What to expect when being counselled for trauma and post-traumatic stress disorder
Information for clients - August 2017

Common responses to traumatic events

Following traumatic events you are likely to experience a range of unfamiliar psychological, emotional, and physical reactions. Different people exposed to the same trauma may respond in different ways. You may have difficulty in collecting your thoughts and handling your feelings about what has happened. This article will give you an idea of some general ways in which people often react. We hope the information will help you to understand and handle your thoughts and feelings.

The first few days and weeks

Most people are affected in some way by trauma. In the first few hours people may be shocked and stunned and have difficulty believing what has happened to them. In the days and even weeks following an event, many people will continue to feel confused, distressed and fearful. It is important to understand that to think and feel this way immediately following trauma is a normal response to an abnormal situation.

The sorts of experiences that are reported may include:

• being on edge – on the lookout for danger, worrying that something is going to happen 
• being jumpy – easily startled by loud noises, sudden movements, etc 
• difficulty sleeping – difficulty in getting off to sleep, waking up during the night, having vivid dreams or nightmares
• intrusive memories – thoughts or images of the traumatic event ‘come out of the blue’, or are triggered by sounds, smells, or sights that somehow bring it all back
• feeling as if it were happening again – this may feel as if the traumatic events are recurring all over again
• feeling overwhelmed - by intense feelings and bodily sensations that you feel you cannot handle
• guilt and shame – feelings about letting yourself or others down, about being in some way responsible, or because you survived when others didn’t
• anxiety – feelings of fearfulness, nervousness and sometimes panic
• sadness – feelings of low mood and tearfulness
• anger – at the injustice or the person who is responsible 
• emotional numbness – feeling detached and unable to have feelings
• withdrawal – retreating into yourself, avoiding company
• disappointment – thinking that other people (including family) do not understand
• mental avoidance – of thoughts and memories associated with the event
• behavioural avoidance – of activities, places, people and situations which remind you of the incident
• physical reactions – such as feeling shaky, trembling, muscular aches, tiredness, difficulty concentrating, being forgetful, palpitations, shallow rapid breathing, dizziness, stomach upset, nausea, vomiting and diarrhoea, disturbance of menstrual cycle or loss of interest in sex
• impact on relationships – the experience of trauma and bereavement can however sometimes place strains on relationships. You may feel that too little, or the wrong sort of help and support is offered, or that others do not appreciate what you have been through and expect too much of you
• drink and drugs – sometimes, there is a tendency for people to rely on drink or drugs as a means of coping
• loss of confidence and self esteem – feeling that nothing you do is good enough
• feelings of irritability, frustration, and anger – if things do not work out as you want

Understanding post-traumatic stress

It is important to emphasise that there are no right or wrong ways to react after a traumatic experience. Everyone’s reactions will be individual and not everybody will experience all of the feelings described above, nor experience them to the same degree.

Individual reactions will vary from those of other people for a number of reasons, including: 

• differences in personality
• differences in ways of expressing emotion
• differences in styles of coping 

People also vary in terms of: 

• their previous experiences of trauma
• the extent to which there are other stresses and strains in their life
• the amount of support and help they have
• their capacity to understand and process their reactions/responses to trauma 

While most people involved in a traumatic incident will be shaken by what has happened, and may experience some of the problems listed above, most people adjust well to their experiences and recover within the first three months to a level where they are able to get on with their lives as they did before. This is not to say that people forget what has happened. It is possible to come to terms with past events, put them in perspective, and carry on with your life.

But not everyone does reach a state of recovery. Sometimes the problems listed above are still causing difficulties many weeks, months or years later and interfering with life so much that professional help is required.  

If after several weeks or months you are still experiencing many of the problems listed above, and they are interfering with your life so that you are struggling to manage at home and work, it is likely that you are experiencing what counsellors refer to as post-traumatic stress. Sometimes just knowing this and that there is a name for what you are experiencing can be helpful. 

One of the things that many counsellors will do is to try to help you make sense of your experiences. They may say something like the following: 

“When someone is exposed to a traumatic event there is so much going on, so much to take in, that it’s like we hurriedly pack an imaginary bag with our thoughts and feelings, which we then take away with us from the scene of the trauma. However, this ‘emotional luggage’, because it has been badly packed, may frequently burst open from time to time or when it is ‘knocked against’ something. This is often experienced as distressing thoughts, images and feelings. What we need to do is unpack and repack the bag to help us make sense of what happened. This can be very upsetting to do, and we might not want to do it, but eventually it allows us to re-arrange things so that we can carry the bag without it bursting open unexpectedly.”

Making sense of the next steps – professional help

Where to seek help

If you wish to find out more about the availability of confidential counselling you could, in the first instance, approach your own GP, who may be able to advise you on options and put you in touch with someone who can help. Some options may be: 

• a counsellor in the GP surgery
• a mental health professional from the local community mental health team (psychiatrist community mental health nurse, social worker, psychologist, specialist therapist or occupational therapist)
• specialist trauma and bereavement services

Specialist services are available in some areas and accessed for you by your GP. If there are no services locally, your Clinical Commissioning Group (CCG) may be able to fund you to attend specialist services for assessment and treatment in another part of the country.

Support may be available from organisations such as Cruse or Victim Support.

There is also an increasing availability within the voluntary and charitable sector where you can seek help from a trained counsellor or psychotherapist with experience in working with post-traumatic stress.

You may wish to seek help privately from a therapist or counsellor. Ask them about their experience, qualifications and most importantly their experience of working with psychological trauma or traumatic bereavement.

Some occupations provide for peer-support interventions, where people who are trained to offer support to colleagues can do so. This is particularly the case within the armed forces in areas such as combat stress and some high risk occupations such as the rail industry where similar peer-support schemes might be available.

Sometimes it might be helpful to talk to a counsellor who has experience of working with people who have had similar experiences to you. They may be able to help you to think through the things you can do to help you manage your thoughts and feelings. There are many forms of counselling and you should explore what is available, both on the NHS, and where there may be a long wait for NHS therapy, perhaps look for free or low-cost therapy options locally. Ask your counsellor to describe the type of therapy they offer, what it involves, how long it might last, etc.

The important thing to remember is that you shouldn’t feel as if you have to do anything you don’t want to do. Your counsellor might make some suggestions for doing things that they think will be helpful but an experienced counsellor will only do this when they think you are ready. If it turns out that you are not ready to do the things they suggest or you don’t agree that it would be helpful, an experienced counsellor will not then push you further. You are in the driving seat. A counsellor or psychotherapist who is registered with BACP will be working within our Ethical Framework and will respect your decisions and your right to autonomy.

What to expect from psychotherapy and counselling

Psychotherapists and counsellors are skilled at listening to people and can offer people valuable help in working through trauma and what it means to them, and in rebuilding their lives. One of the most important aspects of trauma is recognising that life for us has changed and our old ways of looking at the world sometimes don’t seem to make much sense anymore. Sometimes we have to rethink the ways in which we live our lives and what is important to us. We need to take time to reflect on what we have learned from our experiences. Working with an experienced counsellor or psychotherapist can give us the opportunity to do this.

Also, trauma sometimes has the potential to be a springboard for something positive. In the aftermath of the struggle with adversity it is common to find benefits. People often report that their values change in such a way that they have learned to live life more fully, or that they appreciate their family and friends more, or that they feel themselves to be in some ways wiser, more mature, and stronger as a result of their experiences. 

Talking things through with a counsellor or psychotherapist can be helpful. Sometimes they will offer suggestions for ways to deal with some of the specific problems you might have.

Cognitive Behavioural Therapy (CBT)

Research suggests that a type of psychological therapy, known as Cognitive Behavioural Therapy (CBT), can be effective. It is especially effective for the treatment of psychological trauma. CBT operates on an understanding that how we feel and behave is linked to what we think (our cognitions). So, we can change our behaviours and modify how we feel by paying closer attention to our cognitions and learning to identify new cognitive strategies. The focus here is on the identification of the shattered beliefs and assumptions and the rebuilding of these through what is described as ‘cognitive restructuring’, in other words trying to help individuals think differently about the experience and develop new meanings. Trauma-focused CBT attempts to change problematic meanings of the traumatic experience such as ‘what happened shows that I am bad/inferior/ useless person’, ‘I cannot trust anyone anymore’; and changing problematic coping responses, such as thought suppression, ruminating on negative outcomes or selectively attending to threat.

CBT is conducted over a relatively short space of time, usually 8–12 sessions, over a period of months. It is an active form of therapy aimed at helping individuals to develop ways to confront and eventually overcome their fears, avoidances and anxious thoughts. Techniques include:  

• challenging anxious thoughts
• confronting feared situations in a safe environment
• diary keeping 

Exposure

One technique that is often used as part of CBT is called exposure. Avoidance of fearful situations is common among people who have experienced trauma. But the more avoidant we are, the less chance we have of learning to overcome our fear. Exposure involves exposure to the feared/avoided situation. Sometimes this is just done in the imagination with the therapist getting you to think about the thing you are frightened of. For example, someone too fearful to use public transport might be asked to imagine going on a bus. Sometimes, it is done in real life situations, where the therapist might accompany you on a bus trip.

Depending on the circumstances, sometimes exposure is done gradually. If the thought of going on a bus is  just too much, the therapist might start by asking you to imagine standing at a bus stop, and over time work up to actually going on a bus. 

Imagery rescripting

Different techniques are also used in CBT to help you to deal with the upsetting memories. Imagery rescripting  is a technique where you are encouraged to think of your memories as ‘ghosts from the past’. You will be encouraged to transform your images in memory using more creative imagery, so they become less distressing. For example, you may be asked to imagine watching the image on TV, then switching it off, making it smaller, further away, dimmer… freeze the image, make it black and white.  

Eye Movement Desensitisation and Reprocessing (EMDR)

A technique known as Eye Movement Desensitisation and Reprocessing (EMDR) is often included as part of CBT, or counselling and psychotherapy. This technique involves the counsellor sitting close to you and passing their hand back and forth across your field of vision). While this seems strange, and it is not fully understood why this therapy is helpful, research suggests that it is often very helpful. The technique will be explained by your therapist if they are considering its use. 

Another technique that is sometimes used is Emotional Freedom Technique (EFT). EFT stems from Thought Field Therapy (TFT) which has developed specific trauma treatment involving the therapist tapping at points (similar to the acupuncture points) on the upper body (in TFT the client may tap on themselves, following the therapist’s guidance. This could be important if unwanted or invasive touch has been the source of the trauma). This does not have the same robust research support as EMDR but some clients may find it helpful.  

Medication

It is also common for people suffering from low mood, anxiety, or panic attacks to be supported with medication as well as talking therapy and in these instances your therapist might recommend that you discuss with your GP the possibility of taking a course of antidepressants or other medication. Some people do find medication helpful, but not everyone does and it is important that you talk this through with your therapist and GP. In many cases, psychological help is all that is needed for people to recover from trauma, and medication can always be considered at any point in therapy if additional support becomes necessary. 

Children and trauma

Children, adolescents, and young people may also experience trauma and develop psychological problems. In most respects their reactions are similar to adults. But there are differences. For younger children, especially, there may be repetitive play in which themes related to the trauma are acted out. There may be a regression to behaviours typical of when the child was younger, (typically in toileting or language). As adults we have to be careful to listen to children and to watch what they do as they may not be able to put into words how they are feeling and what difficulties they may be having. Other ways in which trauma is expressed in younger people is through: 

• somatisation, the young person might complain of stomach pains or headaches
• fears of being alone, monsters, or the dark, seem exacerbated
• hyperactivity, being so full of energy that they can hardly sit down
• a combination of the above, ie clinginess alternating with hyperactivity
• aggression, temper, problems at nursery or school

Some self-help tips

There are many things that you can do that are likely to be helpful: 

• accessing and accepting support from others – it is important not to reject support by trying to appear strong, or trying to cope completely on your own. Often, talking to others who have had similar experiences, or understand what you have been through, is particularly important. (However, some people who have been involved in the same traumatic situation as you might unwittingly add to your traumatic experience)
• taking time out for yourself – in order to deal with your thoughts and feelings. You may however at times find it necessary to be alone, or just be with close friends or family
• confronting what has happened – confronting the reality of the situation, eg talking may help you come to terms with the event 
• staying active – the body and mind are connected, so keeping active, taking exercise is important. It can help us feel better. But it’s also important to be aware of any obsessive exercise/ activity, which can mask coping difficulties 
• returning to your usual routine – it can be helpful to return to your usual routine as soon as possible 
• finding ways to manage your feelings – such as learning how to relax, to find ways to make yourself feel better 
• thinking through how your life has changed – working out how to live your life differently now 
• express your emotions – take the opportunity  to review the experience within yourself and with others, let your family share in your grief. Children need opportunities to express their feelings to a safe and responsive adult, using children’s ways of learning and thinking about their world, such as stories, drama, art or sand play

Conclusion

Following a traumatic event it is usual for people to be troubled by memories of what happened and to feel  on edge. Some people continue to be troubled months later and then it is advisable to seek professional help. This takes different forms, but this article will prepare you for what to expect if you visit a counsellor or a psychotherapist. They may use a variety of techniques, which may include cognitive behavioural therapy, exposure, imagery rescripting, eye movement desensitisation and reprocessing, TFT or EFT. But it is important to know that you should be in charge of your therapy. This means that an experienced therapist will not put you under pressure to do something you don’t want to do. 

Some useful reading

Adults

Herman, J.L. (1992) Trauma and Recovery – From Domestic Abuse to Physical Terror. Harper Collins. London. 

Regel, S. & Joseph, S. (2010) Psychological Trauma – the Facts. Oxford University Press. 

Children

Dyregrov, A. (1991) Grief in Children: A Handbook for Adults. Jessica Kingsley, London. 

Self-help

Kennerley, H. (2000) Overcoming Childhood Trauma: A self-help guide using Cognitive Behavioural Techniques. Robinson, London. 

Advice on medication 

Moncrieff, J. (2009) A straight talking introduction to Psychiatric Drugs. PCCS Books, Ross on Wye.  

Useful websites

General trauma websites

David Baldwin’s Trauma Pages (an excellent portal for trauma related information and resources)  

UK Psychological Trauma Society (UKPTS)  

NICE Guidelines PTSD

Useful organisations

British Psychological Society  

British Association for Behavioural and Cognitive Psychotherapies 

The European Society for Traumatic Stress  

International Society for Traumatic Stress Studies  

Victim support 

Cruse Bereavement Care  

Combat Stress  

VIVO Foundation (For Narrative Exposure Therapy – NET) 

About the authors

Stephen Joseph is Professor of Psychology, Health & Social Care at the University of Nottingham, where he is co-director of the Centre for Trauma, Resilience, and Growth, and an Honorary Consultant Psychologist in Psychotherapy in Nottinghamshire Healthcare NHS Trust. 

Steve Regel is principal behavioural psychotherapist and Co-director of the Centre for Trauma, Resilience and Growth, Nottinghamshire Healthcare NHS Trust in the Centre for Trauma, Resilience, and Growth and an honorary lecturer in the school of sociology and Social Policy at the University of Nottingham.  

Belinda Harris is Associate Professor in the School of Education at the University of Nottingham. Belinda is an experienced school teacher, humanistic counsellor and Gestalt psychotherapist with special interests in children and young  people. She is responsible for the postgraduate counselling practice programme at the University of Nottingham. 

David Murphy is a Chartered Counselling Psychologist and employed as a lecturer practitioner in trauma studies at the University of Nottingham where he is responsible for the management of the student placement unit in the Centre for Trauma, Resilience, and Growth.