Common Client Issues in Counselling An Australian Perspective Trauma in Adults

TRAUMA IN ADULTS 171 Trauma in Adults AMY JOHN AND BRYCE ABSTRACT Clients with presentations seeking counselling are a unique with specific needs and challenges . The nature of this work can be both challenging and rewarding and have significant potential to affect the individuals life trajectory in positive ways . Counselling can provide a forum to assist with support , validation , and processing of trauma to assist people to live to their potential . Therefore , this chapter will provide an overview of types of trauma and the psychological effects of trauma . It will identify relevant screening and distress assessment tools relevant to trauma , as well as an overview of possible interventions . The chapter then discusses considerations for counsellors when working with clients . Learning Objectives Describe the nature and types of trauma and possible psychological effects . Identify screening tools relevant to trauma across the lifespan . Understand risk and protective factors among individuals and priority groups . Increase awareness of growth and resiliency . Consider relevant professional issues when working with clients , Gain awareness of possible interventions . INTRODUCTION The term trauma represents an aggregate grouping of salient , negative life events and their associated psychological sequelae . This chapter is intended to provide a broad overview of the nature and types of trauma , and the ways in which counsellors can assist individuals and groups to recognise trauma , provide , and clients with assessment and therapeutic interventions . This chapter is not intended to provide an exhaustive account of all traumas nor intended to be a compendium for the treatment of trauma . This is highly specialised area requiring further training and under ongoing clinical supervision to ensure safety , wellbeing , and duty of care for both the client and practitioner . Counsellors may work with clients with trauma in a range of settings ( domestic and family violence ) however given the high rates of lifetime prevalence ( estimated at and for lifetime prevalence for any potential trauma ) et al . 2020 ) and de and ( 2009 ) 171

172 argue that trauma is likely to be a common feature of client presentations and history within any counselling . A trauma response is something that one experiences that is typically out of the ordinary and may initially be life shattering . Some traumatic events may be anticipated ( knowing that a flood may occur at some time in a specific region , but not knowing exactly when this may occur or the death of a loved one after a long and arduous battle with cancer ) A traumatic event , however , is often unexpected , whereby the individual experiences a range of predictable and typical reactions to something highly atypical and potentially life threatening . Traumatic events can be one off , acute isolated events ( earthquake , sexual assault , house fire , accident ) or experienced as ongoing ( repeated childhood sexual abuse , due to political circumstances ) likewise , they may have been recent or historical , including from childhood ( et , 2007 Higgins , 2000 et , 2005 et , 2013 ) People may also experience a range of distinct traumatic events throughout their lifetime , which may result in cumulative and confounding trauma and potentially poorer . Trauma reactions are most commonly experienced by those directly exposed to the however , vicarious trauma can also occur as a result of being exposed to other people traumatic ( as counsellors ) or based on the viewing of repetitive media images ( such as after occurred in the USA ) Lowell et , 2018 ) Other examples of traumatic events include climactic ( cyclone , floods ) domestic and family violence , political ( terrorism ) and trauma associated with hate crimes ( discrimination , assault or persecution based on gender , sexuality , or ethnicity ) People may experience trauma in relation to distressing birth events or a diagnosis of a chronic health condition ( fear of cancer recurrence or stigma associated with HIV ) et , 2004 et , 2018 et , 2015 ) Trauma may also coincide with public health emergencies ( pandemic ) and disaster responses ( both directly and vicariously and with cumulative effects due to repeated exposure , other factors salience of the trauma . Mental Health First Aid may be provided to assist with psychosocial support after such events ( Jacobs Meyer , 2005 ) The wide range of examples provided here regarding trauma is intended to demonstrate the heterogeneity and those associated with individual experiences and help you to build a context and terminology regarding trauma when working with future clients . Within an Australian context it is estimated a lifetime prevalence of of a potentially traumatic event ( Mills et , 2011 , 2002 ) Further , the majority of Australians will experience at least one traumatic event during their lifespan , however , individual reactions and adjustment processes vary tremendously . Australian research suggests that the most common traumatic events experienced by Australians are experiencing an unexpected death of a close loved one witnessing a person critically injured or killed , or finding a body and being in a car accident ( Phoenix Australia ( PA ) 2019 ) Like the wide range of trauma examples , the individual effects and trajectories can vary if two or more people have experienced the same event at the same time . Reactions and adjustment to trauma can also be heavily influenced by how a trauma was dealt with at the time and the extent to which the individual felt sufficiently supported , as well as psychological factors ( de et , 2020 ) For example , if an adolescent has been sexually assaulted and then attempts to seek support from their parents and is not believed , experiences a negative interaction with police when trying to make an official report , these subsequent experiences will likely have further compounding ( sense of injustice , vulnerability ) and negative ( defectiveness , helplessness ) associated with the compared to if the individual had felt well supported after the incident ( see et , 2019 ) Seeking support and not receiving it can result in further trauma or secondary . PREVALENCE OF TRAUMATIC LIFE EVENTS IN ADULTS Most people will encounter a traumatic at some point . Exposure to a potentially traumatic event ( is a common experience , with large community surveys in Australia and internationally revealing that of people report at least one traumatic event in their lives ( et , 2016 ) include any threat ,

TRAUMA IN ADULTS 173 actual or perceived , to the life or physical safety of a person , their loved ones or those around them . While are not uncommon experiences , only a small number of people who encounter trauma will go on to develop stress disorder ( et , 2017 ) Overall , the prevalence rate of in the general population ranges from to ( et , 2017 ) Some groups may be predisposed to , as relevant to social of health and minority stress theory , and these predispositions may include childhood environment , prior exposure to trauma , psychopathology , and life stress ( et , 2016 ) Additionally , demographic variables like gender , race , and socioeconomic status can be risk factors for developing following a ( et , 2016 ) and . Further , people who experience discrimination and ( migrants , members of sexually and gender diverse ) may be less likely to engage with formal due to past negative experiences or fear of future mistreatment and may require more innovative health promotion approaches ( see et , 2020 ) and staff training ( see et , 2017 ) to more appropriately meet the needs of these at risk , priority communities . While there is a chance that the majority of people will encounter a In their lifetimes , there are some jobs that pose increased risk . Emergency service professionals ( such as police , firefighters , paramedics , emergency nurses and doctors , defence force personnel , and State Emergency Services , are frequently exposed to as part of their everyday work that may be considered traumatic . In unique and challenging work environments , are often required to provide immediate and urgent interventions in crisis situations and operate under conditions that may present some personal danger . Consequently , the prevalence of is higher among than the general population , ranging from to ( Dobson et , 2012 Forbes et , 2016 et , 2015 et , 1996 et , 2017 ) COURSE OF TRAUMA REACTIONS , DIFFERENTIAL DIAGNOSES , AND CASCADE OF IN ADULTS Trauma , as described above , is a psychological and emotional response to a distressing event or experience , such as an accident , an assault , or a natural disaster ( American Psychological Association , 2021 ) Such traumas may be singular or multiple in nature , and the research suggests that repeated and chronic trauma is more common through maltreatment , and ( Higgins , 2000 , 2005 ) maltreatment has been proposed as a theoretical framework for understanding the interrelatedness of the five childhood abuse types ( sexual , physical , emotional , neglect , witnessing domestic and family violence ) however is a model which focuses on in childhood in the broader sense , taking into account other forms of , including but not limited to , bullying , neighbourhood conflict and crime which might in childhood ( et , 2013 ) is also a broader model , exploring the same adversities as , although from a whole of lifespan perspective ( Bryce , 2018 ) To acknowledge the multiplicity of trauma , the term complex trauma is used to the complexity of traumatic outcomes for survivors of repeated traumas across the lifespan . Two diagnosable conditions are recognised as possible outcomes of trauma and complex trauma , acute stress disorder ( and post traumatic stress disorder . It is important to acknowledge that all presentations of and are caused by trauma or complex trauma , but not all trauma results in these diagnosable conditions . This highlights that these two terms speak to the heterogeneity of traumatic and . In the case of , similar initial conditions may lead to dissimilar outcomes , depending on the mix of ecological risk and protective factors . holds that multiple causal pathways can result in the same outcome , In this case maltreatment . In the acute phases after a traumatic event , it is expected and typical for individuals to experience a wide and variable range of anxiety ( stress , and depressive ( low mood ) symptoms ( American Psychiatric Association , 2022 ) This can initially manifest as an acute stress reaction or an adjustment disorder ( as per the ) which over time and after a longer duration of course may be better accounted for by a diagnosis of . Beyond the symptoms of , those with are 80 more likely to have another mental health condition , in comparison with those without ( et , 2004 et , 2013 )

174 The most common include mood and anxiety conditions , such as major depressive disorder , which has a with of 50 ( et , 2013 ) Further , among people within inpatient substance abuse treatment centres , it is estimated that approximately 50 meet criteria for ( 2008 ) In an attempt to symptoms , individuals exposed to trauma may also develop related conditions associated with use or substance dependence ( van Dam et , 2012 ) This indicates that a serious disorder such as can have a significant effect , which may adversely impact many aspects ofa person life . TRAUMA SYMPTOMS AND DIAGNOSTIC CRITERIA IN ADULTHOOD Diagnosis , whilst not typically in the scope of a role , is critical knowledge which informs practice and assists the practitioner to engage with professionals to holistically support the client . There are two main models of stress disorder ( in the mental health diagnostic sphere of understanding the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders ( model ( American Psychiatric Association , 2022 ) and the World Health Organization International Classification of Diseases ( model ( WHO , 2022 ) Both models require an individual to have encountered a , however , there are some differences in between these models . A comparison of the diagnostic criteria in each model is presented below in Table . The diagnostic criteria of list 20 symptoms separated into four factors or symptom clusters ( American Psychiatric Association , 2022 ) The first factor , intrusion ( Criterion ) focuses on five symptoms of intrusion ( memories and flashbacks ) including the distress the intrusive thoughts can cause . The second factor , avoidance ( Criterion ) represents two symptoms that relate to the active avoidance of reminders of the traumatic event , both internal ( memories ) and external ( places , people , or situations ) The third factor , negative alterations in and mood ( Criterion ) is comprised of seven symptoms that relate to poor mood and negative beliefs and feelings . The fourth factor , alterations in arousal and reactivity ( Criterion ) is comprised of six symptoms that relate to poor functioning ( sleep issues , concentration problems , aggressive behaviour ) The model has six symptoms across three symptom clusters ( WHO , 2022 ) The first factor , experiencing , focuses on two symptoms that relate to the traumatic event ( upsetting dreams and flashbacks ) The second factor , like the model , is avoidance , and relates to two symptoms avoidance of reminders of the traumatic event including internal ( memories ) and external ( places , people , or situations ) aspects . The third factor , sense of threat , is focused on feelings and perceptions of threats that are disproportionate to the actual stimuli ( to threats and perceived threats ) The has classified an additional model of . This model of has the symptoms previously mentioned , and includes additional symptoms of disorganised self organisation across three symptom clusters . These clusters include affective ( emotional ) negative ( feelings of ) and disturbances in relationships ( feeling disconnected from others ) Table symptom for the , and ( Complex ) diagnostic criteria

TRAUMA IN ADULTS symptoms A . Exposure to trauma symptoms ( Exposure to Trauma 175 symptoms ( Complex ) Exposure to Trauma Intrusion . Distressing memories . Upsetting Dreams . Distressing dreams . Flashbacks . Flashbacks Avoidance reminders . Psychological distress . Avoidance of internal reminders ( memories ) Avoidance of internal reminders ( memories ) Physical reactivity . Avoidance of physical reminders . Avoidance of physical reminders Avoidance Sense of threat . Avoidance reminders ( distressing memories , thoughts , feelings ) Avoidance of external reminders ( people , places , conversations , activities , objects , situations ) Hype musal . Negative alterations in and mood Affective Di . Inability to recall key features . Emotional Reactivity . Exaggerated negative thoughts . Emotional Numbing . Distorted leading to blame Negative . Negative emotional state . Failure . Diminished interest in significant activities 10 . Worthless . Feelings of detachment or estrangement Disturbances in relationships . Inability to experience positive affect 11 . people Alterations in arousal and reactivity 12 . Hard to stay close to people . Irritability or angry outbursts . Risky or behaviour . Exaggerated startle reaction . Problems with concentration . Sleep disturbance SCREENING AND ASSESSMENT TOOLS FOR ADULTS FOR TRAUMA INDICATORS AND CONDITIONS Counsellors can work within a vast range of government and organisations and settings ( child safety , substance use , domestic and family violence ) where they may be required to administer standardised measures to determine eligibility for engagement with services , assess severity of symptoms , and measure changes in distress and coping over time . Such measures may also be required to meet the organisation funding or clinical governance requirements or as part of the organisation minimum data set regarding clients and service engagement . Examples of brief screening and assessment tools are available within the public domain and can assist with screening for symptoms of trauma and include Patient Check Civilian Version ( Weathers et , 2014 ) and the Impact of Events ( Weiss , 1997 ) Further , other psychometrically validated scales can be used by mental health practitioners to screen for frequently occurring post trauma , including for alcohol and other substance use ( Alcohol Use Disorders Identification Test ( AUDIT ) Drug Use Disorders Identification Test ( Severity of Dependence Scale ( and the Depression , Anxiety and Stress ( 1995 ) Diagnostic clarification can be further provided by a qualified mental health professional , psychologist , doctor , or psychiatrist . Counsellors ( as with all ) must check whether or not measures

176 are freely available within the public domain or require prior permission or purchase for use , and must confirm prior whether they meet the requirements for administration of measures based on training and qualifications . INTERVENTIONS FOR TRAUMA WITH ADULTS AN OVERVIEW The following section will provide a brief overview for counsellors regarding commonly utilised based interventions for trauma , which are typically provided by psychologists , psychiatrists , and counsellors with specific training in trauma . It is not intended to provide a comprehensive treatment guide , but rather to provide readers with a working knowledge of approaches to interventions their clients may be exposed to . The following useful summary from Phoenix Australia ( PA ) a research centre in Melbourne , provides a useful summary of information they have developed in relation to the Australian Guidelines for the Treatment of Acute Stress Disorder and Posttraumatic Stress Disorder ( 2017 ) The interventions for trauma are psychological in nature and includes cognitive behavioural therapy ( eye movement desensitization reprocessing ( cognitive processing therapy ( structured writing therapy ( These therapies include common elements narrative exposure ( writing about the trauma and its symptoms ) gradual exposure to reminders of the trauma unlearning the fearful responses to distressing reminders changing how a person thinks about themselves , the future , or the world around them . This is particularly important for people who blame themselves or others for their trauma . relaxation techniques , including breathing activities , to help manage the distress caused by memories or flashbacks that helps to explain to a client how and why they are experiencing these symptoms . This helps them to take control of their own recovery . The or adjunct interventions include serotonin reuptake inhibitors ( antidepressants ) These are normally only used to stabilise a person enough so that therapy can begin to be effective and are prescribed by a psychiatrist or other qualified physician . COGNITIVE BEHAVIOURAL THERAPY ( is the intervention for . Normal focuses on challenging negative and emotions , and changing behaviours ( de et , 2014 ) In this case , is similar , but with a focus on the thoughts , feeling and behaviours ( de et , 2014 ) Many individuals who have experienced trauma hold unhelpful beliefs about their trauma ( they are responsible for their trauma ) and this can result in destructive behaviours ( anger or numbing ) aims to reframe these negative , and identify behavioural coping mechanism and goals ( de et , 2014 ) From an evidence perspective , it has relatively strong outcomes for . This is supported by , for example , 29 studies that compared to waitlist or control conditions and a further 38 studies that compared to treatment as usual or another intervention ( PA , 2019 )

TRAUMA IN ADULTS 177 EYE MOVEMENT DESENSITIZATION AND REPROCESSING ( is a therapy that focuses on using eye movements and other types of stimuli , like hand tapping , to unblock the mental processes associated with memory ( Shapiro Solomon , 2010 ) A client focuses on a traumatic memory , and the therapist evaluates the client eye movements to see how the rapid eye movements are intensified by traumatic memories . These traumatic memories are often avoided by the client and remain unprocessed . Once a memory is found that is significantly distressing , the therapist will explore the memory in more detail and provide coping mechanisms ( Shapiro Solomon , 2010 ) Six studies compared to waitlist , and a further studies compared to treatment as usual or another intervention ( PA , 2019 ) showing to be efficacious . COGNITIVE PROCESSING THERAPY ( is another type of therapy that assists a person to identify unhelpful thoughts beliefs ( stuck points ' challenge them and replace with rational alternatives . typically includes about trauma and mental health and will focus on allowing the client to reframe the traumatic event ( PA , 2019 ) The process begins with the client writing a narrative about the trauma , and then the therapist assists in challenge unhelpful beliefs , like ( et , 2016 ) This type of therapy can also include artificially creating exposure to distressing circumstances . is a relatively young therapy , but it has been shown to be highly effective in Australian veterans ( et , 2016 ) STRUCTURED WRITING THERAPY ( utilises the act of writing about a client memories of trauma , as well as the thoughts and feelings that the trauma invokes , to process the trauma itself ( et , 2002 Smyth ) By writing about a traumatic event , the client is processing the negative feelings associated with the trauma , and these negative feelings will begin to ease . It has been found that can be beneficial for both the mental and physical health ofa client ( et , 2002 Smyth , 1999 ) This therapy can be delivered in online , distance , or , making it an effective form for clients who wish to remain anonymous or live some distance from a mental health clinic . SOCIAL AND FAMILIAL SUPPORTS One ofthe major things that can help a person recover more effectively and completely is support from friends and family . A person can not undertake the recovery process professional and personal support are typically needed . It is often that witness the full spectrum of symptoms before the recovery process , so encouraging family to be involved in the recovery process and their own self care is vital . Social support is crucial for persons with , as it reduces the feelings of isolation , and increases life satisfaction ( Taylor , 2011 ) Additionally , education and support from both professionals and the community are very helpful . Education for understanding , how to take care of themselves , and how to get both practical and emotional support for the whole family can often make a huge difference for effectiveness of interventions ( PA , 2019 ) also provides family members with greater understanding and compassion for the person experiencing . Additionally , incorporating aspects of the recovery model into therapeutic interventions can promote healing by supporting the individuals to regain a sense of meaning , support , and ( et , 2018 ) as well as supporting them through processing associated grief and existential issues . Sufficient investment in building rapport and therapeutic alliance is also vital in relation to creating a sense of safety for your client and are relevant to outcomes of intervention .

178 RISK FACTORS FOR TRAUMA AMONG ADULTS There is strong evidence to suggest that a person genetics play a role in the development of , with approximately 30 of the variance within diagnosis being accounted for by genetic factors ( et , 2012 True et , 1993 ) Studies into twins exposed to combat in the Vietnam War found that monozygotic twins ( identical twins ) were more likely to both have developed than dizygotic twins ( twins ) et , 2012 True et , 1993 ) It has been found that genetic predisposition to other mental health concerns , such as anxiety or panic disorders , can also predict genetic predisposition to developing ( et , 2012 ) Further , we know that environmental stress can permanently influence genes that can contribute to vulnerabilities and resilience via epigenetic factors . This supports the notion of the interaction between environment and biology via the biology can influence environment , and conversely , environment can also influence biology . Protective factors for trauma among adults There are several factors that can be protective for developing following exposure to a resilience people who have high levels of psychological resilience report lower levels of following a social support high levels of support from is a strong protective factor against developing disclosure following trauma individuals who open up about their traumatic event are less likely to develop the belief in one abilities to take control of their engagement with therapeutic intervention and recovery health coping mechanisms people who have healthier ways of coping with mental health concerns ( seeking help ) and who avoid unhelpful coping mechanisms ( excessive use ) have a greater chance of not developing or recovering once being diagnosed general healthy lifestyle choices exercise and a good diet are further protective measures against ( et , 2016 , 1998 ) Individuals who possess strong or resilience are less likely to develop , or experience lower levels of distress following a ( 2012 ) This is likely related to the adaptability associated with resilience . Additionally , individuals with strong and diverse social support networks are more buffered from the negative effects of than individuals with lower levels of social support , following and feelings around the event to trusted friends and family ( Campbell , 2013 et , 2012 ) The support provided by an individual social network , as well as the feeling of being heard with regards to the can be a buffer between the stress of the event and mental health . Individuals who experience high levels of and translate this into healthy coping and behaviours are also less likely to develop following a ( Adams et , 2020 et , 2009 ) This is due to the belief that one can overcome a traumatic event , as well as the belief that one can get help and succeed in maintaining healthy functioning and behaviours . It is also worth noting that exercise and healthy diet has also been shown to buffer and individual from the stress of and the effects this can have on health ( Adams et , 2020 ) As trauma can have a negative effect on physical health , it is important that individuals who experience trauma maintain a healthy lifestyle ( Ryder et , 2018 ) SUMMARY There are a wide range of trauma experiences that can result in subsequent significant and varied symptomatology associated with distress impaired functioning for an individual . may also be common , including hazardous and harmful substance use . The symptomatology , course , prognosis ,

TRAUMA IN ADULTS 179 and process of recovery can vary considerably from person to person and is influenced by a wide range of factors . The role of the mental health professional can help to provide psychosocial support , and counselling to assist the individual to more effectively cope with their traumatic experiences and develop adaptive coping strategies . GROWTH AND RESILIENCY While the development of significantly impacts a person life in many negative ways , a number of people who encounter trauma can experience positive psychological changes . These changes , known as posttraumatic growth ( come from the successful processing and navigation of adverse life events ( see , 2013 ) This has been supported by recent epigenetic studies ( et , 2020 ) Following a traumatic event , a person can experience intrusive thoughts and feelings about the event , which can be distressing . However , it has been found that deliberately ruminating on the traumatic event , and seeking to understand and process the feelings around the event , can lead to ( et , 2021 ) If an individual their personal narrative to see the as a potential catalyst for positive changes in their life , this can result in improved mental and physical health outcomes . This can lead to greater resilience when encountering future stressful or difficult life events . can also result in positive spiritual or personal growth , improved relationships with loved ones , improved life directions , stronger , and a greater appreciation for life ( see Brown , 2017 ) Other factors that have been associated with greater among those who have experienced a traumatic event include sharing negative emotions , positive coping strategies ( positive reappraisal ) and personality traits ( agreeableness ) et , 2021 ) CONSIDERATIONS FOR COUNSELLORS WHEN WORKING WITH INDIVIDUALS Given the prevalence of counsellors entering the helping profession with a personal history of trauma , as well as the nature of the work itself , it is critical for counselling practitioners to maintain their own when working with people affected by trauma . Vicarious trauma is defined as the permanent transformation in the inner experience of the clinician that comes about as a result of empathic engagement with clients trauma material ( 201 ) and secondary refers to the experience symptoms from learning others stories ( 2017 ) and ( 2015 ) identify that it is often those who do this work well who are the most vulnerable to what is known as secondary traumatic stress , vicarious trauma , or compassion fatigue . Counsellors are exposed to traumatic stories and want to assist their clients . This exposure and desire to assist lead to a specific form of stress that creates compassion fatigue ( 1995 ) Given the nature of the work of counsellors , with the risk of vicarious trauma or secondary traumatic stress high , the need for proactive care is imperative . is a strategy that has been found to reduce vicarious trauma and burnout while promoting compassion satisfaction ( 2007 , 2009 ) is often difficult for counsellors to prioritise but it is vital to mitigating the risk of vicarious trauma , and thereby sustaining the capacity to continue helping . It is necessary that when counsellors are suffering and may sense they need to take action seek counselling , support , or therapeutic intervention . A counsellors motivation to enter the helping professions to heal their own wounds , may diminish their capacity for effectiveness with clients ( Ford , 1963 ) 1992 ) that issues related to child abuse , including counter transference , may adversely affect the competency of helping professionals . Some researchers have argued that experiencing an accumulation of childhood , especially emotional abuse and neglect , can increase the risk of helping professionals experiencing secondary traumatic stress ( 1995 Harris , 2003 ) This is also reflected in literature which asserts poor mental

180 health contributes significantly to a lack of career success , including acquiring and maintaining employment ( 2014 et , 2013 ) Whilst a counsellor own experience of adverse experiences in childhood may increase the risk of bias or counter transference and impair or diminish objectivity , a personal history of trauma can also provide strengths that may support an individual professional capacity ( 2006 ) This reflects post traumatic growth and resiliency . If counsellors are resilient and remain positively connected to their work there is potential for growth , also known as compassion satisfaction ( 1995 , 2009 ) Clinical supervision is an important strategy for mitigating the impact of working with clients who have experienced trauma . Supervision forms a central tenet of ethical and effective professional practice , invaluable in assisting helping professionals to acquire the knowledge and skills necessary to achieve a high standard of professional performance ( et , 2013 , 2002 , 2010 ) Supervision offers practitioners the opportunity to debrief and challenge assumptions and biases , explore alternative perspectives , and make informed decisions ( et , 2013 ) Legal issues may emerge during engagement with intervention related to the client experiences of trauma . A client , for instance , could seek to prosecute a perpetrator of trauma ( for domestic violence ) or to sue for damages sustained in an accident or natural disaster . The role is not to provide legal advice , but to offer support during the process and , if needed , refer the client to appropriate legal help . Legal matters may permeate the counselling experience and a client progress may be intimately associated with the trajectory and resolution of a legal matter . The impact of the legal context is an important consideration in working with trauma survivors . Given the relational origins and complications of trauma one of the most important considerations in working with individuals is the therapeutic alliance and the building of rapport . Successful intervention with traumatised individuals is significantly influenced by a strong therapeutic relationship ( et , 1995 et , 2010 , 2009 ) The therapeutic alliance , commonly defined as agreement on goals , task collaboration , and an emotional bond ( 1979 ) has been shown to be linked with outcome in individual child , adolescent , and adult therapy ( et , 2011 et , 2014 Shirk et , 2011 ) It is recommended the counsellors develop and hone their skills in rapport and the therapeutic relationship to maximise engagement and outcomes of intervention . Given the nature of the counselling role , the prevalence of individuals entering the helping professions , and the emotional toll counselling can take on the practitioner , important considerations must be acknowledged to ensure a safe and effective therapeutic experience for client and counsellor . To prevent burnout , secondary trauma or , supervision and form imperative considerations for counsellors and support the development ofa safe and positive therapeutic relationship . CONCLUSION In summary , there are a range of experiences that can result in stress reactions for individuals . However , the likelihood of developing clinically significant trauma responses varies significantly from person to person , and may manifest somewhat differently for affected and providing a useful framework for substantiating diagnostic threshold . This chapter has presented a range of based interventions , along with risk and protective factors . Further it is well documented that growth can occur concurrently with trauma responses . Finally , it is important to maintain optimal and supervision to promote and longevity in the profession when counselling those who have experienced traumas .

TRAUMA IN ADULTS 181 LEARNING ACTIVITIES Learning Activity Please take to 10 minutes to sit in a quiet space and on your memories and experiences regarding in the USA or a similar event . What do you recall about this event ?

Where were you at the time that you heard about this event ?

What images did you see on ?

What sorts of psychological impacts did these events have on those who were directly involved and the broader community ( including internationally ) What were your at the time ?

What are your own now ?

Learning Activity Consider the following case study Your client , James , has sought therapy for issues with alcohol abuse over the last 12 months . After a number of sessions , James discloses to you that he was the victim ofa violent robbery years ago . He describes being unable to watch television that portrays criminal acts , has memories surface from that event at seemingly random times , and has mood issues that he needs to numb . is it possible that James issues with alcohol are related to this trauma ?

Clients will often take time to build a therapeutic relationship before disclosing trauma . Reflect on how clients can present with an immediate issue , like alcohol abuse , but may have trauma in their past that could be related . Learning Activity I Please watch the following recording regarding nature and impacts among responders One or more interactive elements has been excluded from this version of the text . Vou can view them online here Reflect on the following questions What are some reported challenges as a first responder ?

How do individuals attempt to cope who work in this field ?

What are some ofthe unique stressors associated with these roles ?

How can the nature of this work impact upon vicarious trauma , cumulative trauma , and susceptibility to coping with trauma ?

Learning Activity 182 Please read this article on growth after trauma How does your personal values , beliefs and experiences influence your thoughts and feelings about posttraumatic growth ?

Do you believe that negative , traumatic experiences can be to a person ?

When does posttraumatic stress move into growth ?

Can the two happen at the same time ?

Learning Activity Please watch the following recording regarding for counsellors and mental health professionals One or more interactive elements has been excluded from this version of the text . Vou can view them online here ?

What are some ways in which you can nurture your own wellbeing on a regular basis , now and throughout your work and career in mental health ?

What are the elements of your daily , weekly , and monthly plan ?

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TRAUMA IN ADULTS 183 GLOSSARY OF TERMS processing therapy ( for veterans ) a recent therapy found to be effect in veterans American Psychiatric Association Diagnostic and statistical manual of mental disorders Text revised version ( movement desensitization and reprocessing , a therapy for service professionals ( police , firefighters , paramedics ) High risk in which encountering potentially traumatic events are to be expected as a part of thejob World Health Organisation international classification of diseases ( traumatic event , an event in which the individual feels that they or someone else is at risk ( assault or car accident ) growth , or positive psychological changes that can come from processing traumatic events stress disorder serotonin reuptake inhibitors ( antidepressants ) cognitive behavioural therapy , the gold standard of interventions REFERENCES Adams , Forte , Fogle , 2020 ) exercise frequency and Results from the National Health and Resilience in Veterans Study . Acta , 142 ( American Psychiatric Association . 2022 ) Diagnostic and Statistical Manual Disorders . Text revised . Author . American Psychological Association ( 2021 ) Trauma and shock . Author . Kessler , Stein , Hill , Bunting , de , Huang , 2016 ) The epidemiology of traumatic event exposure worldwide Results from the World Mental Health Survey Consortium . Psychological medicine , 46 ( doi . 2012 ) Beyond resilience and Mapping the heterogeneity of responses to potential trauma . Psychological Trauma Theory , Research , Practice , and Policy , 74 . 1979 ) The of the psychoanalytic concept of the working alliance . Psychotherapy Theory , Research and Practice , 16 ( 1992 ) Child abuse trauma Theory and treatment effects . Sage . Higgins , 2007 ) Cumulative harm and chronic child maltreatment . Developing Practice , 19 , Brown , 2017 ) The experience of psychological distress , symptoms of trauma , coping and growth in parents of children with congenital heart disease A systematic review of literature . Masters thesis , University of Southern . Bryce , I . 2018 ) A review of cumulative harm A comparison of international child protection practices . Children Australia , 43 ( DOI , 2006 ) Handbook growth Research practice . Lawrence Associates Publishers . 2013 ) Posttraumatic growth in clinical practice . Campbell , 2013 ) symptoms , disclosure , and relationship distress Explorations of mediation and associations over Disorders , 27 ( Field , Spain , A . 2016 ) Contributions of risk

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TRAUMA IN ADULTS 187 support in mediating the relation between and social functioning in veterans returning from Iraq and Afghanistan . Psychiatry Interpersonal Biological Processes , 75 ( van Dam , 2012 ) Psychological treatments for concurrent posttraumatic stress disorder and substance use disorder A systematic review . Clinical Psychology Review , 32 ( Weathers , Litz , Marx , 2014 , February ) Checklist for ( National Center for . Try it yourself at Weiss , 1997 ) The Impact of Event . In Wilson ( Assessing psychological trauma and A practitioner handbook ( Press . 1998 ) Vulnerability and protective factors for posttraumatic stress disorder . Psychiatry and Clinical , 52 ( World Health Organization . 2022 ) for mortality and morbidity statistics . AUTHOR INFORMATION Amy , BA , MAPS , University of Southern Professor is a clinical and health psychologist in the School of Psychology and Wellbeing at the University of Southern . She has worked for over twenty years across public and private sectors working with client who experience mental and physical health . Professor research and clinical experience on novel health promotion initiatives to reduce health disparities in partnership with priority communities . University of Southern is a clinical psychologist and senior lecturer in the School of Psychology and Wellbeing at the University of Southern . He has worked for over a decade in both public and private sectors offering child and adolescent mental health services . As a of the Trauma Informed Positive Behaviour Support ( program , research and clinical experience has focused on addressing the social emotional needs of children and adolescents impacted by child maltreatment . john , University of is a Postdoctoral Research Fellow at the University of School of Social Sciences . His research focus is on program evaluations for policing interventions , and the use of statistics and research methodology in modern policing research . also focuses on the application of statistical techniques to diagnostic criteria for a number of developmental and mental health concerns , including autism and . has also published work on the use of statistics in modern sociological and psychological research . India Bryce , Ed , Cous , Forensic Studies ) Qual ) University of Southern India Bryce is a Senior Lecturer and Academic in the School of Counselling , at the University of Southern and a member of the Centre of Health Research ( Health and Social justice ) India current research explores the lived experience of cumulative harm and its influence on life course development , including career choice , trauma informed pedagogy in higher education , and trauma narratives and health . India has published books , book chapters , and journal articles from her research including two reference books , Child abuse and neglect Forensic issues in evidence , impact and management and Child sexual abuse Forensic issues in evidence , impact and management . India has presented on topics related to her research nationally and internationally . She is also specialist consultant in the field of child maltreatment , specialising in cumulative harm . She has worked closely with government and agencies in the design and implementation of family intervention , prevention and preservation programs and has delivered training in child maltreatment and cumulative harm to a broad range of helping professionals across the forensic sector .

188 Please reference this chapter as , Bryce , I . 2023 ) Trauma in Adults . In , Machin du ( Common Client Issues in Counselling An Australian Perspective . University of Southern ,