind of repressing it inwardly because people don’t understand, that
probably is my judgment but at the same time it’s usually true. People who were not
there have a hard time understanding what I’m going through. So I figured that it’s
not worth talking about and it usually brings people down. So I’d rather not talk about
it,
K: Sounds like you’re trying to protect other people by not talking about it, is that
what you’re saying?
J: Protecting, I would say, not wasting their time.
K: oh ok,
J: Because they wouldn’t understand
K: So this conversation with this journalist kind of triggered a resurgence of
remembering specific events that happened in Iraq when you were deployed
there(insert subscript Identify Precipitating Event at 4.13)
J: yes
K; And then since that conversation with him what have you been doing, how have
you been dealing with that, or what’s happened with you?
J; First of all his question about was there any other soldiers who got killed around
me or the soldiers that I knew that were killed, that made me think of going back, to
the time where yes I had soldiers who got killed around me and I think that was fine
with me because I took that as it’s a natural thing, it’s a combat it’s a war, so people
die. So when I was there I was more calm and more stable with that however when
the journalist asked me about that after 2 years, it really gave me a strong flashback of
his face. The conversations we had before he dies, and that it was a strong emotions
that I felt, and felt sorry for their family again,
K: That sounds like sadness
J: Oh yes
K: When you say strong emotion I’m thinking you’re talking about sadness
J: It is a sadness, and enough of this would be an anger toward the situation, toward
the policy toward the decisions that the soldiers are there, dying
K: So some of the thoughts you have about it are that you don’t like the decisions for
the soldiers to be there and die? Is that what you’re saying that gets you angry?(insert
subscript clarification at 6.18)
J: right the fact that this war becomes more unpopular, I don’t want to get political
here but yeah our soldiers are doing their best yet the situation many times is not
getting better, many soldiers are dying, so
K: And that gets you angry(insert subscript reflection at 6.50)
J: It gets me angry, sad, mixed emotions, so yeah I went through severe sadness,
anger, resentment for about 6-8 months, until I got back to school, I decided to start a
veteran’s support group because it’s also a requirement for my major to do an
internships so I was doing an internship at the woman’s center and adult reentry
center to help students and I decided to start this support group and that has been a
great healing process for me, trying to support the soldiers and veterans who have
been through a similar situation, and taking care of their needs,
K: Sounds like it’s taking care of your needs as well
J: Exactly, I didn’t notice until recently that I have no more strong extreme sadness,
anger, resentment because I’m spending positive energy toward other veterans
K: And yet, when this journalist brought up this soldier that you knew that was
killed, it did trigger
J: Right
K: remembrances of that
J: right
K: And one of the things I was thinking about is that you said that when you were
there in combat, and you saw people killed, you seemed to not have a reaction to it,
and yet now when you think about it you are having a reaction to it?
J: Luckily I didn’t get to see that through my own eyes. It was my prayer, I prayed
everyday that I don’t get to see anything, I don’t get to shoot anybody, and I don’t
want to get shot, I was luckily out of the place when something happened and
something would already get cleared up when I got somewhere, so I was pretty lucky
but I got to hear and see the aftermath of the vehicle explosion and so forth
K: And that was traumatic
J: Yes, very traumatic
K: Seeing the aftermath. What were your thoughts when you did see the vehicles
after the explosions?(insert subscript Cognitive Exploration at 9.15)
J: You know, the thing about that is, soldiers that are deployed that are constantly
operating in this kind of pressured and alert situations, they do not feel much. It’s a
constant numbness. If you start focusing on your emotions, you cannot do this. This
is a very difficult job. It’s such a tremendously pressuring and you have to get over
your emotion, you have to get up and go, so when I was there as combat support, and
mail operator and supply sergeant, I had to repress those thoughts and move on,
K: What thoughts did you repress?
J: Wow, people actually got blown up in this vehicle. Just brief thought and brief
emotion.
K: What would be thoughts associated with knowing somebody was killed?(insert
subscript Climbing Cognitive tree at 10.25)
J: That’s going to be, it’s very extreme emotion and feeling, sadness, just, it’s all
kinds of mixed feelings that cannot be explained at one given time
K: It does seem like it’s hard for you even 2 years later to really think about it
J: right
K: And that’s part of that PTSD you were talking about. You know it sounds like,
you mentioned feeling numb, it almost seems like the PTSD starts as soon as the
event happens.
J: right
K: and it begins there, where you numb yourself, and then it just continue throughout
after coming home, there’s more escalation of it. When you were there, were there
flashbacks and other symptoms that you’re having now? Or when you’re there,
you’re such in the heat of it you don’t have the thoughts and the recurring nightmares
or any of those symptoms of PTSD?
J: That’s the environment where you don’t get to think and act according to your
emotions
K: Because you’re hypervigilent which is another symptom of PTSD.. It seems like
the numbness and the hypervigilence, 2 symptoms of PTSD are there at the time
J: But more numbness. The reason why is, where I was I was transferred to 3
different remote places in Iraq. We got mortar attacks all the time. Mortar incoming
is such an easy weapon for them to use and it’s hard to detect, so they would use it I
would say 2-3 times a week, you have mortar incoming and you just don’t know
where it’s going to land and the noise of it the impact of it is just tremendous. And
when you first get there within like 3-4 weeks, you are hypervigilent , you are just so
concerned, you’re so worried, but after that after a certain time, you just can’t be like
that anymore because you got to sleep, you got to eat, you got to do what you got to
do to continue your mission. And many times these mortar landing misses a lot of
people usually end up damaging generators buildings some unlucky people might get
killed. It’s like a random chance. So after a certain period of time you start feeling
numb, you disregard it. It’s a dangerous thing but you cannot focus on it, you have to
move on
(cutdelete from 13.08-13.29)
K: It almost seems like what you’re saying is that you began being hypervigilent, like
you could be prepared for things, but then after time, there’s this realization that
things are happening out your control
J: exactly
K: and it’s almost like an attempt to just survive it rather than escape it or master it.
J: right
K: and that is so typical of what we see with PTSD, but the way I’m thinking about it
and maybe this makes sense to you, when you’re first there, you’re kind of in this
acute stress,
J: right
K: ok, and then after a time or so, a month or so, as you get used to it, you almost go
into like prisoner of war mentality which is like instead of thinking of escaping they
think about surviving.
J: right
Exactly, you know like the soldiers who are driving, for a mission, goes through a lot
of this because they are on the road constantly and the roadside bombs are the biggest
threat for us. And at the beginning of deployment they’re all anxious, all nervous,
who’s going to get hit, what’s going to happen, am I going to be able to survive until
the next day? Everybody’s nervous, but after 2-3 weeks of random, missing of
bombing or no bombing at all, when the situation is so hard to predict,
K: yes
J: They just become numb, and they will just go on the next mission, whoever gets
that bomb, bombing or that attack, I mean, it’s just hard to, it’s out of our control, it’s
out of our control, so we just have to deal with it
K: What goes along with that statement, “It’s out of my control…”(insert subscript
Cognitive Exploration at 15.18)
Is there another thought that goes along with that?
J: It’s a war, It’s a war and
K: So like you just have to put up with it?
J: We have to be strong
K: OK
That’s what you tell yourself, I have to be strong?
J: Exactly That’s the whole military mentality. Otherwise you are not going to be
able to be sane, and stay strong
K: What does strong mean? How is that embedded in you, I must be strong?(insert
subscript Climbing cognitive tree at 15.45)
J: That is disregard your emotions
K: That what strength means to you, disregard your emotions?
J: All the concerns and worries are not going to help your mission, so
K: And now, how much of that thought part of you now?
I must be strong and not show my emotions.
J: right now, well I’ve been living in a much better place now, now I got to appreciate
this civilian life, this life that I have,
K: So when this journalist asked you this and you had this flashback, how much did
that thought enter your head, I must be strong and not share or have or show my
emotions?
J: I went through a brief flashback of that mentality, but now I’m not. I do not tell
myself that I have to be strong. Or I have to disregard my emotions. Luckily I’m a
human service major so I’m learning about how important it is to be focusing on my
emotions. That education helped me be more balanced, but at that moment, I was a
soldier again and seeing somebody dead, or hearing of someone’s death, I have to
move on without crying or talking about it, it’s such a hard thing to do, it’s such a
torture sometimes, and that kind of came up in my head so when it was brought up
K: What’s the most tortuous thing about that?
What makes that so hard for you?
J: Someone that you knew has passed away and not in a good way but in a very
brutal way of death and dying and also thinking about their family, as well as
K: what do you think about when you think about their family and the fact that this
was a tortuous death?(insert subscript climbing cognitive tree at 18.14)
J: I think the situation especially when he had only 1 month left in his deployment,
he survived all the mortar attacks, all the rocket launcher attacks, all these crazy
things and then 1 month before he was going home, he got in this accident and he
died, and that was very unfortunate because I helped him pack his stuff and he was all
ready to go home, he was very happy to see his family. He sent his email, he sent his
video message to his family so..
K: You have such compassion and empathy for other people (insert subscript
reflection at 19.08)
J: I think it’s my nature.
K: I’m just thinking wow, someone with so much empathy must be filled with
emotion and now that you’re safe here maybe the real strength comes with sharing
your emotions and not running from them or repressing them but having them. (insert
subscript reframe at 19.21) It takes strength to acknowledge that pain and deal with
all those feelings. That’s a new way to think about strength now maybe. Maybe back
then it was necessary to not have them so you could do your job, but now maybe the
real strength comes in coming out of that PTSD, surviving it and having some
emotions, and acknowledging then to get past the PTSD
J: right
K: because typically, it’s hard for people to overcome the PTSD without sharing
their emotions and feeling them. (insert subscript Educational statement at 20.03)
With PTSD, typically you have someone who either has flashbacks and recurring
nightmares in other words they reexperience the trauma, and then they alternate
between repressing the trauma. And there has to be, you want to get to the point
where they don’t have uncontrollable flashbacks, and they don’t repress the feelings,
that would be the optimal way to help you get to the optimal point that you want to be
at
J: right
K: and maybe you have some thoughts that it’s been 2 years and I should be over it
J: yeah, that’s part of it, but I know it’s not going to go away, forever. Learning from
the WWII veterans and the Vietnam veterans, it’s always there forever, but it’s hard,
Luckily I have this passion to help other veterans and I truly believe that what goes
around comes around and the support and the care that I want to provide will come
around and really heal a lot of my symptoms. And
K: How do you think it did that?
J: It’s hard to tell. I don’t even know how it happened. After 2 semesters of having
this organization, I just had a little time of looking back and I just realized I’m no
longer going to VA hospital for counseling. I used to go to hospital for counseling
for 6 months, and I did want to do it because I did want to focus on healing. Without
that I was functioning normal, happy, happy emotion is something that is hard to get
while you’re going through PTSD
K: yes
J: But I’m very satisfied with my activities in school, my involvement and having
good time in classes
K: it must be weird then to out of the blue you talk to this journalist and you have
this resurgence
J: exactly
K: and these flashbacks
J: exactly
K: which might not be a bad thing. It might just mean it’s a communication to you
“Maybe I need to do something else, a little different, something more, “You know I
was struck with the groups, maybe they are so beneficial because you don’t feel like
you are wasting their time. Like you felt like you didn’t want to tell other people
because you’d be wasting their time
J: right. Because we all know, we’re all on the same page. We don’t have to explain
anything. We just know. That common interest and common experience
K: you know I see that, that almost brings tears to my eyes because I’m thinking
how, I don’t know what the word it but it’s so poignant, it’s so (insert subscript start
reframe at 23.05)lovely in a sense that you have that unique common bond with
other human beings. That only you guys can connect to. I liken it to my motherchild bond with my son. Nobody else gets to have that bond with him but me. And I
love that. And I’m wondering if that’s something you can see about you
J: exactly
K: having that connectedness, it makes you so special and it makes your relationship
with them so special.
J: yeah, you know, commradery is not in vein, it’s still there
K: it’s very spiritual because it’s such a connectedness
J: right
K: and that could turn into an inner peace(insert subscript complete reframe at
23.40) and through talking and getting through these things, I’m just wondering if the
journalist could trigger these things in you because you don’t have that commradery
with the journalist.
J: no
K: You might not have had that reaction had it been a fellow veteran asking you that
question
J: right
K: interesting phenomena
J: thank you that’s an interesting point of view and it’s true. If a fellow would have
asked me, I would have had different emotions and attitude about that. Yes, journalist
has different take on that yes
K: sure, I’m just impressed that you would be willing to talk to a journalist about that
because this is so painful and difficult. (insert subscript Begin having client
brainstorm coping at 24.26)What things do you think at this point where you’re at
now, since you had the experience with the journalist , what do you think would be
something you could do just enhance and strengthen and help you in the future to
prevent having any further kind of uncontrollable flashbacks or downswings? What
do you think you could be doing for yourself at this point?
J: I think going through that kind of emotion is not really easy to prevent, but it’s
natural, it’s natural, but I think continuing what I’m doing right now, continuing
helping or sharing
K: When you share do you feel feelings?
J: We do not usually talk about the war. We usually talk about the veteran issues,
veteran social events, something more positive.
K: You think it would not be helpful to talk about your feelings related to action?
J: No I think it is healthy and we actually have done some. We are planning for that.
But in a school setting, in this kind of busy environment, it’s just hard, we need to
focus on, we need to prepare, we need to focus on having some kind of special event
for that. So I think that’s going to bring more healing to veterans. But it’s not just
everyday talk, so it’s a little bit different.
K: What about for you and your feelings, and you being able to access them and
share them and (insert subscript Caplan’s characteristic #7 at 26.12)master them
and be in control of them. Because it’s kind of hard to be in control of your feelings
if you don’t have them, if you don’t embrace them, and know them and feel them.
It’s like you’ll never really be in control of them or master them
J: I think I’ve done a lot with reviewing my own emotions, I checked in with my
emotions while I was at the VA hospital
K: That was helpful?
The VA counseling, that was helpful?
J: yeah but the only thing that I stopped and started going to school was the travel. I
was in school, I had a busy schedule. I had to travel from Fullerton to Long Beach in
the middle of the traffic. And then come back to school was very difficult. I was
thinking, we have 300 veterans in school and if they all have to go to the Long Beach
or other place, why don’t we have something in school because we already have a
good number of people that can use it. So that was my motivation and this group of
students actually were able to talk to school and got some promises from the school
that we have some kind of facility for veterans in the future, the near future that will
be able to provide some kind of referrals and some kind of support and services for
the veterans.
K: You know one thought that I had was going back to the strength thing,(insert
subscript reframe at 27.47) how you’re strong if you don’t have feelings, and how
that’s kind of embedded in soldiers, and back to the idea that maybe the real strength
now is in having your feelings
J: right
K: so that you can master them. I’m almost thinking wouldn’t you like to help
others, how would it be for you to take that role as role model to show other veterans
how to have feelings and that it’s ok and necessary so you have the strength to be the
one with the feelings so that they can let loose and have feelings
J: right
K: in a slow way. I’m not saying to (insert subscript Caplans’characteristic #6 at
28.21)let them all out at once, but letting them know through example that it’s ok to
have feelings, the real strength now comes in embracing those feelings, knowing
them
J: right
K: It’s no longer strong to hold them in.
J: right
K: because in a sense that weakens you because it prevents you from being fully
yourself
J: exactly
K: because if you’re repressing any part of yourself you’re not fully alive. And
maybe not able to have full emotional expression and joy(insert subscript reframe at
28.40)
J: exactly
K: if you’re repressing anything
J: yeah, actually thank you for acknowledging that, I think that’s a great point. Yes
that’s part of my mission is that soldiers, most soldiers cut loose and can be who they
are but when they are around students, faculty or nonmilitary people they have to
stand tall and look good. This macho mentality and they are our heroes, this
stereotype this feeding from all these messages make them very unemotional just like
you pointed out. So among the veterans now I see many veterans are starting losing
their kind of strong attitude and they start becoming who they really are,
K: Well my idea is changing the definition of strong, like it’s not necessarily strong
to not have emotions. Because you’re cutting off a piece of yourself.
J: right
K: And if you’re cutting off half of you, you’re only half of a person. And that can’t
be the strongest you that you can be. (insert subscript reframe at 30.02) And so that
might be another way that I hope maybe you can look at
J: right. Actually I don’t think we really use that word anymore, strong, strength,
K: but it’s implicit The idea that I have to stand up
J: right
K: and be a hero
J: It’s an embedded message in their language and thoughts
K: you could be a forerunner in that and be a role model for people on how to have
pain and how feelings make up the whole of you. A whole you is stronger than a half
of you.
J: Right. It might be a little challenging
K: Of course, this whole thing is challenging.
J: right
K: my gosh, you survived something most of never even get close to and so I just
want to personally thank you for your service and being willing to go do that for us
J: thank you
K: Is there anything else you can think of that you want to do that you think would
help you at this point or we can end our session
J: No I think my feeling was felt and my story was heard. I feel good. I will continue
to do what I’m doing.
K; Is there anything else you could do, like one little thing you could add onto what
you’re already doing? One small movement (insert subscript Get commitment at
31.25)
J: Well just like you said, I would like to be a role model as far as having an emotion,
K: You think you can try that?
J: yeah, being a full human being again and enjoying life and I would like to invite
other veterans as a part of a new team, new group so we can enjoy school
environment again.
K: OK thanks
J: thank you
(end tape 2 at 32.09)
CHAPTER 11
Debriefing
(CONTINUE TAPE 1 AT 32.30)
K:Ok, now that I’ve finished the session with Joseph I thought we’d do just a little
debriefing again with my colleague Glennda Gilmour and Joseph and kind of get of
feel of some of her observations and some of Joseph’s reactions. So Glennda, as you
watched this session, what are some things you noticed about the use of basic
attending skills and especially cognitive exploration?
G: You explored his cognitions well, used reflection “that was traumatic for you”
“what were your thoughts” specific thoughts that Joseph was thinking, “what
thoughts did you repress?” you constantly explored what this meant, his personal
experience.
K: Do you remember what some of the cognitions were that Joseph expressed to
some of those questions?
G: To be strong, not to show any emotions
K: Now how was that used later on in terms of any of those therapeutic interaction
statements?
G: You made it into a reframe by saying that was a strength actually it was
something that he could use
K: Yes, and that is what we want to do in a reframe. Take their original frame of
reference and thought and change it around just a little bit to allow the person to think
differently. In fact Joseph, do feel that was effective for you, that particular reframe?
J: Yes, it was very helpful, made me think again, I hadn’t thought about it, I had
insight for me to carry with me.
K: Now did you see or observe any other kinds of therapeutic interaction statements?
Empowerment, educational, anything like that?
G: Educational, yes. You clarified the various PTSD symptoms such as
hypervigilence, But also that it occurred a month afterwards vs. what happened at the
time.
K: I tried to tie in the previous situation which started the PTSD symptoms or what is
known as acute stress disorder and then show how that has developed into a delayed
PTSD reaction
G: right
K: How did that fit for you or what did you do with that information when I educated
you about that?
J: That it’s already known, it’s normal. And what I’m going through, this particular
precipitating event happened to other people as well. It kind of gave me a sense that
this is something I can work at and get better.
K: And that’s one of the reasons we provide those educational statements is to help
normalize events and normalize PTSD symptoms and evidently Joseph that would
make you feel like you could overcome this.
J: right
K: Because it’s more normalized
Did you experience or feel that there was any validation or support comments from
me at all?
J: Yes your knowledge of these PTSD symptoms, your working with similar
individuals like me gave me a confirmation and also a confidence that yes you do
know what you’re talking about and what I’m saying could be heard thoroughly
K: That’s an interesting point that education statements could make the client feel
confident because I know what I’m talking about and therefore what does confidence
do for you?
J: That I’m not going to waste my time, and we could be productive together
throughout the session, so that’s some kind of hope and positive thoughts.
K: Glennda did you notice anything else that you would like to mention or that you
thought was particularly helpful?
G: Well in a sense you gave him power.
K: How so?
G: Because he thought that having emotions and talking about it was maybe a
weakness, but you empowered him that he could control it now He can choose where
he shares
K: Yeah, did you notice that Joseph? That concept that if your emotions happen to
you with a trigger, like what happened to you, you’re out of control of them. But if
you take charge of the emotions and embrace them, it’s an empowerment type of
process.
J: Right, it’s something that I realized once again that soldiers do have emotional
problems, it’s a big problem. And your reframing that gives me an insight that wow
this is something that I need to work with my veterans as well as myself so it’s a new
agenda for me and it made me realize that this is something that I have to work
continually. So it was good. It was good to hear that.
K: Is there anything else Glennda that you wanted to make a comment on, or Joseph
anything you want to make a comment on?
G: Well you did a lot of clarifying. Like, “what was the most tortuous thing?” You
went into what some may be afraid to go into because you don’t want to open up your
client. But you showed him you were willing to go there with him.
J: right
K: and that’s part of climbing the cognitive tress. You really want to understand it
from the client’s point of view
G: You have to be willing
K: well even though I could never really went on there, and I’m not quite sure I want
to, but I want to try to do it as much as you’re willing to let me know what’s going on
your head.
J: right, that’s a good point. Yeah, she did explore the area that is sensitive that is
challenging but because you did it I was able to break that door and started thinking
about it. And there is a lot hidden there. So, appreciate that.
G: And you weren’t alone, the support was that she was with you.
J: right
G: of opening the door
J: and I fully feel that I was heard and just being able to be heard, someone hearing
my story and understand, that’s empowering I think to me. That’s good.
K: OK, well thank you, thank you very much.
(end tape 2 at 39.18)