A6-CT

Briere, J. & Scott, C. (2025). Principles of trauma therapy: A guide to symptoms, evaluation, and treatment(3rd ed.). Sage Publications. ISBN: 9781544333557.

Chapter 4

CENTRAL ISSUES IN TRAUMA TREATMENT

A BASIC PHILOSOPHY OF TRAUMA, RECOVERY, AND GROWTH

Although much of this book is devoted to the technical aspects of treatment, we start this chapter with philosophical and, to some extent, theoretical issues associated with trauma therapy. This is because the way in which the clinician views trauma and trauma-related outcomes, and what they believe to be the overbridging goals and functions of treatment, have significant effects on the process and outcome of therapy.

Intrinsic Processing and Natural Recovery

Perspectives on trauma and its treatment vary among clinicians, and a variety of clinical models can inform effective psychotherapy. The approach that we advocate in this book emphasizes the probably innate tendency for humans to process trauma-related memories and, when possible, to move toward more adaptive psychological functioning. As discussed in more detail in Chapters 4 and 9, many of the reexperiencing symptoms of posttraumatic stress disorder (e.g., flashbacks and nightmares) can be conceptualized as, at least in part, recovery processes that humans have evolved over time as a response to trauma exposure. The function of these reliving experiences appears to be a way to process, desensitize, and integrate upsetting material (Briere, 2002b; Horowitz, 1990). This implies that individuals who present with flashbacks and other intrusive symptoms are, in a sense, attempting to metabolize or internally resolve distressing thoughts, feelings, and memories. Conversely, when the individual overuses avoidance strategies (e.g., substance abuse, DRBs) to decrease awareness of intrusive posttraumatic memories, this natural recovery process may be impeded and lead to chronic posttraumatic stress (Foa, 1997; Pineles et al., 2011).

This perspective reframes many posttraumatic symptoms as, to some extent, adaptive and recovery focused rather than as inherently pathological. It also suggests that therapeutic exposure and other approaches to processing traumatic memories may work by optimizing those activities in which the client is already engaged, as opposed to imposing entirely new or alien techniques. Seen in this light, traumatized individuals are often people who are attempting to recover—albeit not always successfully—from adverse experience. This view allows the therapist to more clearly understand the client’s expressed emotional pain and traumatic symptoms not as intrinsically negative, but rather as reflecting a process wherein they can process their history and ultimately experience reduced emotional suffering.

Posttraumatic Growth

A second, related notion offered here is that trauma can result in psychological or spiritual recovery and, often, growth (Tedeschi et al., 2018). Like many other therapists who work in this area, we have found that adversity and distress—beyond their capacity to disrupt and injure—often help people to develop in positive ways. As documented by various studies, this may involve new levels of psychological resilience, additional survival skills, greater self-knowledge and self-acceptance, a greater sense (and appreciation) of being alive, increased empathy, and a more broad and complex view of life in general (Dell’Osso et al., 2022; Joseph & Linley, 2008; Updegraff & Taylor, 2000). The recently widowed person may learn new independence, the survivor of a heart attack may develop a healthier perspective on life’s priorities, and the person exposed to a catastrophic event may learn important things about their resilience in the face of tragedy. The implication is not that someone is lucky when bad things happen, but, rather, that not all outcomes associated with adversity are inevitably negative, and that the process of surmounting obstacles may lead to increased capacities, and perhaps greater wisdom. The message is not that one should “look on the bright side,” which can easily be seen as dismissive and unempathetic and may support avoidance. Instead, we suggest that the survivor’s life, although perhaps irrevocably changed, is not over, and that future good things are possible.

Of course, some traumatic events are so overwhelming that they make growth extremely difficult; they may involve so much loss that it seems impossible (if not disrespectful) to suggest any eventual positive outcomes to the client. Survivors of traumas like severe childhood abuse, torture, or disfiguring fire may feel that they have been permanently injured, if not ruined for life. In other cases, life experiences may have pushed some survivors so far into withdrawal and defense that they cannot easily see beyond the immediate goals of pain avoidance and psychological survival. Even in such instances, however, we have witnessed examples of recovery and growth in trauma survivors struggling with massive pain, disfigurement, major loss, and seemingly unremitting grief, in contexts ranging from burn units and torture treatment programs to rehabilitation wards and rape crisis centers. These experiences, along with the posttraumatic growth literature, suggest that therapy should not be limited to symptom reduction; it should also include the possibility of new awareness, insights, and skills. In less tragic circumstances, it may even be possible to suggest that adversity can make the survivor more, as opposed to less resilient and wise.

Clearly, a psychologically injured person first needs attention to immediate safety and support and help with painful symptoms; it is often only later that the more complicated and subtle aspects of recovery and growth become salient. Yet, ultimately, some of the best trauma interventions are implicitly existential and hopeful. This perspective can also be beneficial for the therapist—the possibility that the client not only can recover, but also may grow from traumatic experience, brings additional richness and optimism to the job of helping hurt people.

Respect, Positive Regard, and Compassion

One of the implications of this philosophy is that the traumatized client should be seen as someone who, despite being confronted with potentially overwhelming psychic pain and disability, is struggling to come to terms with their history—and, perhaps, to develop beyond it. It is often hard to be in therapy, especially when, as is outlined in the next few chapters, treatment requires one to feel things that one would rather not feel and think about things that one would rather not consider. The easy choice, in many cases, is to block awareness of the pain and avoid unwanted thoughts. It is a harder choice, when the option is available, to directly engage one’s memories and their attendant psychological distress and attempt to integrate them into the fabric of one’s life. It may be that the client must engage in some level of avoidance to deal with otherwise overwhelmed memories, thoughts, and/or feelings during treatment. These responses are logical, sometimes even helpful in sustaining internal equilibrium, and should be understood as such by the clinician. Although sometimes problematic, such “resistance” does not contradict the fact that the client deserves considerable respect for being willing to revisit painful events and to choose some level of awareness over the apparent (although often false) benefits of complete denial and avoidance.

Continuous appreciation of the client’s bravery is a central task for the trauma-specialized clinician—acknowledging the courage associated with the client’s mere physical presence during the therapy hour and taking note of the strength that is required to confront painful memories when avoidance is so obviously the less challenging option. When the therapist can accomplish a respectful and positive attitude, imbued with the notion that the client is doing the best they can with the circumstances that confront them, the therapy process often benefits (see a meta-analysis by Farber and Doolin, 2011). Although the client may not completely believe the therapist’s nonjudgmental, positive appraisal of them (in C. R. Rogers’s [1957] lexicon, unconditional positive regard), visible therapist respect and appreciation helps to establish a therapeutic rapport, increasing the likelihood that the client will make themself psychologically available to the therapeutic process.

Related to positive regard, but extending beyond it, is the notion of compassion. Considered at various points in this book, compassion can be defined as nonjudgmental, nonegocentric awareness and appreciation of the predicament and suffering of another (in this case, the client), with the directly experienced desire to relieve that person’s distress and to increase their well-being. Compassion involves a positive emotional state in the clinician—unconditional caring that is directed to the client regardless of their actual or presumed good or bad qualities. See Germer and Neff, 2015, as well as Chapter 11, for discussions of compassion and its various definitions.

Importantly, compassion is not equivalent to pity, which implies a power imbalance and clinician sympathy regarding the diminished state or status of the client. Rather, it reflects the clinician’s awareness that they and the client share a common human predicament—the impermanence and fragility of life and well-being—and the fact that all humans, including the clinician, will suffer at various points in their lives (Briere, 2012). It also involves the natural caring feelings that tend to arise when we see, without distortion, the struggle and vulnerability of others.

From this perspective, the clinician communicates nonjudgmental caring in a way that is not clinically detached, pathologizing, or superior. In the presence of such valuation, the traumatized client may be able to more fully inhabit, accept, and process their distress, while incorporating a sense of loving acceptance in relationship to another. As we note in Chapter 9, this positive state may activate attachment-related neurobiological phenomena that, in turn, serve to countercondition the client’s negative emotional responses associated with past relational traumas.

Compassion is probably a normal human state, but it can be further developed in the clinician in various ways. These include clinical training and supervision that emphasizes nonegocentric attention and mindfulness, specific didactic and experiential exercises that teach compassion (Germer & Neff, 2015), and, for those interested in this path, contemplative activities such as metta and mindfulness meditation (e.g., Salzberg, 1995).

Hope

Hope is often critical to effective trauma treatment. Repeated experience of painful things (including symptoms) may cause the client to expect continuing despair as an inevitable part of the future. In this light, part of the task of therapy is to reframe trauma as challenge, pain as (at least in part) awareness and growth, and the future as opportunity. This in no way means that the clinician should be Pollyanna-ish about the client’s experiences and current distress; it is very important that the client’s suffering be acknowledged and understood. However, it is rarely a good idea for the therapist to accept and therefore inadvertently reinforce the helplessness, hopelessness, and demoralization that the client may infer from life experiences; to do so is, to some extent, to share in the client’s injury. Instead, the challenge is to acknowledge the sometimes incredible hurt that the client has experienced, while, at the same time, gently suggesting that their ongoing functioning and presence in treatment signals implicit strength, adaptive capacity, and hopefulness for the future.

Instilling hope does not mean that the therapist promises anything. For a variety of reasons (e.g., genetic or biological influences, the possibility of premature termination, treatment interference through substance abuse, especially complex and severe symptomatology, new traumas, and unremitting social maltreatment), not every client experiences major, let alone complete, symptom remission. Because we cannot predict the future, we cannot guarantee that things will go well for any given person. Yet an overall positive view of the client and their future is often justified and helpful. Even when not treated, many of those individuals exposed to major trauma will experience significant symptom reduction over time (e.g., Freedman & Shalev, 2000), probably as a partial function of the intrinsic self-healing processes described earlier in this chapter. Even more important, having completed trauma-focused treatment is associated with greater symptom reduction than not having done so (see Forbes et al., 2020, for a review of most current therapies and their effectiveness for trauma). For such reasons, it is generally appropriate to communicate guarded optimism regarding the client’s future clinical course and to note signs of improvement whenever they occur.

Ultimately, hope is a powerful antidote to the helplessness and despair associated with many major traumas and losses. Although not typically described as a therapeutic goal, the instillation of hope is a powerful therapeutic action (Gallagher et al., 2020; Meichenbaum, 1994; Najavits, 2002). It takes advantage of the ascribed power and knowledge of the clinician to communicate, with some credibility, that things are likely to get better. The impact of this message for many trauma survivors should not be underestimated.

The Pain Paradox

Implicit in various aspects of this discussion is the pain paradox (Briere, 2013, 2019). We refer to a paradox because traumatized or otherwise suffering people may inadvertently engage in pain-enhancing or -sustaining behaviors while, in fact, trying to reduce painful or upsetting states. In an effort to remediate distress and suffering, we may do things that specifically increase, not decrease, posttraumatic distress, and that often make them more chronic.

The paradox lies in how we are socialized to address emotional pain and discomfort. It is not uncommon to receive advice from friends or others to “just get over it,” put their past behind them, or “snap out of it.” The message is often that pain, distress, and dissatisfaction are intrinsically bad things that should be removed, distracted from, or otherwise avoided. Once a person is no longer in pain, or their pain has been numbed, it is implied, they will experience greater happiness.

Unfortunately, although a common approach to distress is to do whatever possible to end it, modern psychology (and, as it turns out, perspectives such as Buddhist philosophy) suggests what can be described as a suppression effect: avoiding unwanted thoughts, feelings, and memories actually increases or sustains pain, symptoms, and distress—whereas directly experiencing and engaging pain often, eventually, lessens its power. For example, numerous studies indicate that those who use drugs or alcohol, dissociate, avoid discussing what has happened to them, or engage in other avoidance behaviors such as denial or thought suppression are more likely to develop intrusive and chronic symptomatology (e.g., Gold & Wegner, 1995; Hayes-Skelton & Eustis, 2020). In contrast, those who can more directly experience distress, or engage in psychotherapy, mindfulness training, therapeutic exposure, or other ways of accessing traumatic memory, are likely to have improved and less chronic outcomes (e.g., Briere, 2013; Thompson & Waltz, 2010). As Buddhist psychoanalyst Joseph Bobrow (2011) notes, “what we cannot hold, we cannot process. What we cannot process, we cannot transform. What we cannot transform haunts us” (para. 5).

The pain paradox thus suggests that people who have been hurt may do best if—to the extent possible—they can stay present in their pain, avoid less, and experience more. From this perspective, emotional pain is not implicitly bad, nor are anxiety or sadness. In fact, as noted earlier, posttraumatic distress and intrusive symptoms often may represent access to experiences that can be cognitively and emotionally processed and once addressed, may lose some of their painful qualities.

Of course, it is easy to say that people in pain should try not to suppress or deny. Trauma-related problems in emotional regulation and tolerance, especially in the context of overwhelming memories, and/or a lack of sufficient social support, may mean that the survivor essentially has no choice but to avoid in order to maintain some measure of internal homeostasis. Asking a substance addicted war veteran, hospitalized burn survivor, or torture survivor to “stay with the pain” can be a potentially harsh, perhaps impossible, request. Yet, even the very beleaguered person may have moments when they could tolerate more direct access to internal distress, painful memories, or potentially difficult realizations. Further, the titrated exposure activities described in Chapter 9 are designed to provide the otherwise avoidant survivor with the opportunity to experience and process small increments of nonoverwhelming traumatic memory. Thus, the suggestion to allow emotional pain rather than avoid it is a general one—not a demand that the overwhelmed trauma survivor open the floodgates of previously suppressed traumatic pain, but rather an invitation to engage when it is safe and appropriate to do so, and only to the extent possible.

The implications of the pain paradox for trauma therapy are significant. They suggest that approaches that encourage awareness of one’s ongoing experience, that allow access to nonoverwhelming amounts of painful memory, and that encourage deeper insight into the basis for ongoing suffering, will be helpful—whereas medications that only numb or mask unwanted emotional states, or therapies that distract, focus merely on support, or even teach avoidance may be less efficacious.

In general, concepts such as the pain paradox and intrinsic processing are ultimately depathologizing: Painful posttraumatic states such as flashbacks, grief, or anxiety are not necessarily evidence of a disorder—in many cases, they represent a beneficial or useful response: access to immediate awareness, even if that awareness carries with it things that cause distress. As the client is more able to hold, tolerate, and process these states and their etiologies, without unnecessary avoidance, the emotional mechanisms described in Chapter 9 will more easily take place and recovery will be more likely.

CENTRAL TREATMENT PRINCIPLES

Beyond a philosophy of trauma and recovery, there are a number of basic principles of effective trauma-focused treatment. Although these principles apply most directly to psychotherapy, some are also relevant to other treatment methodologies, including trauma psychopharmacology.

Provide and Ensure Safety

Because trauma is about vulnerability to danger, safety is a critical issue for trauma survivors (Brand et al., 2022; Najavits, 2002). It is often only in safe environments that those who have been exposed to danger can let down their guard and experience the relative luxury of introspection and connection. In therapy, safety involves, at a minimum, the absence of physical danger, psychological maltreatment, exploitation, or rejection. Physical safety means that the survivor perceives, and comes to expect, that there is little likelihood of physical or sexual assault at the hands of the clinician or others, and that the building is not likely to collapse or burn during the session. Psychological safety, which is sometimes more difficult to provide, means that the client will not be criticized, humiliated, dramatically misunderstood, needlessly interrupted, or laughed at during the treatment process, and that psychological boundaries and therapist–client confidentiality will not be violated. It is often only when such conditions are reliably met that the client can begin to reduce their defenses and more openly process the thoughts, feelings, and memories associated with traumatic events (Briere & Lanktree, 2012). In fact, as discussed in Chapter 9, it is critical that the client experience safety while remembering danger; only under this circumstance will the fear and distress associated with trauma in the past lose its capacity to be evoked by the present.

Unfortunately, to feel safe, not only must there be safety, the client must be able to perceive it. This is often a problem because, as noted earlier, trauma exposure can result in hypervigilance: many traumatized people come to expect danger, devote considerable resources to detecting impending harm, and tend to misperceive even safe environments and interactions as potentially dangerous. As a result, even a safe therapeutic environment may appear unsafe to some clients. For this reason, among others, treatment may take considerably longer—and call more on the clinician’s patience and sustained capacity for caring—than is allowed for by shorter-term therapies (Courtois, 2010). Some multiply traumatized individuals—former child abuse victims, torture survivors, those who have experienced sustained social or political oppression, adolescent gang members, “street kids,” or people exposed to intimate partner violence, for example—may need to attend therapy sessions for relatively long periods of time before they can fully perceive and accept the fact that they will not be hurt if they become vulnerable in treatment.

Hypervigilance to danger is especially likely among people who have been harshly treated or neglected by society. Because people of color, immigrants, those without homes, LGBTQ+ identifying individuals, and others in marginalized groups are more likely to have experienced interpersonal trauma and to have undergone violence or other maltreatment from police and social institutions, people in devalued groups may be suspicious or fearful of so-called “help,” especially if the helper is of the gender, race, age, sexual orientation, occupation, or economic status of those who have hurt them in the past. In such instances, the clinician must work even harder to gain the trust of their clients, and hear their stories, in order to help them to process past experiences—not only of trauma, traditionally defined, but also of social discrimination and maltreatment.

Providing safety also means working to ensure that the client will be relatively free of danger outside of the therapeutic setting. Highly fearful or endangered survivors are unlikely to have sufficient psychological resources to participate in psychotherapy without being emotionally overwhelmed and/or especially avoidant. The battered person should be as safe as possible from further battery, and the sexual abuse survivor should be out of immediate danger from their perpetrator before significant psychological processing of symptoms is attempted. Otherwise, the client’s life and physical integrity may be risked in the service of symptom relief. Although this may seem an obvious fact, many therapists fall into the trap of attempting to process traumatic memories with acutely traumatized individuals who continue to live in obviously dangerous circumstances.

This does not mean that all psychological interventions are ruled out in work with those still at risk—only those having as their sole focus the direct processing of traumatic memories and feelings, or those that prize insight over safety. For example, those exposed to ongoing partner violence may easily gain from psychoeducational activities or cognitive interventions that provide information on increasing personal safety or that support the often-daunting task of leaving an abusive partner (C. E. Jordan et al., 2004). On the other hand, they may be placed at continued risk if the immediate focus of therapy is solely to emotionally process their victimization experience or to analyze what childhood issues are involved in their attraction to abusive partners, as opposed to developing a viable safety plan.

Of course, chronic life-endangering phenomena, such as institutionalized racism or transphobia, or life on the streets, cannot be “fixed” by psychotherapy alone. Nor, for some, are unsafe sexual practices or intravenous substance abuse behaviors easily terminated. As a result, therapy continues to be the art of the possible: helping the client to be as safe as is actually possible, while, when feasible, facilitating symptom reduction and increased coping.

Danger to self. Finally, safety includes the survivor’s safety from themself. As noted earlier, traumatized people often engage in DRBs and other avoidance behaviors in an effort to reduce triggered emotional and cognitive states. Some of these, for example self-injury, suicidality, and unsafe or compulsive sexual behavior, place the survivor at immediate risk. Self-endangering behaviors must be addressed early in treatment, since death, illness, and/or disfigurement are potential outcomes. This typically involves stabilization, as described below, risk assessments (e.g., for suicidality), and initiation of treatment component that address the etiology or dangers of DRBs, especially emotional regulation/tolerance training and psychoeducation (e.g., on safe sex or needle exchange programs). The clinician may also consider calling on outside resources, such as medication providers, advocates, shelters, support groups, specialty clinics (e.g., for severe eating disorders or clients requiring Dialectical Behavior Therapy [DBT; Linehan, 1993]), or in-patient psychiatric facilities.

Provide and Ensure Stability

Stability refers to an ongoing psychological and physical state whereby one is not overwhelmed by disruptive internal or external stimuli. It also implies some degree of capacity to resist the effects of such stimuli in the near future. Stability concerns are highly relevant to work with trauma survivors, since adverse events are often destabilizing and can produce conditions (e.g., chaotic interpersonal or physical environments, posttraumatic stress, depression) that further increase susceptibility to stress. In addition, some trauma-related responses (e.g., substance abuse, problematic personality traits, or reactive psychosis) can contribute to unstable lifestyles, such as lacking a home or shelter, recurrent involvement in chaotic and intense relationships, or chronic self-destructiveness.

Life stability . Life stability refers to generally stable living conditions. For example, those living in extreme poverty, homelessness, chaotic environments, or chronically risky occupations (e.g., prostitution) may have difficulty tolerating the additional distress sometimes activated by trauma therapy. Such conditions may include hunger, fear, racial or gender oppression, and the insecurity associated with inadequate or absent housing—none of which support emotional resilience in the face of activated distress. In fact, without sufficient security, food, and shelter, avoidance of traumatic material (e.g., through numbing or substance abuse) may appear more useful to the trauma survivor than the seemingly counterintuitive notion of reliving painful memories. Trauma therapy is most immediately helpful to those who have the social and physical resources necessary to experience safety and the option of trust. As a result, the first intervention with traumatized people who have few resources is often social casework: arranging adequate and reliable food, shelter, and physical safety.

Emotional stability . In addition to physical stability, trauma survivors should have some level of psychological homeostasis before certain aspects of trauma therapy can be initiated. In general, this means that those with acute psychotic symptoms, high suicidality, extremely high levels of posttraumatic stress, or debilitating anxiety or depression may require other interventions before exposure-based aspects of trauma therapy can be initiated, if at all. These include crisis intervention, development of emotional tolerance and regulation skills, the appropriate use of medication (see Chapter 15), and, in some cases, simple supportive psychotherapy. In the absence of such pretreatment, activation of trauma-related material not only may result in an exacerbation of existing symptoms (e.g., renewed psychosis or posttraumatic stress) but also may overwhelm the survivor’s existing capacity to regulate their emotional states, producing new distress and dysfunction. Exacerbated or newly activated symptoms, in turn, may result in increased avoidance behaviors, such as substance abuse or suicidality, as well as increasing the likelihood that the client will drop out of treatment.

It is not always easy to determine when symptoms are too intense to warrant immediate trauma-specific interventions, as opposed to being worthy targets of treatment. For example, when is posttraumatic stress or anxiety too severe to support therapeutic exposure to traumatic memory, and when are these symptoms in the range that would be appropriate for such treatment? Specific assessment approaches that may shed some light on these issues were presented in Chapter 3. Most generally, the issue is whether the symptoms in question have significantly reduced the client’s capacity to regulate the almost inevitable upsurge of emotion that follows therapeutic exposure to unresolved trauma memories. If the increased activation is not overwhelming, classic trauma treatment is usually indicated. If the response to treatment would be to become flooded with overwhelmingly negative states, more grounding, skills-development, and/or supportive psychotherapy will be required until greater psychological stability is present.

Importantly, some forms of disorder traditionally assumed to be synonymous with psychological instability may not always be contraindications for emotional processing of past trauma. For example, some traumatized individuals diagnosed with BPD or low-level chronic psychosis may be sufficiently stable to tolerate trauma treatment, whereas others with seemingly less diagnostic severity (e.g., generalized anxiety or mild to moderate depression) may not. Clinicians often have appropriate concerns when working with psychotic or personality disorders because such disturbance is frequently associated with emotional regulation problems and more extreme dysphoria. However, the critical issue is less the type of disorder, per se, than the client’s relative capacity to tolerate the emotions associated with exposure to traumatic memories.

Maintain a Positive and Consistent Therapeutic Relationship

One of the most important components of successful trauma therapy appears to be a good working relationship between client and therapist (Courtois & Ford, 2012; Howard et al., 2022; Kudler et al., 2009). In fact, studies indicate that therapeutic outcome is best predicted by the quality of the treatment relationship, beyond the specific techniques used (Norcross & Lambert, 2018). Although some therapeutic approaches stress relationship dynamics more than others, it is probably true that all forms of trauma therapy work better if the clinician is compassionate and attuned, and the client feels accepted, liked, and taken seriously (Ellis et al., 2018). Even in short-term, highly structured treatment approaches (e.g., some forms of cognitive-behavioral therapy), clients with good relationships with their helpers are more likely to persevere in treatment, adhere to whatever regimen is in place, and, as a result, experience a more positive clinical outcome (Rau & Goldfried, 1994). Longer-term and more interpersonal treatment approaches, in which relational issues are more prominent, are even more likely to benefit from a strong therapeutic relationship.

Because trauma therapy often involves revisiting and processing painful relational memories, as well as potentially reactivating feelings of danger and vulnerability, successful treatment is especially contingent on therapeutic support and connection. Distant, uninvolved, or emotionally disconnected client–therapist relationships are, in our experience, quite often associated with less positive therapeutic outcomes (see Dalenberg, 2000, for an empirically based discussion of this issue). At a minimum, a positive therapeutic relationship provides a variety of benefits. These potentially include decreased treatment dropout and more reliable session attendance, less avoidance and greater disclosure of personal material, greater treatment adherence and medication compliance, greater openness to—and acceptance of—therapist suggestions and support, and more capacity to tolerate painful thoughts and feelings during therapeutic exposure to trauma memories.

In addition to supporting effective treatment, the therapeutic relationship is more likely to be helpful to the extent that it both (1) gently activates memories and schemas associated with prior relational traumas and (2) provides the opportunity to process these activations in the context of therapeutic caring, safety, and support. As is described in more detail in Chapters 9 and 10, even the most benign client–therapist relationship may trigger at least some rejection or abandonment fears, misperception of danger, or authority issues in survivors of extended or severe trauma. When these intrusions occur at the same time that the client is feeling respect, compassion, and empathy from the therapist, they may gradually lose their generalizability to current relationships and become counterconditioned by positive relational feelings. In this sense, a good therapeutic relationship is not only supportive of effective treatment, but it is virtually integral to the resolution of major relational traumas.

Tailor the Therapy to the Client

Although a review of some currently available treatment manuals might suggest that clinical interventions are applied more or less equally to all mental health clients with similar complaints, this is almost never the case in actual clinical practice. In fact, the highly structured, sometimes manualized nature of some empirically validated therapies more directly reflect the requirements of treatment outcome research (i.e., the need for treatment to be highly similar and equally applied for each client in a given study) than any clinically based intent to provide equivalent interventions for all presenting clients (Westen et al., 2004). In the real world of clinical practice, clients vary significantly with regard to their presenting issues, culture, comorbid symptoms, and the extent to which they can utilize and tolerate psychological interventions. For this reason, therapy is likely to be most effective when it is tailored to the specific characteristics and concerns of the individual person (Cloitre et al., 2002; Norcross & Wampold, 2019). We next describe several of the more important individual variables that should be taken into account when providing mental health interventions, including trauma therapy.

Emotional regulation and memory intensity issues . As noted previously, emotional regulation refers to an individual’s relative capacity to tolerate and internally reduce painful emotional states without undue avoidance. People with limited emotional regulation abilities are more likely to be overwhelmed and destabilized by negative emotional experiences—both those associated with current negative events and those triggered by painful memories. Since trauma therapy often involves activating and processing traumatic memories, individuals with less ability to internally regulate painful states are more likely to become highly distressed, if not emotionally overwhelmed, during treatment.

The emotional regulation construct can be oversimplified, however. For example, some people are better at tolerating or regulating one type of feeling (e.g., anxiety) than another (e.g., anger), despite the common implication that any given person has a generalized capacity to regulate emotions. As well, some people’s emotional responses may be more intense than others’ as a function of having been exposed to more painful experiences. In this regard, it may take more emotional regulation capacity to down-regulate emotions associated with some very painful memories (e.g., of torture) than those associated with less intense memories (e.g., of an automobile accident). It is rarely enough to decide that someone has “emotional regulation difficulties” without also determining the affective load that requires regulating.

Variability in emotional regulation capacity—and the severity of the memory-triggered emotions to be regulated—has significant clinical implications. Most generally, individuals with impaired affect regulation—especially in the context of easily triggered, highly painful memories—are more likely to experience overwhelming emotionality when exposed to upsetting memories during treatment and to respond with increased avoidance, including “resistance” and/or dissociation. Such responses, in turn, reduce the client’s access to traumatic material and to the healing aspects of the therapeutic relationship. As described in Chapter 9, treatment of those with impaired emotional regulation capacities and/or a heavy trauma load should proceed especially carefully, such that traumatic memories are activated and processed in smaller increments than otherwise might be necessary.

Often described as titrated exposure or working within the therapeutic window (Briere, 1996, 2002b) or the window of tolerance (Siegel, 2012), this usually involves adjusting treatment so that trauma processing that occurs within a given session does not exceed the capacities of the survivor to tolerate that level of distress—while, at the same time, providing as much processing as can reasonably occur (see Chapter 9). In individuals with substantially reduced emotional regulation capacities (and/or especially distressing memories), this level of exposure and processing may be quite limited at any given moment. Nevertheless, over time, even seemingly small amounts of trauma processing tend to add up, ultimately leading to potentially significant symptom relief and greater emotional capacity without the negative side effect of overwhelming affect.

Preponderant schemas . As noted in Chapter 2, trauma exposure often has effects on cognition. Depending on the type of trauma and when in development it occurred, this may include easily triggered perceptions of oneself as inadequate, bad, or helpless; expectations of others as dangerous, rejecting, or unloving; and a view of the future as hopeless. Such distortions inevitably affect the client’s perception of the therapist and of therapy. For example, the survivor may expect the therapist to be critical, unloving, or even hostile or abusive.

Early child abuse and neglect may result in latent gestalts of preverbal negative cognitions (Baldwin et al., 1993; DePrince et al., 2009) and feelings that are easily evoked by reminiscent stimuli in the immediate interpersonal environment. These relational schemas, when triggered, may result in sudden, intense thoughts and feelings that were initially encoded during childhood maltreatment and that are hard for the survivor to discriminate from current, real-time perceptions. As a result, the adult abuse survivor may experience sudden feelings of abandonment, rejection, or betrayal during psychotherapy and attribute them to the therapist.

Because the cognitive effects of trauma vary from client to client, as a function of the individual’s specific history, therapy must be adjusted to take into account each client’s preponderant schemas of self and others (Pearlman & Courtois, 2005). In general, this means that the clinician should do as much as possible to (1) respond in ways that specifically do not reinforce the client’s negative expectations and (2) avoid (to the extent possible) triggering underlying cognitive-emotional gestalts related to broader themes such as interpersonal danger or rejection. The individual with a tendency to view important interpersonal figures with distrust, for example, may require a therapist who is especially supportive and validating and who is careful not to trigger too many memories of maltreatment. This does not simply involve statements to the client that they are safe or positively valued—more important, the therapist should act and respond in such a manner that safety and caring is demonstrated and can be inferred. Because the distrustful client will be predisposed to miss such signs, and perhaps even actively misinterpret them, therapeutic interventions must be even more explicit and obvious in these areas than is the case for those without (or with less of) this cognitive set.

It is important to note here that tailoring one’s treatment approach to a given person’s major cognitive issues does not mean that these distortions or disruptive schemas are no longer evoked in therapy. As noted in Chapter 10, no matter how hard the clinician tries, the survivor who has been substantially maltreated in the past is likely to view some of the therapist’s behaviors as punitive, critical, or abusive, and thus issues in this area almost unavoidably become a topic of discussion during therapy. However, because the therapist is working hard to minimize the extent of these misattributions and triggered schemas, whatever emerges over time in therapy is likely to be less intense and more easily demonstrable as archaic and contextually inaccurate. The repetitive experience of fearing that one’s therapist is cold and rejecting, for example, and yet finding, over time, that these perceptions are manifestly untrue, often can be extremely helpful.

Significantly, although clinicians works hard to communicate an absence of criticism or rejection, this does not mean that they discourage the client’s discussion and processing of these perceptions and feelings as they relate to subtle client–therapist dynamics or to others in the client’s environment. Ultimately, the goal is to make treatment possible for those who are especially sensitive and suspicious of the vulnerability, connection, and intimacy that are part of the normal operating conditions of psychotherapy. Knowledge that client X has “abandonment issues,” client Y tends to perceive caring as intrusive or sexual in nature, or that client Z responds to authority figures with expectations of hostility or domination can allow the therapist to adjust their approach so that it does not unnecessarily activate these issues and thereby unduly interfere with the process of treatment.

Gender issues . There is little doubt that men, women, and those who identify as nonbinary undergo many of the same traumatic events and suffer in many of the same ways. Yet, it is also clear that (1) some traumas are more common among those socialized or appearing as one gender than another, (2) North American culture tends to punish those who do not conform to traditional gender/orientation expectations, and (3) gender-role socialization often affects how such injuries are experienced and expressed. These differences, in turn, have significant impacts on the content and process of trauma-focused therapy.

As noted in Chapter 1, on average those identified as women in our culture are more at risk for victimization in close relationships than are men, and girls and women are more likely to be sexually victimized than their male counterparts. In contrast, those identified as boys are at greater risk than girls of childhood physical abuse, and boys and men are more likely to experience nonintimate physical assaults than girls and women. And, regardless of perceived gender, individuals identifying as transgender or nonbinary are more likely to be victimized than their cisgender peers (e.g., Newcomb et al. 2020).

In addition to trauma exposure differences, people socialized as men and women tend to experience, communicate, and process the distress associated with traumatic events in different ways. Although there is major variation among people within any gender category and across cultures and sexual orientations, those socialized as women are often taught to express more directly certain feelings, such as fear or sadness, but are taught to dampen or avoid others, such as anger, whereas those socialized as men are often more permitted the expression of anger, but may be socially discouraged from communicating “softer” feelings, such as sadness or fear (Cochran, 2005; Renzetti & Curran, 2002).

Those socialized as men and women may also differ in how they act upon feelings and needs. In many cultures, men are to some extent taught to externalize or cognitively suppress unpleasant feelings, and to act on the environment in order to reduce pain or distress, whereas women are often socialized to express their distress to trusted others, and are, overall, less prone to externalizing their pain through acting on the environment (Feuer et al., 2002; Renzetti & Curran, 2002). These gender-role-related differences in symptom expression and behavioral response often manifest themselves during trauma-focused psychotherapy. All things being equal, for example, trauma survivors in treatment who were socialized as males may be more prone to expressions of anger—or to denying posttraumatic distress entirely—than female survivors, whereas those socialized as female may be more open to emotional expression, especially of feelings of sadness, fear, or helplessness, but avoid discussing any angry feelings.

Given these sociocultural influences, the therapist should be alert to ways in which trauma survivors express or inhibit their emotional reactions based on gender-role based expectations. Often, this will involve supporting the client to express the full range of feelings and thoughts associated with a traumatic event, as opposed to only those considered socially appropriate to their gender. In fact, to the extent that (as described in Chapter 9) feelings and thoughts are more easily processed when fully expressed during treatment, unaddressed gender-role constraints are likely to inhibit full psychological recovery.

The therapist also should be aware of gender differences in how trauma is cognitively processed. Because those socialized as boys and men are often trained to present themselves as strong and able to defend themselves, victimization may be more of a gender-role violation for them than it is for girls and women (Depraetere et al., 2018). Such social expectations can result in different responses to trauma. Some victimized men, for example, may struggle with feelings of inadequacy, shame, and low self-esteem associated with the social implication that an inability to fight off maltreatment reflects, irrespective of sexual orientation, lesser masculinity or competence (Briere, 1996).

In addition, some sexually assaulted or abused males have sexual orientation concerns related to their trauma. In the case of childhood sexual abuse, for example, heterosexual boys and men may fear that molestation by another male has caused them to be (or be seen as) latently homosexual (Alaggiaa, 2005)—a response that, in a homophobic culture, may result in compensatory hypermasculinity or overinvolvement in heterosexual activity. Conversely, for example, gay or bisexual men who were sexually abused by males as children may believe that their sexual orientation somehow caused them to be abused by men or that their abuse caused them to be paradoxically attracted to men.

This is a complex issue, since some studies indicate that LGBTQ+ people do disproportionally report childhood histories of, for example, sexual abuse, and gender nonconformity is associated with physical assaults in childhood (Friedman et al., 2011; Roberts et al., 2012). It is also unclear what role early sexual contact with older people, violent or otherwise, play in influencing sexual orientation (Roberts et al., 2013). Above-and-beyond these issues, however, social attributions of responsibility can be internalized by the survivor to suggest that their nonconforming gender expression or nonheterosexual orientation means that they asked for or deserved what happened to them, leading to misplaced feelings of guilt, shame, and self-hatred (Briere, 1996).

Gender-role expectations also affect how some traumatized women view their victimization. Those socialized as women may have been made to believe that they in some way enticed their perpetrators into raping them—a concern that reflects the traditional stereotype of females as sexual objects who are intentionally or unintentionally seductive (Baugher et al., 2010). Similarly, women assaulted or otherwise abused by their partners may believe that their supposed lack of subservience or failure to perform as an adequate mate means that they deserved to be maltreated (Walker, 1984).

Given these gender-specific influences on trauma-related cognitions, the clinician is likely to be more helpful if they closely attend to concerns about unacceptability, self-blame, low self-esteem, shame, and sexual orientation as they are expressed in survivors’ cognitive reactions to trauma. Traumatized people socialized as men may require additional reassurance that they are not less masculine (regardless of sexual orientation) by virtue of having been victimized and may gain from interventions that support the full range of emotional and cognitive expression without fear of stigmatization. Especially relevant in this regard is the need for some victimized men to process feelings of shame associated with viewing themselves as deviant and socially unacceptable. Some women survivors, on the other hand, may gain from interventions that support self-determination and that help them to reject feelings of responsibility for their abuse, including the unwarranted notion that they somehow sought out or otherwise deserved maltreatment.

Be Aware of—and Sensitive to—Sociocultural Issues

Social maltreatment. As described in Chapter 1, social, gender, economic, and racial discrimination, as well as marginalization of people who identify as LGBTQ+, are associated with a greater risk of trauma and are likely to have direct negative psychological effects that are, in a sense, posttraumatic. Social maltreatment and marginalization also means that many traumatized people continue to have reduced access to appropriate mental health services (Berthold, 2015), let alone trained, trauma-informed clinicians. Combined with the discrimination often experienced by racial, ethnic, and gender minorities—and the relatively dangerous living environments in which many are forced to live—social inequality provides a vast depot of trauma and trauma impacts in North America (Brown, 2008). For these reasons, it especially important that therapists take the reality and effects of social injustice into account when providing services to socially marginalized clients and work to ensure that their therapeutic responses are manifestly antisexist, antiracist, and fully accepting of LGBTQ+ people.

Refugees, asylum seekers, and other immigrants. Immigrants are notably at risk of discrimination and maltreatment in North American and other cultures because they tend to arrive with little social status or money and often are of minority racial or ethnic status in their new country. Further, officials of many countries (including the United States) have been known to arrest and jail undocumented migrants, separate them from their children, and/or place them in overcrowded holding facilities until their immigration status can be adjudicated (Berthold & Libal, 2019). The stress of relocation, in combination with such adversities, has been shown to increased anxiety, depression, posttraumatic stress, and other psychological difficulties (Berthold, 2000).

Beyond socioeconomic, racial, and immigration issues, refugees often carry with them traumas experienced in transit or from their countries of origin. Mental health centers specializing in refugee, asylum seekers, or immigrant issues regularly deal with the effects of holocausts or mass murder (e.g., ethnic cleansing), political imprisonment, war, torture, trafficking, “honor” killings, sexual violence, and extreme ethnic or gender discrimination (e.g., El Baba & Colucci, 2018; Lahuis et al, 2019). The effects of such experiences tend to be especially long lasting, In one sample of 80 Vietnamese refugees resettled to Norway, for example, the majority still had very high symptom scores on a standardized measure 23 years later (Vaage et al., 2010). The combination of social adversity and ethnic variation means that cultural and historical issues are often highly relevant to the process and content of trauma-focused psychotherapy and should not be overlooked (Nickerson et al., 2011).

Cultural variation . Partially because ethnic and racial minorities are more likely to be traumatized, and partially due to the general multicultural mix present in many modern societies, individuals presenting for trauma services are likely to reflect a wide range of cultures and ethnic groups. Such cultural differences are not merely a function of race: People of low socioeconomic status often have different world views and experiences than those of the same race or ethnicity who have more economic and social opportunities. Similarly, merely knowing that someone identifies as, for example, “African American,” “Hispanic,” “Asian,” or “American Indian” says little about their cultural context. An individual from Vietnam, for example, may be quite different in perspective, language, and emotional style from a person raised in Japan.

These wide cultural differences often translate into different trauma presentations and idioms of distress, as described in Chapter 2. In addition, above and beyond their social status in North America, people from the various cultures and subcultures of the world have widely different expectations of how clinical intervention should occur, and the ways in which clinicians and clients should interact (Comas-Diaz, 2006; Van der Veer, 1995). In one culture, for example, eye contact between clinician and client is a sign of respect; in another, it may be the opposite. Similarly, in some cultures, certain topics (e.g., sexual issues, visible loss of dignity) are considered to be more embarrassing or shameful than in others, and thus should be raised only when relevant to treatment, and then with great sensitivity.

Overall, a central point should be made: Cultural awareness and sensitivity are important parts of any psychotherapeutic process—including trauma therapy. Clinicians who find themselves, for example, regularly working with Cambodian refugees, Hmong clients, or immigrants from Mexico have a responsibility to learn the primary rules of clinical engagement with people from these cultures, as well as something of their culture, history, and, ideally, language.

Monitor and Control Counteractivation

An additional important concept in trauma-focused therapy is what is commonly referred to as countertransference (described as counteractivation in self-trauma theory [Briere, 2002b]; see Chapter 10). Although this phenomenon has many different definitions, we use it here to refer to occasions when the therapist responds to the client with cognitive-emotional processes (e.g., expectations, beliefs, or emotions) that are strongly influenced by prior personal experiences. In many of these cases, these experiences involve childhood maltreatment, adult traumas, or other upsetting events. Of course, all behavior is influenced by past experience, and not all counteractivation responses are negative (Dalenberg, 2000). Even positive countertransference, however, must be monitored by the therapist, since it may produce unhelpful responses such as idealization of the client, the need to normalize what are actually problematic client behaviors or symptoms, or even sexual or romantic feelings. Ultimately, the concern is that counteractivation can interfere with treatment by leading to either (1) a deleterious clinical experience for the client or (2) processes that disrupt the treatment process.

For example,

Therapist A was raised by a critical, psychologically punitive parent. They now find that they tend to experience angry or guilty feelings when their clients complain about any aspect of the therapy.

Clinician B experienced a traumatic miscarriage a month ago. Upon hearing her client’s excitement about a new pregnancy, she experiences unexpected anger and distress.

Therapist C, who is dealing with a recent traumatic death of a loved one, finds that they are prone to feelings of extreme sadness and emptiness while treating a client whose son was killed in a fire.

Clinician D grew up in a violent, chaotic family atmosphere, where safety and predictability were rarely in evidence. Their supervisor notices that Clinician D has a strong need to control the process of therapy and tends to see certain clients as especially manipulative, malingering, or engaging in therapeutic “resistance.”

As a child, Clinician E was often protected by a supportive aunt when his mother would go into angry, abusive tirades. He is now treating an older, kindly woman whom he has a difficult time seeing as psychologically compromised, despite her obvious symptomatology.

Clinician F was raised in a family where cynicism and confrontation were the norm and any “abnormal” behavior or role violations were sharply criticized. As an adult, they tend to dismiss the concerns of clients who report seemingly unusual symptoms, such as severe dissociative responses or episodes of posttraumatic reliving, or who describe especially horrendous and complicated abuse scenarios.

An additional form of counteractivation involves therapist denial or cognitive avoidance of certain subjects or themes during the treatment process. A clinician who tends to avoid thinking about unresolved traumatic material in their own life may unconsciously work to prevent the client from exploring their own trauma-related memories and feelings. In such instances, the clinician may even become resentful of the client for restimulating their own avoided memories or feelings or may reinterpret appropriate client attempts to confront the past as hysteria, self-indulgence, or attention seeking.

The primary manifestations of an unconscious desire to distance oneself from the client’s distress are attempts to avoid discussion of the client’s trauma history and generally decreased emotional attunement. In each instance, the underlying strategy is the same: reduced therapeutic contact as a way to reduce the likelihood of triggered emotional pain. When this response is especially powerful, the clinician may slow or neutralize therapy by decreasing the client’s exposure to traumatic material to such a point that it is not processed. At the same time, therapist distance or lack of attunement may activate client abandonment or neglect issues, further impeding treatment.

Reducing counteractivation . As noted earlier, not all counteractivation is necessarily problematic, and, in fact, probably all therapists experience some degree of counteractivation in their work. When it interferes with treatment, however, steps must be taken to reduce its influence.

One of the best preventive measures against countertransference problems is regular consultation with a seasoned clinician who is familiar with trauma issues and, hopefully, the therapist (Dalenberg, 2000; Pearlman & Courtois, 2005). Another option is to form a consultation group with one’s peers. However structured, such meetings should allow the clinician to share the burden of their daily exposure to others’ pain as well as to explore ways in which their own issues can negatively affect therapeutic outcome. In many instances, inappropriate identification or misattribution can be prevented or remedied by the consistent availability of an objective consultant who is alert to countertransference issues in general, and the clinician’s vulnerabilities in specific.

An additional intervention, for clinicians who acknowledge the impacts of trauma in their own lives, is psychotherapy. It is an ironic fact that, at least in some environments, clinicians endorse the power of psychological treatment for others yet eschew it for themselves as somehow shameful or unlikely to help. This double standard is unfortunate, since having experienced psychotherapy is usually a good thing for therapists. Therapy is not only likely to reduce the clinician’s trauma-related difficulties; it can also increase the richness of their appreciation for human complexity and can dramatically decrease the intrusion of their issues into the therapeutic process.

Practice Ethically and Within the Standard of Care

A final topic in this chapter is that of ethical and professional practice. Because the trauma client is often in a vulnerable state, and psychotherapy generally involves a relative power imbalance between client and therapist, it is very important that the clinician attend to any issues or dynamics that might even remotely result in maltreatment, exploitation, or inadequate care (Courtois et al., 2009).

In many cases, ethical and risk-reducing activities correspond to what would be good therapeutic practice in any event. For example, honoring the client’s boundaries, refraining from any form of exploitation or maltreatment, reporting and (when appropriate) intervening in potential danger to the client and others, and guarding the client’s confidentiality all reflect activities that increase safety, support identity development and functioning, and encourage a positive therapeutic relationship. Similarly, therapists should take care to not overdisclose their personal history, relationships, preferences, or ideas about things unrelated to the client, and should limit the extent to which the client and therapist interact outside of the treatment environment. This not only allows them to better manage the client’s trauma activations, but it also addresses professional and ethical issues around dual relationships, clinical boundaries, and professional standards of care. Finally, professional requirements regarding documentation and charting allow the clinician to monitor the client’s progress in therapy, such that treatment interventions correctly address the client’s current needs, as well as providing relevant information to other professionals when warranted.

As noted earlier, because the form of treatment outlined in this book emphasizes relational connection with—and positive regard toward—the trauma survivor, issues associated with counteractivation are especially salient. Although compassion—requiring nonegocentric caring and the need for the therapist to be interpersonally “present”—is an important part of trauma-focused psychotherapy, these issues occasionally can be challenging for the clinician. For example, when are one’s caring feelings for the client based on compassion and appreciation of their suffering, and when do they potentially represent the clinician’s own needs for intimacy or connection, or unprocessed sexual, romantic, or attachment issues? Similarly, how is the therapist to discriminate and address understandable anger at the client’s trauma perpetrator, or sadness at their irrevocable losses, from counteractivation of the clinician’s own childhood memories? What is the exact boundary point that must be reinforced when the client requests additional attention, caring, or self-disclosure from the therapist? In some cases, responsivity and slightly increased connection or attunement can be helpful, if it is appropriate to the situation and monitored for counteractivational distortions. In other cases, the therapist’s overresponse to such demands or requests may reflect co-transferential dynamics and produce problems.

Although this is obviously a complex topic, we offer several suggestions:

Therapy boundary violations, including voyeurism, emotional gratification, exploitation, dual relationships (inside or outside of the therapy environment), romanticization, or any sexual behavior are unethical and potentially very harmful to the client. If the clinician believes that any of these phenomena might be occurring, they should proceed under the assumption that the concern is valid. Under such circumstances, outside help, consultation, or (in the case of actual behavior) intervention should be sought.

Authoritarian or overly directive treatment can have negative impacts. A corollary of this is that the therapist should not be definitive when the issues are complex, the client is, in some ways, unknowable to the therapist, and absolute truth is hard to find. Interventions that involve lecturing or heavy-handed declarations of fact are likely to go awry and may be bad practice. Examples include the following:

Telling the client that they have or have not been abused, despite their statements to the contrary or a lack of evidence one way or the other

Making definitive interpretations about the meaning or etiology of the client’s current behavior when such hypotheses are largely speculative

Validating or supporting prejudicial social messages about sex, race, age, ethnicity, sexual orientation, gender identity, or socioeconomic status

Reinforcing dependency or acquiescence in someone who needs to become more entitled, self-referenced, and independent

Rejecting or dismissing extreme trauma symptoms such as identity dissociation or prominent somatic symptoms as not real or the products of fantasy

Making value judgments about things that are best seen nonjudgmentally, for example “bad” or “immoral” behavior

Duty to report trumps confidentiality. If the therapist becomes aware—or has reasonable suspicion—of child, elder, or dependent adult abuse, or of the client’s danger to themself or others, the clinician must do whatever is required by law and professional ethics to ensure safety. This may involve the child welfare system, law enforcement, or involuntary hospitalization. Issues in this area are sometimes hard for clinicians to confront, especially when the correct action goes against the wishes of the client. There are no easy answers to the breach of trust that the client may feel in such circumstances. We strongly recommend, however, that clients be informed at the onset of therapy about what the law or professional ethics require the therapist to report or intervene in, so that such actions at a later date are less surprising.

Clinician counteractivation responses are, in our experience, typically triggered ones. If the therapist notes a sudden, significant change in their internal state or perspective, or intrusive phenomena similar to those outlined for trigger management in Chapter 8, they should entertain the hypothesis that such responses are at least partially a function of their own history, as opposed to solely client-level stimuli. Although this is not always true—sometimes sudden affective or cognitive shifts reflect insight or compassion—we generally recommend the psychoanalytic dictum that if the therapist suddenly wants to make an exception to the relational rules in therapy, the best advice often is not to do it and to reflect on the impetus.

As a correlate to the above, be wary of very strong feelings or reactions during therapy, even if they seem to be about social justice, the client’s entitlements, or things that have been done to them. It is entirely appropriate to be on the client’s “side,” even to be their advocate when necessary and therapeutically appropriate. And social injustice should be confronted whenever possible. However, if the therapist detects strong anger, outrage, overidentification with the client, or an intrusive need to protect or parent, it is at least possible that they are being triggered and is responding to their own needs rather than solely those of the client. Such instances violate a significant principle of relational treatment: The central unit of reference in psychotherapy is the client, not the therapist. All of this is difficult to parse in some instances, and we do not mean that the therapist should be distant or uninvolved. Rather, we suggest that the attuned and helpful clinician is someone who carefully scrutinizes their therapeutic behaviors to make as sure as possible that they are dedicated to the client’s safety and well-being, as opposed to reflecting their own history, needs, or inappropriate expectations.

This work is sometimes very difficult, albeit important and meaningful. As noted earlier, we recommend that the trauma-focused clinician (as well as other helpers) access resources that can provide the support necessary to sustain this process—whether in consultation, supervision, or one’s own psychotherapy. The clinician’s willingness to hear painful things, connect with people who may have difficulty with interpersonal connections, and do this work rather than something else, is a tremendous gift to the traumatized client. But such work should not be done alone.

The reader is referred to the following sources for more detailed information on ethical practice, counteractivation/countertransference issues, and professional standards of care related to trauma treatment: Courtois and Ford (2012); Dalenberg (2000); and Kinsler et al., (2009).

Chapter 5

PSYCHOEDUCATION

Although much attention is paid in the treatment literature to the cognitive and emotional processing of traumatic memories, psychoeducation is also an important aspect of trauma therapy (Najavits, 2002, 2024). Many survivors of interpersonal violence were victimized in the context of overwhelming emotion, narrowed or dissociated attention, and, in some cases, a relatively early stage of cognitive development, all of which may have reduced the accuracy and coherence of the survivor’s understanding of these traumatic events. In addition, interpersonal violence frequently involves a more powerful figure who justifies their aggression by distorting objective reality—for example, by blaming victimization on the survivor. These fragmented, incomplete, or inaccurate explanations of traumatic events are often carried by the survivor into adulthood, with predictable negative results.

Therapists can assist in this area by providing, when indicated, accurate information on the nature of trauma and its effects, and by working with the survivor to integrate this new information and its implications into their overall perspective. Although often presented relatively early in treatment, psychoeducational activities are helpful throughout the therapy process. For example, as the client addresses traumatic material later in treatment, they may gain from additional information that normalizes or provides a new perspective on traumatic memory. Notably, even though psychoeducation can be an important component of trauma therapy, it is unlikely to be especially effective as a freestanding treatment (although see Ghafoori et al., 2016).

Psychoeducation is usually provided during ongoing individual treatment, but also can occur in clinician-led support groups, wherein a small number of people with similar trauma histories compare stories, give each other advice, and discuss interpersonal violence and its effects. An advantage of group interventions is that the survivor can learn from the similar experiences of others—a process that may be more powerful and enduring than when similar material is delivered solely by the therapist. On the other hand, by their very nature, support groups may be less efficient than face-to-face psychotherapy for the client’s own processing, integration, and personal application of whatever they learn from such information.

HANDOUTS

Whether it occurs in individual therapy or in a guided support group, psychoeducation sometimes includes the use of printed handouts. These materials typically provide easily understood information on topics such as the prevalence and impacts of interpersonal violence, common myths about victimization, and social resources available to the survivor.

The therapist should keep at least four issues in mind when deciding what (if any) written material to make available and how it should be used:

1. The quality of the materials. Some handouts contain misinformation, may advocate religious or social perspectives that indirectly blame, proselytize, or exclude, or may be written at a level that is not easily understood by the survivor.

2. The language of the materials. For example, a person whose primary language is Spanish may gain little from materials written in English.

3. The cultural appropriateness of the information or depictions. For example, materials may reflect more middle-class concerns, or visual depictions may be limited to Caucasian figures.

4. The risk of insufficient cognitive-emotional integration. Merely offering educational materials is not the same as providing effective psychoeducation, especially if the materials are distributed without sufficient discussion or application to the client’s own history or current situation.

Most important, handouts should be considered tools in the psychoeducation process, not stand-alone sources of information. The public health literature, for example, suggests that didactic material alone may not be especially effective in changing the beliefs or behaviors of victimized individuals (Becker et al., 1998). Instead, the clinician should ensure that the information is as personally relevant to the survivor as possible, so that whatever is contained in the handout or media is directly applicable to their life, and thus has greater implicit meaning.

Client-oriented brochures and information can be obtained from a number of organizations, either via the web or by requesting materials by mail. At the time of this writing, web sites that include especially useful consumer (and professional) information include the following:

International Society for Traumatic Stress Studies: https://istss.org/home

National Center for PTSD: https://www.ptsd.va.gov

Office for Victims of Crime (U.S. Department of Justice): http://www.ojp.usdoj.gov/ovc/help/welcome.html

American Professional Society on the Abuse of Children: https://www.apsac.org

SAMHSA: https://www.samhsa.gov

NCTSN: https://www.nctsn.org

BOOKS

Clinicians may also refer clients to readily available books that are survivor friendly, including Judith Herman’s (1992b) still popular and relevant book Trauma and Recovery. Although obviously limited to individuals with adequate reading skills, such books allow clients to read up on traumas similar to their own. Other books are specifically written for the survivor or interested layperson (e.g., Lisa Najavits’ [2019] Finding Your Best Self, Revised Edition: Recovery from Addiction, Trauma, or Both; Christine Courtois’s [2020] It’s Not You, It’s What Happened to You: Complex Trauma and Treatment; and Schielke et al.’s, [2022] Finding Solid Ground Workbook) and contain advice as well as information. Some materials may be too emotionally activating for some survivors with unresolved posttraumatic difficulties, however—at least those individuals who are early in their recovery or treatment process. Other books may suggest self-help strategies that are not, in fact, helpful. For these reasons, we recommend that the clinician personally read any book before recommending it to a client—not only to make sure that it is appropriate to the client’s needs and is factually accurate, but to gauge its potential to activate significant posttraumatic distress in those unprepared for such emotional exposure.

VERBAL INFORMATION DURING THERAPY

Although written psychoeducational materials can be helpful, more typically information is provided verbally by the clinician during the ongoing process of psychotherapy. Because the educational process is directly imbedded in the therapeutic context, it is often more directly relevant to the client’s experience, and thus more easily integrated into their ongoing understanding. Psychoeducation provided in this manner also allows the therapist to more easily monitor the client’s responses to the material and to clear up any misunderstandings that might be present. As noted at the end of this chapter, however, over- or misapplication of psychoeducation during treatment can also impede therapy progress; as with many aspects of good therapy, the issue is often the correct balance of content versus process and sufficient attunement to the client’s clinical response.

GENERAL FOCUS

Whether through written or verbal means, clinicians in the trauma field often focus on several major topics during psychoeducation. These include

The prevalence of the trauma. Data on the prevalence of interpersonal violence tends to contradict the common belief that the client was specifically selected by the perpetrator by virtue of weakness, badness, or unconscious provocation, or that the client is virtually alone in having experienced the trauma. For example, knowing that approximately 1 in 5 women in the general population have been raped at some point in their lives, or that up to five percent of men have been sexually abused as children, may be a meaningful antidote to the survivor’s fear that they alone have experienced such events and that something specific to them caused the event to occur.

Common myths associated with the trauma. Interpersonal violence often occurs within a broader social context that blames victims for their experiences and/or supports perpetrators for their behaviors. For example, sexual assault survivors are often believed to have been seductive or otherwise to have “asked for” their victimization; interpersonal violence may be justified as appropriate and rightful dominance of women by men; and it may be assumed that individuals, in general, frequently lie about having been abused or assaulted in the service of manipulation or retribution. When the client subscribes to these myths, they are more likely to blame themself for the victimization or explain away the trauma as something not worthy of treatment (Resick & Schnicke, 1993). For this reason, it can be helpful to discuss, for example, rape myths or common myths about partner battering in a way that makes it clear that such beliefs are not accurate.

The usual reasons why perpetrators engage in interpersonal violence. This may include describing the often compulsive, multivictim nature of many perpetrator behaviors, and the psychology driving the perpetrator’s actions—including the offender’s frequent need for power and dominance in the face of insecurity and feelings of inadequacy. Such information can reduce the client’s self-focused explanations for the assault and increase their awareness of the perpetrator’s dysfunctional or malignant characteristics. This shift in attribution may make self-blame appear less logical to the survivor. In addition, knowledge that the client was “one of many” for the perpetrator may further decrease their tendency to take personal responsibility for what was done to them.

Typical immediate responses to trauma. Among other survivor reactions to adverse events, this may include peritraumatic dissociation (e.g., “spacing out,” out of body experiences, or experiencing time distortion at the time of the trauma), rare but occasional sexual responses associated with sexual traumas (as opposed to, in many cases, actual positive psychological feelings), relief at not being injured or killed when others have been, and Stockholm syndrome response, wherein the survivor becomes attached to or traumatically bonded with the perpetrator (Cantor & Price, 2007). Because these are all relatively normal responses to trauma, despite their apparent negative qualities, the client may experience relief, as well as decreased guilt and self-blame, following nonjudgemental and normalizing discussions with the therapist.

The potentially enduring responses to victimization. Information on the commonness and logical nature of posttraumatic stress symptoms (e.g., flashbacks, numbing, or hyperarousal responses) and other trauma-related responses (e.g., substance abuse, panic attacks, or intimacy fears)—as described in Chapter 2—are an important part of most good trauma therapy. As the client comes to understand that posttraumatic symptoms are normal (in the sense that such symptoms are logical and relatively common) responses to abnormal or toxic circumstances, they are less likely to experience themself as damaged or mentally ill and may feel less out of control. Similarly, it is almost always preferable to view oneself as suffering from a well-understood cluster of typical responses to traumatic events (e.g., PTSD) than it is to see oneself as besieged by a variety of bizarre, unrelated symptoms. Psychoeducation may also prepare the client for symptoms that arise in the future. By preemptively describing symptoms before they occur, the clinician can help normalize emerging symptoms and difficulties. This, by itself, may significantly reduce posttrauma anxiety. And successfully predicting potential symptoms enhances the overall credibility of the therapist especially in terms of their nonpathologizing analysis of what symptoms mean and do not mean.

The role of triggers in posttraumatic stress and avoidance behaviors. As described in Chapter 2, posttraumatic reactions such as flashbacks and startle responses may appear to emerge out of nowhere, and avoidance responses such as substance use or indiscriminate sexual behavior may seem impulsive or evidence of being “bad” or out of control. An important role of psychoeducation is to help the client to see that these and related responses are often triggered by elements of the current environment that are reminiscent of past maltreatment and represent normal brain/mind processes. As the client becomes more aware of the mechanics of triggering and triggered responses, they are less likely to pathologize or demonize what are actually logical phenomena, and even, as described in Chapter 8, may begin to problem-solve around triggerability.

Reframing symptoms as trauma processing. Psychoeducation can help reframe certain posttraumatic responses more positively, even as evidence that recovery is occurring. This is a somewhat more active process than the normalization of symptoms described earlier. Not all symptoms can be reframed, of course, nor should they be. Depression, panic attacks, suicidality, or psychosis, for example, are generally what they appear to be: evidence of psychological disturbance or injury of some form or another. On the other hand, as described in previous chapters, posttraumatic reliving symptoms are often signs of attempted psychological processing (even when unsuccessful), and posttraumatic avoidance, as noted, is frequently an attempt to reduce the overwhelming aspects of reactivated distress. By reframing posttraumatic symptoms as potentially adaptive, the clinician may counter some of the helplessness, perceived loss of control, and stigmatization that often accompanies flashbacks, activated trauma memories, or psychological numbing. In fact, clients who accept the reframing of flashbacks as trauma processing may even come to welcome some reexperiencing responses as evidence of movement toward recovery.

Safety plans. People who are at risk for ongoing intimate partner violence may need to learn about “safety plans” that others have used successfully in similar circumstances. Typically, this involves developing a detailed strategy for exiting the home (e.g., prepacked suitcases, escape routes) and finding a new, safer, environment, whether it be a friend’s home or a local women’s shelter (Jordan et al., 2004). Other clients may benefit from concrete information on how to access medical or social services, a child protection worker, or police assistance (Briere & Jordan, 2004), or ways to regulate feelings and behaviors in the face of powerful triggers (Najavits, 2002). The goal of such interventions is to increase the power of survivors to ensure their own safety, and thus to decrease not only the likelihood of continued victimization, but also some of the helplessness often associated with exposure to chronic interpersonal violence.

CONSTRAINTS

Despite its generally salutatory effect, psychoeducation can backfire if not carefully adapted to the individual client, or if the conclusions that the client draws from the information are not monitored. For example, while information on the commonness of interpersonal violence may reduce the client’s sense of being the only one who has been victimized, it may also reinforce the client’s overestimation of the amount of danger in the interpersonal environment, leading to increased fear and avoidance of others. Similarly, too much focus on offender dynamics may support the client’s need to excuse their perpetrator, and information on standard posttraumatic reactions may inadvertently cause the client to feel disordered or dysfunctional.

Ultimately, psychoeducation should not occur in a vacuum. Information is often helpful and may be antidotal to distorted beliefs and maladaptive responses, but it must occur in the context of ongoing therapeutic discussion and evaluation (Najavits, 2002). Specifically, the clinician should attend carefully to how clients integrate new information into their world views and how they apply such information in their daily lives. Simply teaching (let alone lecturing) clients about what to do or not do or suggesting how they should think about trauma and its effects, is rarely helpful in and of itself (Neuner et al., 2004). Instead, psychoeducation is most useful when it is integrated into the ongoing therapeutic process.

Chapter 6

DISTRESS REDUCTION AND EMOTIONAL REGULATION TRAINING

As described in Chapter 2, treatment-seeking trauma survivors often experience chronic levels of anxiety, dysphoria, and posttraumatic arousal. Many also describe extreme emotional responses to trauma-related stimuli and memories—feeling states that are easily triggered and hard to accommodate internally. When faced with overwhelming arousal, distress, and/or emotionally laden memories, the survivor is often forced to rely on emotional avoidance strategies such as dissociation, substance abuse, or external distress-reduction activities. Unfortunately, as described in Chapter 9, excessive avoidance often inhibits psychological recovery from the effects of traumatic events. In the worst case, the need to avoid additional posttraumatic distress may lead the hyperaroused or emotionally dysregulated client to avoid trauma-related material during therapy, or to drop out of treatment altogether. As well, emotional states that are aversive enough to overwhelm available emotional regulation resources may negatively affect the client’s perception of the treatment process and the psychotherapist.

This chapter describes two sets of interventions: those intended to reduce acute, destabilizing emotions and symptoms that emerge during the treatment process or in their daily lives, and those focused on the client’s more general capacity to regulate negative emotional states. This material is presented early in the treatment part of the book because, as noted, overwhelming posttraumatic stress and low emotional regulation capacity usually should be addressed before more classic trauma therapy (e.g., emotional processing) can be fully accomplished. The interventions outlined here can be used at any point during therapy. For example, although the breath-based relaxation techniques described in this chapter may be initiated early in treatment, these and other approaches to emotional regulation are relevant whenever the survivor experiences escalating or intrusive negative internal states.

The techniques presented here are variously described in the trauma and anxiety literature as forms of grounding, relaxation training, cognitive therapy, stress inoculation, meditation, and anxiety management. However labeled, they all focus on the client’s increased capacity to deescalate painful emotional states, during treatment and in their ongoing life.

DEALING WITH ACUTE INTRUSION

In response to stimuli or memories triggered in therapy or at other times, the client may experience sudden panic, flashbacks, intrusive negative thoughts, dissociative states, or even transient psychotic symptoms. These internal processes can be frightening—if not destabilizing—and can diminish their moment-to-moment psychological contact with the therapist. In other cases, they may motivate the use of distress reduction behaviors (e.g., self-injury, aggression, or risky sexual behavior). At such times, it may be necessary to refocus the survivor’s attention onto the immediate therapeutic environment (with its implicit safety and predictability), the therapist–client connection, and the possibility that triggered states are not, in fact, “real” or good representations of the current state of reality.

There are a number of different things that the triggered client can do when they have been triggered inside or outside the session. As described in Chapter 8, they are generally subsumed under trigger management. Several of the most helpful of these are presented below, and expanded upon in later chapters.

Grounding. This intervention can be quite useful in acute situations. It is also, however, potentially distracting or disruptive to the treatment process. Grounding techniques tend to alter the immediate narrative/relational stream of psychotherapy and sometimes run the risk of implying that something is going awry, such that a sudden, “emergency” procedure is required. For this reason, grounding should be used only to the extent necessary to reduce the client’s internal escalation, and should be framed in such a way that it does not stigmatize the client or overdramatize the experience. In some cases, other therapeutic interventions may be just as effective, such as gently moving the client’s narrative into more cognitive or less emotionally intense aspects of whatever is under discussion (see Chapter 9), or by engaging in some other intervention that does not involve an obvious change in focus.

When grounding is indicated (that is, the client is acutely overwhelmed by intrusive symptoms or escalating trauma memories, and psychological contact with the therapist is diminishing), we suggest the following general steps.

1. Focus the client’s attention onto the therapist and therapy, as opposed to whatever internal processes are occurring. This does not mean, of course, that the therapist behaves in an unduly intrusive manner. Nor does it suggest that one should touch the client, since physical contact can intensify the client’s fear or sense of invasion, or trigger memories of interpersonal violence. Whether to touch or not is contingent on the specifics of the situation, including, for example, the nature of the trauma and whether the therapist is well known to the client and trusted by them.

2. Ask the client to briefly describe their internal experience. For example, “is something going on/upsetting you/happening right now?” If the client is clearly frightened or responding to distressing internal stimuli, but can’t or won’t describe them, go to Step 3. If the client is able to talk about the internal experience, however, it is often helpful for them to generally label or broadly describe it. This does not mean the survivor should go into great detail—detailed description of the flashback or memory may increase its intensity, thereby reinforcing the response rather than lessening it.

3. Orient the client to the immediate, external environment. This often involves two, related messages: (a) that the client is safe and is not, in fact, in danger, and (b) that they are here (in the room, in the session, with the therapist) and now (not in the past, undergoing the trauma). In some cases, the client can be oriented by reassuring statements, typically using the client’s name as an additional orienting device (e.g., “Ava, you’re okay. You’re here in the room with me. You’re safe.”). In other, more extreme cases, grounding may involve asking the client to describe the room or other aspects of the immediate environment (e.g., “Joon, let’s try to bring you back to the room, okay? Where are we? Can you describe what’s around you?”). The client might be asked to focus their attention on the feeling of the chair or couch underneath them, or of their feet on the floor. However accomplished, the client’s reorientation to the here and now may occur relatively quickly (e.g., in a few seconds) or may take longer (e.g., a number of minutes).

4. If indicated, focus on breathing or other methods of relaxation. This is an example of when breath or relaxation training (as described later in this chapter) can be especially helpful. In general, the client should be taken through the relaxation or breathing exercise for as long as is necessary (typically for several minutes or longer), reminding the client of their safety and presence in the here and now.

5. Repeat Step 2 and assess the client’s ability and willingness to return to the therapeutic process. Repeat Steps 3 and 4 as needed.

For more detailed information on assisting clients with grounding, we suggest Lisa Najavits’ text, Seeking Safety (Najavits, 2002) and Schielke and colleagues’ (2022) workbook, which provide detailed advice on grounding dissociated and other triggered trauma clients and includes a specific grounding script.

Urge surfing. Another approach to triggered states during (or outside of) therapy involves urge surfing (Marlatt & Gordon, 1985). In this approach, the client learns how to dispassionately watch their internal experience immediately post-triggering, “ride the wave” of their rising and falling distress without trying to stop or fix it, and, in an alternating fashion, (a) allow titrated awareness of nonoverwhelming painful emotion, and (b) intersperse distress with grounding activities that pull attention away from pain (see Chapter 8 and Appendix 4 for more details on this procedure).

ReGAINing. Described in detail in Chapter 8 and Appendix 5, ReGAINing is a step-wise procedure that encourages the triggered client to

recognize that they have been triggered,

use the grounding techniques outlined above,

allow the experience to unfold without judgement, rather than resisting it,

investigate the source of the trigger, and

develop insight into the fact that triggered states are “just” memories from the past and not necessarily relevant to what is really happening in the outside world.

The ReGAIN procedure can be invoked in treatment whenever the client feels triggered or overwhelmed by memories or in outside circumstances, for example at work, on a date, or in interactions with loved ones. Beyond its frequent capacity to deescalate triggered states, ReGAIN can increase the survivor’s sense of self-efficacy as they get more expert at the procedure and are able to employ it more quickly and effectively.

Back to therapy . If the client is able to stabilize and deescalate sufficiently, it is often possible for therapy to return to its earlier focus. When this is possible, the clinician should normalize the traumatic intrusion (e.g., as a not-unexpected part of trauma processing) and the stabilizing activity (e.g., as a simple procedure for focusing attention away from intrusive events). It is important that the client’s temporary reexperiencing or symptom exacerbation be neither stigmatized nor given greater meaning than appropriate. The overall message should be that trauma processing sometimes involves the intrusion of potentially upsetting memories, thoughts, and/or feelings, but such events are part of the healing process, as opposed to evidence of psychopathology or loss of control.

INTERVENING IN CHRONIC EMOTIONAL DYSREGULATION

In contrast to the above, which addresses relatively acute emotional intrusions or activations, this section describes psychological interventions in the sustained hyperarousal anxiety, and general triggerability experienced by many survivors of major, chronic trauma. Notable, especially in the case of breath-based relaxation and mindfulness training, these longer-term practices—once learned—can also be used in acute triggering, as described above. However, because skills development in this area can take time and practice, it is rarely possible for the client to learn deescalation techniques while, in fact, emotionally escalated. For this reason, we recommend that these techniques be taught to the client when they are not in acute distress, so that they can invoke them later when needed.

Relaxation and Mindful Breathing

One of the most basic forms of arousal reduction during therapy is learned relaxation. Strategically induced relaxation can facilitate the processing of traumatic material during the therapy session by reducing the client’s overall level of anxiety. Reduced anxiety during trauma processing both lessens the likelihood the client will feel overwhelmed by trauma-related distress and probably serves to countercondition traumatic material, as described in Chapter 9. In addition, relaxation can be used by the survivor outside of treatment as a way to reduce the effects of triggered traumatic memories. For individuals with especially easily activated anxiety or intrusive reexperiencing, the benefits of calling upon an internal relaxation mechanism cannot be overstated.

There are two general approaches to relaxation training, breath training and progressive relaxation, both of which are described only briefly here.

Progressive relaxation . This technique involves clenching and then releasing muscles, sequentially from head to toe, until the entire body reaches a relaxed state (Jacobson, 1938). As clients practice progressive relaxation on a regular basis, most are eventually able to enter a relaxed state relatively quickly. Some practitioners begin each session with relaxation exercises; others teach it initially in treatment, then utilize it only when specifically indicated, for example, when discussion of traumatic material results in a high state of anxiety. Two points should be made about the use of relaxation training in the treatment of posttraumatic stress, however: (1) use of this technique alone (i.e., in the absence of coexisting trauma-processing activities) is unlikely to significantly reduce trauma-related symptoms, per se (Rothbaum et al., 2000), and (2) clinical experience suggests that a minority of traumatized individuals may have unexpected anxious or dissociative reactions to induced relaxation (e.g., Fitzgerald & Gonzalez, 1994) or may not be able to successfully self-induce a relaxed state. Those who are chronically flooded with flashbacks and other reexperiencing symptoms initially may be less likely to gain from relaxation training (Taylor, 2003). In our experience, progressive relaxation can be quite helpful, when indicated, but the client should be monitored for possible, seemingly paradoxical, increases in anxiety or arousal during this procedure.

Mindfulness-based breath training . Although progressive relaxation is successfully used by some clinicians, our preference—all other things being equal—is to teach breathing techniques. When stressed, many people breathe in a shallower manner, hyperventilate, or, in some cases, temporarily stop breathing altogether. Teaching the client “how to breathe” during stress can help restore more normal respiration, and thus adequate oxygenation of the brain. Equally important, as the client learns to breathe in ways that are more efficient and more aligned with normal, nonstressed inhalation and exhalation, there is usually a calming effect on the autonomic nervous system.

Breath training generally involves guided breathing exercises that teach the client to be more aware of their breathing—especially the ways in which it is inadvertently constrained by tension and adaptation to trauma—and to adjust their musculature, posture, and thinking so that more effective and calming respiration can occur. There are a number of manuals that include information on breath training during trauma treatment (e.g., Foa & Rothbaum, 1998). One simple breath training protocol is Mindfulness-Based Breath Training (MBBT)1. Presented in Appendix 3, this exercise is very similar to the protocol presented in the second edition of this book, except that it includes reference to mindful attention and slightly changed breath instruction.

Eventually, the client can extend this exercise to additional times in the day as well, for example, during stressful situations or medical procedures, when in physical pain, or whenever they feel anxious. Importantly, brief periods of MBBT may be helpful in deescalating triggered negative emotional states during titrated exposure (see interspersal in Chapter 9). For example, the clinician may choose to begin and/or end exposure sessions with MBBT and use it midsession whenever therapeutic exposure is associated with destabilization or momentarily overwhelming emotional stress. Eventually, the client may be able to employ this skill outside of treatment, for example when triggered in their day-to-day life.

After the first one or two sessions, inquire as to whether doing the exercise has yielded any benefits for the client, including decreased anxiety, pain reduction, or a greater ability to relax. If not, normalize the situation, stating that MBBT sometimes takes a while to work. If it is proving helpful, note and praise any progress.

It should be reiterated that although relaxation training of whatever type is often a helpful component of trauma therapy, it is not always necessary or indicated. Some clients are neither so hyperaroused nor so anxious that they require special intervention in this area. Other clients (and therapists) find relaxation training too mechanistic, or a distraction from the relational process of psychotherapy. Like some other techniques presented in this book, relaxation training is an option, not a requirement, for trauma treatment.

Meditation and Yoga

In addition to grounding and breathing exercises, meditation and yoga may be effective ways to regulate emotions and reactivity. Because the clinician may not be sufficiently trained or prepared to teach meditation (let alone yoga) in any extended way, many therapists have found that, as described in Chapter 11, referring appropriate trauma clients to outside centers or instructors can broadly assist the trauma therapy process. See pp. 189-190 for a discussion of screening clients for entering meditation training.

Meditation . Meditation typically involves sitting or lying in a specific position, walking in a certain way, focusing attention on the breath, chanting, or attending to an external stimulus (e.g., a candle flame or a mandala). In some instances, the meditator learns to maintain this attention for relatively long periods of time, noting inevitable distracting thoughts and feelings without judgment, then returning to their ongoing focus of attention. As described in Chapter 11, this may lead to a state of present-centered, moment-by-moment, relatively dispassionate and nonjudgmental awareness referred to as mindfulness—a phenomenon known to have positive psychological effects, including on posttraumatic stress.

What has not been fully ascertained at present is the relative contributions of the vehicle for mindfulness (meditation) versus mindfulness itself. For example, transcendental meditation is not normally used to increase mindfulness, per se, yet it has been shown to be helpful in reducing posttraumatic stress (e.g., Kang et al., 2018). As well, a meta-analysis of the effects of meditation and yoga on PTSD found that all types of meditation (mindfulness, transcendental, mantra based, and yoga) were equivalent in their effectiveness in reducing PTSD symptoms (Gallegos et al., 2017). Although this analysis was limited by the smaller number of studies on non-mindfulness-based mediation, it suggests that meditation, per se, perhaps irrespective of whether it induces mindfulness or not, can be helpful for those experiencing PTSD.

Yoga. Like meditation, yoga is a contemplative exercise that, over time, appears to improve psychological and physical functioning (Emerson & Hopper, 2011; Ross & Thomas, 2010). Involving careful stretching, and specific movements, postures, and positions in specific sequences, it also includes attention to breath, meditation, relaxation, diet, and a specific philosophical perspective. Yoga not only appears to calm the mind, but it also may increase physical strength, flexibility, and capacity, with associated reductions in psychophysiological stress (Harvard Mental Health Letter, 2009). Research suggests that regular involvement in yoga practice may be associated with improvements in posttraumatic stress, anxiety, and depression (Descilo et al., 2009; Jindani et al., 2015), although some studies have significant methodological flaws. Notably, to date, one meta-analysis suggests that yoga is generally as effective as more mindfulness-based interventions (Hilton et al., 2016) in addressing PTSD, whereas another found only weak support for the efficacy of yoga, largely because of methodological problems with some studies (Cramer et al., 2018).

Obviously, meditation and/or yoga is not for everyone, and many trauma survivors do not begin such practices solely as a method of stress reduction or emotional regulation. However, many trauma-exposed people find themselves drawn to such contemplative practices and gain significantly from them.

Medication

When dysphoria or posttraumatic arousal is of sufficient intensity that it interferes with treatment and recovery, psychoactive medications also may be helpful. As described in Chapter 15, pharmacologic agents that target anxiety and/or hyperarousal, or stabilize mood, sometimes may be helpful in reducing such symptoms during trauma-focused psychotherapy. As also noted, however, such medications are not a cure-all for dysregulated emotional states; their efficacy is variable from case to case and may be contraindicated in some instances because of significant side effects. Often, the best approach to high pretreatment arousal and anxiety is to use psychiatric medication, if necessary, but also to apply psychological interventions that reduce anxiety and increase emotional regulation skills, as described in this chapter.

Increasing General Emotional Regulation Capacity

Above and beyond immediate methods of distress reduction, such as grounding, relaxation, and meditation or yoga, there are several suggestions in the literature for increasing the general emotional regulation skills of trauma clients. All are focused on increasing the survivor’s general capacity to tolerate negative feeling states, thereby reducing the likelihood that they will be overwhelmed when triggered.

Identifying and discriminating emotions. An important component of successful emotional regulation is the ability to correctly perceive, label, and discuss emotions as they are experienced (Linehan, 1993). Such “affect labelling” not only facilitates emotional regulation, but is also often associated with distress reduction (Torre & Lieberman, 2018). Yet, many survivors of early, chronic trauma have trouble knowing exactly what they feel when activated into an emotional state, beyond, perhaps, a sense of feeling “bad” or “upset” (Luterek et al., 2005). In a similar vein, some individuals may not be able to accurately differentiate feelings of anger, for example, from anxiety or sadness. Although this sometimes reflects dissociative disconnection from emotion, in other cases it appears to represent a basic inability to “know about” one’s emotions. As a result, the survivor may perceive their internal state as consisting of chaotic, intense, but undifferentiated emotionality that is not logical or predictable. For example, the survivor triggered into a seemingly undifferentiated negative emotional state will not be able to say, “I am anxious,” let alone infer that “I am anxious because I feel threatened because of how that person is acting.” Instead, the experience may be of overwhelming and unexplainable negative emotion that comes “out of the blue.”

The clinician can assist the client in this area by regularly facilitating clients’ exploration and discussion of their emotional experiences. Often, the client will become more able to identify feelings just by being asked about them on a regular basis. On other occasions, the therapist can encourage the client to do “emotional detective work” (Briere & Lanktree, 2012), involving attempts to hypothesize an experienced, but not understood, emotional state based on the events surrounding it. For example, the client may guess that a feeling is anxiety because it follows a frightening stimulus, or anger because it is associated with resentful cognitions or angry behaviors.

Emotional identification and discrimination occasionally can be fostered by the therapist’s direct feedback, such as “It looks like you’re feeling angry. Are you?” or “You look scared. Is that right?” This option should be approached with care, however. There is a certain risk of labeling a client’s emotion as feeling A when, in fact, the client is experiencing feeling B—thereby fostering confusion rather than effective emotional identification. For this reason, we recommend that, in all but the most obvious instances, the therapist facilitate the client’s exploration and hypothesis testing of their feeling state, rather than telling them what they are feeling. The critical issue here is not, in most cases, whether the client (or therapist) correctly identifies a particular emotional state, but rather that the client explores and attempts to label and “talk about” their feelings on a regular basis. In our experience, the more this is done as a general part of therapy, the better the survivor becomes at accurate feeling identification and discrimination.

Learning to identify and counter thoughts that precede intrusive emotions. It is not only feelings that should be identified—in many cases, it is also thoughts. This is most relevant when a cognition triggers a strong emotional reaction, but the thought is somehow unknown to the survivor. As suggested by some clinicians (Cloitre et al., 2002; Linehan, 1993), emotional regulation capacities often can be improved by encouraging the client to identify and counter the cognitions that exacerbate or trigger trauma-related emotions. Beyond the more general cognitive interventions described in Chapter 7, this involves the client monitoring whatever thoughts mediate between a triggered traumatic memory and a subsequent negative emotional reaction. For example, upon having child abuse memories triggered by an authority figure, the survivor may have the unconscious or partially suppressed thought, “He is going to hurt me,” and may then react with extreme anxiety or distress. Or the survivor of sexual abuse might think, “She wants sex with me,” when interacting with an older woman and then may experience revulsion, rage, terror, or guilty arousal. In such cases, although the memory itself is likely to trigger negative emotionality (conditioned emotional responses, or CERs; see Chapter 9), the associated cognitions often exacerbate these responses to produce more extreme emotional states. In other instances, thoughts may be less directly trauma related, yet still increase the intensity of the client’s emotional response. For example, in a stressful situation the client may have thoughts such as “I’m out of control” or “I’m making a fool of myself” that produce panic or fears of being overwhelmed or inundated.

Because triggered thoughts may be out of superficial awareness, their role in subsequent emotionality may not be observed by the client (Beck, 1995). As they are made more aware of the cognitive antecedents to overwhelming emotionality, the client can learn to lessen the impact of such thoughts. In many cases, this is done by explicitly disagreeing with the cognition (e.g., “Nobody’s out to get me,” or “I can handle this”), or merely by labeling such cognitions as “old tapes” rather than accurate perceptions. In this regard, one of the benefits of what is referred to as insight in psychodynamic therapy is often the realization that one is acting in a certain way by virtue of erroneous, archaic beliefs or perceptions—an understanding that often reduces the power of those cognitions to produce distress or motivate dysfunctional behavior (see Chapter 7).

When the thoughts that underlie extremely powerful and overwhelming emotional states are triggered by trauma-related memories, the therapist can focus on these intermediate responses by asking questions such as “What happened just before you got scared/angry/upset?” or “Did you have a thought or memory?” If the client reports that, for example, a given strong emotion was triggered by a trauma memory, the therapist may ask them to describe the memory (if that is tolerable) and to discuss what thoughts the memory triggered. Ultimately, this may involve exploration and discussion of four separate phenomena:

1. The environmental stimulus that triggered the memory (e.g., one’s partner’s angry expression)

2. The memory itself (e.g., of maltreatment by an angry parent)

3. The current thought associated with the memory (e.g., “She hates me,” “I must have done something wrong,” or “He is blaming me for something I didn’t do”)

4. The current feeling (e.g., anger or fear)

These triggered, often catastrophizing cognitions can then be discussed as to their relevance to the current situation. In such instances, the client is generally asked to explore the accuracy of such thoughts, their possible etiology (often involving childhood abuse, neglect, or other maltreatment), and what they could do to address such thoughts (e.g., remind themself that the thought is not accurate or that it is “just my childhood talking”). As the client becomes better able to identify these cognitions, place them in some realistic context, and counter them with other, more positive thoughts, they often develop greater capacity to forestall extreme emotional reactivity, and thereby better regulate the emotional experience.

Emotional regulation learning during trauma processing. Emotional regulation and tolerance also can be learned implicitly during the ongoing process of longer-term, titrated exposure-based trauma therapy. Because, as discussed in later chapters, trauma-focused interventions involve the repeated activation, processing, and resolution of distressing but nonoverwhelming distress, such treatment slowly teaches the survivor to become more at home with some level of painful emotional experience and to develop whatever skills are necessary to deescalate emotional arousal. As the client repetitively experiences titrated (that is, not overwhelming or destabilizing) levels of distress during exposure to trauma memories (Chapter 9), they may slowly develop the ability to self-soothe, reframe upsetting thoughts, and call upon relational support. In addition, by working with the client to deescalate distress associated with activated memories, the therapist often models emotional regulation strategies, especially those involving normalization, soothing, and validation. However developed, this growing ability to move in and out of strong affective states, in turn, fosters an increased sense of emotional control and reduced fear of negative emotions.

Chapter 7

COGNITIVE INTERVENTIONS

As noted in Chapter 2, trauma survivors—especially survivors of interpersonal violence—are prone to self-blame, guilt, shame, low self-esteem, overestimation of current danger, and other negative beliefs and perceptions. The rape survivor may believe that they somehow asked to be assaulted or otherwise caused themself to be victimized, and the survivor of intimate partner violence may assume that they deserved to be beaten. Individuals who have been repeatedly exposed to situations in which they were helpless to escape or reduce their trauma exposure may develop a sense of having little power to affect future negative events. Some survivors view their posttraumatic symptoms as evidence of being defective or “crazy.” Those who have experienced sexual trauma often feel ashamed and isolated by their experiences.

In general, cognitive therapy of traumatically altered cognitions involves the guided reconsideration of negative perceptions and beliefs about self, others, and the relative safety of the environment. As these assumptions are reevaluated, a more affirming and empowering model of self and others can take its place. At the same time, the client may develop a more detailed and coherent understanding of the traumatic event, an outcome that is associated with clinical improvement (Foa et al., 1995).

COGNITIVE PROCESSING

In most cases, trauma-related cognitive disturbance is addressed through detailed verbal exploration of the traumatic event and its surrounding circumstances. As the client repeatedly describes the trauma in the context of treatment, they, in a sense, relive the past while viewing it from the perspective of the present. By recounting the traumatic event in the session, the client has the opportunity to hear themselves verbalize assumptions, beliefs, and perceptions that were encoded at the time of the trauma, understand the reasons they arose, and compare them with what they now know. Together, the client and therapist can then work to create a more accurate cognitive model of what occurred.

This interactive process frequently fosters more positive self-perceptions as the client comes to reinterpret former “bad” behaviors, supposed deservingness of maltreatment, and presumed inadequacies in a more accurate light. For example, the client who has always interpreted their behavior just prior to a sexual assault as having “asked for it” may gain from the opportunity to relive and review what actually happened and to see if their judgments about themself seem valid. Exploration of the events prior to the assault may reveal that they were not behaving in a “seductive” manner, nor are they likely to recall wanting to be abused or otherwise hurt.

A growing awareness of what one could reasonably have done at the time of the trauma—that is, what one’s options actually were—can be antidotal to inappropriate feelings of responsibility, self-blame, or self-criticism. For example, describing memories of childhood abuse—while at the same time listening to them from the perspective of an adult—may lead to the realization that one had few options other than subservience or accommodation at the time of the abuse. The notion that “I should have done something to stop it,” for example, might be countered by a greater experiential understanding of the size and power differentials inherent in an adult forcing their will (and body) on a 7-year-old child.

Finally, blaming or shaming statements made by an assailant may gradually lose their power when examined in the context of a safe environment. Many survivors of interpersonal violence tend to internalize or otherwise accept rationalizations used by the perpetrator and reinforced by society at the time of the assault (Salter, 1995). These include batterer statements that the survivor deserved violence for failing to be a good spouse, rapist statements that the survivor was asking to be sexually assaulted, and child abuser statements that physical abuse was merely appropriate punishment for bad behavior. For example, a refugee may have partially accepted statements made by their torturers that they were responsible for their family’s death by virtue of being “a traitor,” when, in fact, (1) they did nothing to justify such horrible events, and (2) the deaths were committed by the government, not by them. The childhood trauma survivor may internalize perpetrator comments that they are bad, fat, ugly, or worthless. As the client and therapist discuss the circumstances of the event and consider perpetrator statements in the absence of danger or coercion, the objective lack of support for these statements may become more apparent to them.

Because they are often more able to see these cognitive distortions than is the client, the clinician may feel pressed to voice an opinion regarding the lack of culpability of the survivor or the obvious cruelty of the perpetrator. This is understandable, and, in small doses, is usually appropriate. But such statements should be presented as a form of “going on the record” regarding the therapist’s clear understanding that the survivor was, in fact, victimized. Rarely will such statements, in and of themselves, actually change the client’s opinion. In fact, clinical experience suggests that cognitive therapy is rarely helpful when the clinician merely disagrees (or argues) with the client about their cognitions or memories or makes definitive statements about what reality actually is or was. Rather, interventions may be most effective when they provide opportunities for the client to experience the original trauma-related thoughts and self-perceptions (e.g., feelings of responsibility and guilt when recalling being assaulted), while at the same time considering a more contemporary and logical perspective (e.g., that the beatings were, ultimately, about the perpetrator’s chronic anger, alcoholism and feelings of inadequacy, and not due to the client’s failure to wash the dishes or provide sex on demand).

As suggested by Resick and Schnicke (1993) and the reconsolidation research cited in Chapter 9, the reworking of trauma-related assumptions or perceptions is probably most effective when it occurs while the client is actively remembering the trauma and reexperiencing the thoughts and feelings they had at the time. In other words, merely discussing a traumatic event without some level of emotional memory activation is less likely to allow the client to change the cognitions related to the memory. In contrast, active recall and description of a traumatic event probably trigger two parallel processes: (1) observation of one’s own trauma-related attributions regarding the specifics of the event, and (2) activation of the emotions associated with the event. The second component of this response is covered in detail in Chapter 9. However, it is important to acknowledge it here because emotional activation allows the client to relive the traumatic event more directly, such that any cognitive interventions are more directly linked to specific memories of the trauma.

There are two major ways that the client can remember and, to some extent, reexperience traumatic events during the process of treatment: (1) by describing them in detail, and (2) by writing about them. In the first instance, the therapist encourages the client to describe the traumatic event or events in as much verbal detail as is tolerable, including feelings they experienced during and after the victimization experience. As noted in Chapter 9, this is an important component of emotional processing. It also facilitates cognitive processing to the extent that it includes discussion of conclusions or beliefs the survivor formed from the experience. In response to the client’s description, the therapist generally asks open-ended questions that are intended to make apparent any cognitive distortions that might be present regarding blame, deservingness, or responsibility. As the client responds to these questions, the therapist provides support and encouragement, and, when appropriate, gently offers information that counters the negative implications or self-perceptions that emerge in the client’s responses. The client might then have responses that lead to further questions from the therapist. Or the topic might shift to the client’s emotional processing of the implications of any new information, insights, or feelings that arose from the discussion process.

The second major form of cognitive processing involves the use of “homework,” wherein the client is asked to write about a specific topic related to the trauma, bring it to the next session, and read it aloud in the presence of the clinician. In this way, the client has the opportunity to continue therapeutic activities outside of the session, including desensitization of traumatic memories and continued cognitive reconsideration of trauma-related assumptions and perceptions. In fact, research suggests that the mere act of writing about an upsetting event can reduce psychological distress over time (Pennebaker & Campbell, 2000), as witness the effectiveness of written exposure therapy (WET; Sloan et al., 2019) (see Chapter 9).

The goal of cognitive treatment and related homework is to activate the client’s memories of the traumatic event so that they can be cognitively processed in subsequent discussions with the therapist. The initiation and maintenance of such discussions often center on what is known as the Socratic Method: a series of gentle, often open-ended inquiries that allow the client to progressively examine the assumptions and interpretations they have made about the victimization experience.

Typical questions, in this regard, include (but are not limited to)

“Did you have any thoughts while it was happening? What were they?”

“Given the situation, do you think there was anything else you could have done?”

“So, that made you feel that you were to blame/responsible/bad/stupid/seductive. Can we go over what happened and see what made you think that?”

“Do you think you actually want them to assault/abuse/hurt you? Do you remember ever wanting that?”

“You say that you were hurt/abused/beaten because you asked for it/were seductive/didn’t lock the door/were out late. Can we see if that makes sense?”

“If this happened to someone else, would you come to the same conclusions?”

“It sounds like you believe what they said about you. Were they the kind of person you would usually believe when they said something?”

The goal here is for the client to update their trauma-based understanding—not merely to incorporate the therapist’s statements about the true state of reality or the client’s “thinking errors.” Although therapist statements about the presumed reality of things may sometimes be helpful, much of the knowledge the client acquires in therapy is best learned from themself. By repeatedly comparing “old” trauma-based versions of reality with newer understandings that arise in the context of a detailed examination of past events, the client can often revise their personal history—not in the sense of making things up, but by updating assumptions and beliefs that were made under duress and were never revisited in detail. This new understanding may then be incorporated (reconsolidated) into the memory, as described in Chapter 9.

This approach also can be used to examine distorted beliefs about future events, not just feelings of responsibility or self-blame. Most typically, these thoughts involve beliefs such as

I am broken and will never get better/be loved/get what I want.

The world is dangerous, and I will be hurt again.

I am helpless to avoid additional traumas.

People/men/women/authority figures are predatory and can’t be trusted.

The future is hopeless.

Cognitive interventions for such trauma-related assumptions are much like those used to address self-blame, except that they focus more on an analysis of future outcomes. Among the general questions the therapist might ask—without leading the client or appearing to judge—are the following:

“What are the chances that something like that would actually happen to you in the future?”

“Can you think of any examples that wouldn’t fit your belief about the future? Could there be exceptions to the rule?” (e.g., any men who wouldn’t sexually assault you, any places where you would be safe, any things you could do to avoid potential exposure to the trauma, at least one person you can probably trust)

“Is there any way in which you might be underestimating yourself when you say that?”

The therapist may ask such questions, which obviously will vary from client to client and session to session, as the description of the trauma unfolds or after the client’s rendition is completed. We tend to favor the latter approach: encouraging the client to describe the trauma in detail, and then following up with questions. In doing so, the client is more able to expose themself more fully to the story, with its attendant emotional triggers, and the therapist has a better chance of determining what the client thinks about the trauma without the rendition being affected by therapist responses. On the other hand, when cognitive processing is more conversational, it may be appropriate to support client exploration of their statements as they occur, as long as they do not feel interrogated or criticized.

However accomplished, the central goal of cognitive therapy in this area is to assist the client to explore their beliefs or assumptions more fully and accurately, and the context in which they arose, without lecturing, arguing, or labeling such beliefs as wrong. Instead, such cognitions should be viewed (and reflected back to the client) as entirely understandable reactions to overwhelming events that involved extreme anxiety and distress, incomplete information, coercion, confusion, and, in many cases, the need for survival defenses. Trauma-related cognitions should be treated not as the product of thinking error or of inherent neurosis, but rather as initial perceptions and assumptions that require updating in the context of safety, support, introspection, and new information.

While addressing cognitive distortions about the event and what it means to the client, the clinician also may encounter distortions the client has formed regarding the meaning of symptoms they are experiencing. In general, these involve beliefs that the intrusive-reliving, numbing-avoidance, and hyperarousal components of traumatic stress represent loss of control or major psychopathology.

In the style outlined earlier for trauma-related cognitions, the therapist can facilitate cognitive processing of these perceptions or beliefs by asking the client—especially after some level of psychoeducation has transpired—about (1) what might be a nonpathologizing explanation for the symptom (e.g., the survival value of hypervigilance, or the self-medicating aspects of substance abuse), (2) whether the symptoms actually indicate mental illness (e.g., whether flashbacks are the same thing as hallucinations, or whether it is really “paranoid” to be fearful about trauma-reminiscent situations), and (3) whether it is better to actively experience posttraumatic stress (especially reexperiencing) than to “shut down” or otherwise avoid trauma memories. Each of these (and similar) questions may stimulate lively and useful conversations, the goal of which is not for the clinician’s view to prevail, but for the client to explore the basis for (and meaning of) their internal experience.

DEVELOPING A COHERENT NARRATIVE

In addition to the cognitive processing of traumatic memories, therapy can provide broader meaning and context. Clinical experience suggests that client descriptions of past traumatic events often become more detailed, organized, and causally structured as they are repeatedly discussed and explored in therapy. Research (e.g., Amir et al., 1998) indicates that such increased narrative coherence is directly associated with a reduction in posttraumatic symptoms. Although it is likely that coherence is a sign of clinical improvement, the development of an integrated version of one’s trauma also may have a positive effect on further recovery (Pennebaker, 1993). As the client is increasingly able to describe chronologically and analytically what happened, and to place it in a larger context, they may experience an increased sense of perspective, reduced feelings of chaos, and a greater sense that the universe is predictable and orderly, if not entirely benign (Meichenbaum & Fong, 1993; Vrana et al., 2019). Further, creating meaning out of one’s experiences (including conclusions about cause and effect) may provide some degree of closure, in that the experiences make sense and thus may not require further rumination or preoccupation. Finally, a more coherent trauma narrative, by virtue of its organization and complexity, may support more efficient and complete emotional and cognitive processing (Amir et al., 1998; Vanderveren et al., 2020). In contrast, fragmented recollections of traumatic events that do not have an explicit chronological order and do not have obvious cause–effect linkages can easily lead to additional anxiety and confusion and inhibit effective trauma processing.

The development of a coherent narrative usually occurs naturally during effective trauma-focused therapy. As the traumatic event (or events) is discussed repetitively and in detail, a process sometimes referred to as context reinstatement (Anderson & Bower, 1972) may occur. Specifically, a detailed trauma description may increase the survivor’s access to more aspects of the memory that, in turn, may trigger recall of additional details. For example, a client might initially report that “he hit me on the head, and there was yelling and blood.” In the moment of making this statement, the reference to blood might activate more specific memories of blood on the carpet, which, in turn, might trigger additional recollection of the location or, perhaps, the feeling of pain associated with a scalp laceration. Further discussion might then provide the context for a chronological sequence. For example,

As the sequence and details of the event become clearer, there is more material to cognitively process, and a greater sense of stability associated with “knowing what happened.” Further, as described earlier, greater detail often provides information that is antidotal to cognitive distortions. For example, a client might state

Or, in a date rape scenario,

Although a more coherent narrative often arises naturally from repeatedly revisiting the trauma in therapy, the clinician can work to further increase the likelihood of this happening. This generally involves gentle, nonintrusive questions regarding the details of the trauma, and support for the client’s general exploration of their thoughts and feelings regarding the event—in the same manner described earlier for cognitive processing. In partial contrast to cognitive processing interventions, however, narrative interventions support the development of broader explanations and an overbridging “story” of the traumatic event, its antecedents, and its effects. In addition to its obviously clinical effects, an integrated version of adverse experiences may lead to a broader overall perspective on life, and, perhaps, greater personal wisdom, as described in Chapter 4.

COGNITIVE CHANGES ARISING FROM NON-OVERWHELMING EMOTIONAL ACTIVATION

As emphasized by Foa and Rothbaum (1998), not all cognitive effects of trauma therapy involve verbal reconsideration or “restructuring” of traumatically altered thinking patterns—it is also possible for the survivor’s beliefs to change during the process of remembering and processing upsetting memories during treatment. Summarizing a cognitive component of Foa and Kozak’s (1986) emotional processing model, Rogers and Silver (2002) note that

In the context of processing traumatic memories in therapy, the client repetitively experiences three things: (1) anxiety that is conditioned to the trauma memory; (2) the expectation that such anxiety signals danger and/or is, itself, a dangerous state and must be avoided; and yet (3) an absence of actual negative outcome—they do not actually experience physical or psychological harm from anxiety or what it might presage. This repetitive disparity (a technical term discussed in greater detail in Chapter 9) between the expectation of anxiety as signaling danger and yet, the subsequent experience of non-danger in therapy probably changes the expectation over time (in Foa & Kozak’s [1986] parlance, it modifies the attendant “fear structure”). Beyond its cognitive effects on beliefs and assumptions associated with the specific trauma memory, the repetitive experience of feeling anxious within the context of therapeutic safety probably lessens the negative valence of anxiety, per se. In many cases, this means that the client is less anxious about anxiety; coming to see it as merely an emotion and not necessarily as a harbinger of danger, loss of control, or psychological disability. Viewed in this context, the interconnection between trauma processing and emotional regulation training, as described in the previous chapter, becomes clear: increased ability to experience negative emotions without the associated catastrophizing cognitions reduces the likelihood that such states will be overwhelming and therefore avoided.

COGNITIVE INTERVENTIONS AND INSIGHT

As noted earlier in this chapter, one of the major goals of cognitive interventions is to change how the client views themself, their prior life experiences, and others in their interpersonal environment. Such cognitive reconsideration (Briere, 2002b) is often equivalent to the psychodynamic notion of insight. For example, when the client understands (has insight into the fact) that there really wasn’t much that they could have done in the face of an uncontrollable traumatic event, self-blame for having experienced or deserved the trauma—or for not having avoided it—is actively contradicted. Although, as noted, such newer cognitive understanding may not have immediate positive effects, over time and upon repeatedly revisiting this fact in treatment, the disparity between old assumptions and perceptions versus more recent, more accurate appraisals can serve to contradict distorted trauma-related cognitions more permanently (see discussions of expectancy violation and inhibitory learning in Chapter 9).

A greater understanding of the past—and insight into the various ways in which it differs from the present—also may reduce the capacity of stimuli in the current environment to trigger posttraumatic responses. As noted in Chapters 7 and 9, for example, realizing through cognitive reconsideration and/or ongoing interactions in safety with a benign therapist that interpersonal closeness is not always dangerous may reduce the amount of distrust, fear, or anger triggered by relationships in one’s adult environment. In a sense, what would otherwise be a trigger for memories of previous interpersonal violence can be changed. For example, if people are not immediately equated with one’s abusive parent, batterer, or rapist, close relations with people—in general—are less likely to trigger trauma-related memories and associated distress. Similarly, the experience that one can be anxious without “losing it” may result in an increased sense of security and, in some cases, better interpersonal functioning.

Finally, it is often possible to increase the client’s understanding of the difference between sensations and thoughts associated with activated trauma memories, as opposed to what is “really going on” in the external world. Referred to as metacognitive awareness (Teasdale, 1999) in Chapter 8, this capacity allows the survivor who, after being triggered into an abuse-related cognition (e.g., harsh self-denigration), emotion (e.g., shame or self-hatred), or flashback, to say to themself “This isn’t real; I’m just remembering what happened to me,” “Just because I feel like a bad person doesn’t mean that I actually am one,” or “These are just thoughts, not facts.” As described later in the context of trigger management, insight into the “not real” but nevertheless compelling aspects of triggered memory can reduce the client’s emotional reactivity and acceptance of cognitive distortions.

There are theoretical differences in how psychodynamic and cognitive clinicians seek to address cognitive distortions. Whereas the cognitive therapist generally works to help the client identify inaccurate thinking and to supplant it with more accurate perceptions and beliefs, the psychodynamic clinician is especially invested in helping the client understand the original basis for such distortions. As the analyst Marcia Goin (1997) notes, “The cognitive therapist battles the illogic with logic, while the psychodynamic therapist searches for the logic in the illogical” (p. 308). In trauma therapy both phenomena ideally occur: The client is provided with opportunities to identify prior inaccurate thoughts about self, others, and the future, and is supported in finding more accurate models of reality, but also learns the logical, often historical basis for these internal intrusions. In the latter instance, this greater understanding of the “whys” of cognitive distortion allows a more coherent narrative of the past, its logical effects on the survivor, and, ultimately, the greater validity of more recent, less trauma-influenced, understandings and self-perceptions.

The similarity and confluence between the notion of “insight” and cognitive interventions is emblematic of the hidden similarities between many supposedly different therapeutic approaches. Most of the best therapies provide new information and opportunities to reconsider triggered, archaic assumptions and perceptions, often in the context of a supportive therapeutic relationship. Frequently, the issue is less what specific treatment is involved in this process than it is how well the client’s access to—and integration of—new information and perspectives is accomplished. The heavy-handed cognitive confrontation of “erroneous” thinking is probably as likely to be unsuccessful as is the ill-timed or disattuned use of interpretation in psychodynamic treatment. On the other hand, a therapeutic approach that facilitates the client’s growing knowledge of themself, both now and in the past, can have substantial impacts on their psychological recovery.

ADDRESSING THE COGNITIVE IMPACTS OF SOCIAL MALTREATMENT

As noted at various points in this book, trauma not only involves interpersonal victimization, natural disasters, and severe neglect, it also arises from systemic social maltreatment. The effects of such inequities are, in our view, at least as deleterious as child abuse or adult assaults (see Briere et al., 2024a), and may include pervasive feelings of shame, nonentitlement, hopelessness, low self-esteem, and even self-hatred (Brown & Trevethan, 2010). The individual may understandably expect future danger from members of the dominant group and may experience pervasive anger and/or fear as they interact with a culture that has done them harm.

Notably, the cognitive effects of social maltreatment often reflect relatively accurate perceptions of a harsh external world, although the inferences formed may be distorted (e.g., misogynistic treatment leading to low self-esteem). The survivor of racism may appropriately feel some degree of helplessness or hopelessness, and their preoccupation with danger may be contextually accurate. Yet, at the same time, such responses, if extreme, can be debilitating, and while their genesis should be explicitly identified and validated, other cognitive states, such as self-empowerment, hope, and pride are obviously meaningful goals. The unhoused person or undocumented immigrant deserves—as does the child abuse survivor—support for self-acceptance, self-determination, and freedom from crippling self-doubt.

The question is how these issues can be addressed clinically. The therapist may be of the same gender, race, class, sexual orientation, or cis status as those who have maltreated the client and thus may have questionable credibility and inadvertently trigger memories of past social victimization. Because social inequity is unlikely to resolve any time soon, some degree of alienation is certainly understandable and may be hard to argue against. In fact, such reactions may be appropriate and useful to the extent that they support the client’s ongoing survival in a harsh world.

Yet, in some sense, there is little difference between (a) assisting clients with abuse-related cognitive impacts and (b) providing a therapeutic environment within which the cognitive sequels of social maltreatment—for example internalized self-hatred or global helplessness—can be processed. Both may require careful attention to safety issues (including the therapist’s vigilance to their own unconscious discriminatory behavior); cognitive processing of adverse events, including microaggressions; the development of a coherent narrative regarding the reality and unfairness of oppression and the client’s entitlement to social equality; and therapeutic attention to internal processes (e.g., danger preoccupation, triggering) that, while entirely understandable, may be a source of considerable suffering.

Equally important, successful work with survivors of social discrimination and maltreatment generally requires a clinician who has closely examined and addressed their own potential for bias, is visibly anti-racist and anti-sexist, and explicitly accepts all sexual orientations and gender identities (Comas-Diaz, 2006; Danzer, 2012). Even this may not be enough. It sometimes may be impossible (or even inappropriate), for example, for a White therapist to help a client of color process trauma narratives involving racism or aggression by White people, or for a male therapist to assist female survivors of male sexual assault or gender microaggressions. When this is true, the best approach may be to facilitate whatever same-race/gender/orientation therapist–client dyads are appropriate. Even in this instance, however, the final decision rests with the client; some survivors may not have a strong opinion regarding the gender, orientation, race, or ethnicity of their therapist.

Chapter 8

TRIGGER MANAGEMENT

As noted throughout this book, people who have been traumatized in childhood or later on may be prone to triggered intrusions of implicit trauma or attachment memories, for example posttraumatic flashbacks or sudden abandonment fears that seemingly come out of nowhere and motivate DRBs to reduce their effects. Because triggering is often a component of trauma-related difficulties, the third edition of this book now includes a formal consideration of trigger management (Briere, 2019), previously described as trigger identification and intervention (e.g., Briere & Lanktree, 2012). Discussed to some extent in previous chapters, trigger management occurs when the client

becomes aware of the reality of triggers, including their etiology and their role in their current difficulties;

is able to identify when triggering has occurred, so that they can determine whether an experience is “real” (i.e., based on the here and now), as opposed to being a triggered memory masquerading as the present;

discovers what internal and external stimuli lead to triggering, so that they can identify and control exposure to triggers;

learns how to reduce the effects of triggering, so that activated trauma-related sensations, emotions, and thoughts have less impact and avoidance responses are less needed.

As noted in Chapter 2, triggered memories of trauma are not intrinsically negative phenomena. However, they can motivate behaviors that—although sometimes effective in reducing triggered distress—may be maladaptive or even self-destructive in contexts where focused attention and adaptive strategies would be more helpful (Ford, 2021b). Successful trigger management can facilitate a greater sense of control and self-efficacy in the survivor by allowing them to avoid or alter situations in which these triggers might occur and problem-solve emerging negative states before they produce behavioral problems. Ultimately, as noted later, this approach can decrease the chaos in the survivor’s life and increase their emotional regulation and tolerance.

Trigger management is generally taught as a regular component of trauma therapy, so that it can be called upon later when the survivor encounters a trigger in their environment. Importantly, it is often hard to determine exactly what to do in the moment when triggering has occurred—it is better to have previously identified a given trigger (among others), its etiology, and its possible solutions, in the context of therapeutic guidance and support.

This process has been described by a young client with an unusual affinity for the singer Sting as akin to creating a “message in a bottle”:

Discussing in treatment what to do when triggered (writing the message)

Developing strategies for later use (placing it in a bottle)

and then

Calling upon this information or plan once it is remembered (reading the message), allowing a more measured and thought-out approach to what otherwise might be a crisis situation

STEPS OF TRIGGER MANAGEMENT

Increasing Resilience

Because DRBs may be more likely in the context of phenomena that lower the threshold for triggering, such as poor physical health, substance abuse, social marginalization, homelessness, self-neglect, and diminished social and personal resources, it is important that the client be as resilient as possible. In this regard, proactive resilience typically involves physical and emotional stabilization. A good example of resilience-increasing activities is Linehan’s (2014) PLEASE approach:

Treat Physical i Llness

Balance Eating

Avoid mood-altering drugs or alcohol

Balance Sleep

Exercise

Unfortunately, increasing resilience by decreasing physical or emotional vulnerability is not always easy. For example, sleeping or eating well may be difficult for people without a safe place to stay, or who are suffering from PTSD, depression, or an eating disorder. And drug or alcohol use may be hard to lessen or give up when (a) the survivor is stressed or triggered, especially in the presence of low emotional regulation capacity, or (b) is psychologically or physically addicted. This does not mean that such activities are impossible for some, but rather that these seemingly simple suggestions may require considerable therapist effort and support before they can be followed.

More generally, resistance to triggers and triggered states can be fostered by helping the client to seek outside sources of emotional support, whether developing friendships, attending a support group, or finding a pet.1 These options, too, may be difficult for some, especially those who are socially avoidant or withdrawn, but nevertheless can be explicit goals of treatment.

Psychoeducation

As described in Chapter 5, psychoeducation is an important component of trigger management. This is because many people—perhaps especially those with less contact with therapists or self-help groups, and those from cultures where trauma or posttraumatic stress are not part of the general social narrative (Marsella et al., 1996)—may be unaware of triggering as a concept. As well, triggering often involves the activation of implicit memories which do not contain information that they are, in fact, memories, as opposed to direct experiences. This can easily produce source attribution errors (see Chapter 9), whereby the traumatized person attributes their reactions and perceptions to the immediate triggering context rather than to the trigger’s original source. For example, the client may believe that their triggered rage following a friend’s minor criticism is in response to the friend’s seeming harsh rejection of them, when, in fact, they are responding to triggered memories of child abuse and neglect. The effect of this attribution error is that the trauma survivor may not realize that they have been triggered, as opposed to just responding to real-world events, and hence is unaware of the role of trauma in their current distress.

In general, psychoeducation about triggers and triggering involves some version of the following points, adapted as needed:

Early trauma and attachment disruption is largely encoded in nonverbal/implicit memory, primarily in the form of emotions, sensations, and simple cognitions associated with these negative experiences.

Later in life, these implicit memories may be triggered by experiences or events in the current environment that are similar to some aspect of the original trauma, whether it be people, places, conversations, emotions, or situations that remind the survivor of a past event, or smells, sounds, physical sensations, or other sensory input that are similar to the trauma.

When triggered, these memories may appear in the form of intrusive sensory experiences (e.g., auditory, tactile, or visual flashbacks), unwanted thoughts (e.g., self-hatred or misperceptions of danger), and sudden, painful emotions (e.g., panic, anger, or desperation).

Because triggered implicit memories are experiential, as opposed to verbal, the client may experience confusion about where exactly they are originating from, and may

feel as if they are back in the original traumatic circumstance, or that the traumatic event is repeating in the present,

assume that the current environment is dangerous, or maltreatment is imminent, or

attribute these responses to whatever triggered them (i.e., make a source attribution error).

If these feelings are overwhelming, they may motivate behaviors that distract, soothe, numb, or otherwise reduce distress, such as excessive substance use, dissociation, or DRBs like self-injury, indiscriminate sex, food bingeing, or aggression.

Unfortunately, while often temporarily effective, these avoidance responses can interfere with ongoing functioning, decrease situational awareness, block emotional processing, and increase the risk of victimization or illness. They also may be followed by an upsurge of shame, guilt, or low self-esteem, thereby ultimately increasing, not reducing, emotional distress and potentially motivating further avoidance (Briere & Gil, 1988).

Psychoeducation on these topics typically is not limited to a single session, and, although especially relevant earlier in treatment, occurs throughout therapy. As noted in Chapter 5, this process is often best achieved not through clinician lectures or handouts, but rather in the context of two-way conversations in which the therapist helps the client to explore their experiences with triggers, triggering, and activated states.

Exploring Trigger History

Following some degree of psychoeducation, the next step in trigger management is for the client to explore instances when they were triggered in the past. For some clients, this list may be relatively short: source attribution errors may have caused triggered experiences to masquerade as perceptions of current reality, or the client may assume that only major phenomena (e.g., a dramatic flashback to the past) involve triggering. As the client discusses these events in detail, however, it may become easier for them to discover and reinterpret other times when triggering has occurred. This process accomplishes two goals: It reinforces to the trauma survivor that triggers and triggering are real phenomena that are relevant to their life, and helps them to identify their specific triggers.

Trigger Identification

Trigger identification occurs when the client is able to identify specific stimuli that regularly precede intrusions of unwanted sensory or emotional memory, label them as triggers, and thereby predict—or retroactively identify—triggered responses. This sometimes involves a degree of detective work, as the client learns to objectively evaluate the environment to see what trauma-reminiscent stimuli regularly antedate extreme or inappropriate reactions. For example, a client might realize that seemingly out-of-proportion anger occurs when interacting with people physically similar to their previously physically abusive father. Other examples of stimuli that the client might come to recognize as triggers include the following:

Interpersonal conflict

Criticism

Microaggressions

Perceived rejection

Physical touch

Angry faces

The smell of alcohol

Sexual situations or stimuli

Interactions with authority figures

People with physical or psychological characteristics that are similar to the client’s past perpetrator(s)

Perceived abandonment

Boundary violations

Media depictions of violence or sex

Betrayal

Someone crying or yelling

Sirens

Gunshots

The trigger identification process often occurs throughout treatment; although the client may only be able to identify one or two triggers initially, the goal is to uncover as many of them as possible over time. As the trauma survivor becomes more aware of the number and power of triggers in their life, they may become less reactive to them, correctly seeing them as activated sensory-emotional memories rather than environmental events that are real and indicate danger, trauma, or loss.

Although many triggers are obvious and easily recognized (e.g., fireworks display triggering combat memories, or sudden anger or fear when encountering someone reminiscent of a past perpetrator), this is not always the case. Triggers are less easily identified when

source attribution errors are more prevalent (e.g., in conflictual relationships, during which anger or fear may appear to be based on current difficulties);

the original memory was preverbal, and thus the client cannot recall the circumstances of the trauma and, as a result, stimuli that might serve as triggers; or

the trigger activates dissociation, denial, or another avoidance strategy and blocks the client’s awareness that a trigger is present.

Identifying Triggered States

When the client is unable to detect a trigger, despite evidence that one is present, they may have to rely on indirect identification (Briere, 2019). This occurs when the client is able to infer that triggering probably has occurred based on sudden changes in their internal state, despite not recognizing an actual trigger. Examples of potentially triggered states include

Contextually inappropriate or overly intense emotions (e.g., unexpected intrusions of anxiety or panic, anger, sadness, or shame)

Intrusive cognitions (e.g., sudden shame, self-hatred, helplessness or hopelessness, distrust)

Bodily reactions (e.g., sudden shortness of breath, flushing, dizziness, rapid heartbeat, coldness of extremities)

Brief dissociative periods (e.g., “spacing out,” out-of-body experiences, sudden numbing, feelings of unreality)

Sudden regression (e.g. feeling younger, as if a child)

Déjà vu experiences

Micro-flashbacks (very rapid, often fragmentary images, sounds, or sensations)

As mentioned, in some cases these intrusions can be erroneously interpreted as reactions to real-world danger or rejection. For this reason, the client may gain from asking themself questions such as

Does this thought/feeling/sensation “make sense” in terms of what is happening around me right now?

Does this experience seem too intense, based on the current context?

Does this thought, emotion, or sensation carry with it memories of a past trauma?

Is this a situation in which I usually get triggered?

Exploring Trigger–Trauma Linkages

Once the client has become aware that they likely have been triggered, the next step is to link the trigger or triggered state to specific past traumas or negative attachment experiences. This is not always possible, of course, especially if the adverse event was preverbal, for example involving early parental abuse, rejection, or disattunement. In other instances, the trigger–trauma relationship may be easier to establish, for example linking sexual triggers to earlier sexual victimization, or triggers involving loud noises or perceived physical danger to combat trauma.

Trigger–trauma linkage can serve several purposes. First, it further reifies for the client the reality of triggers and triggering, and thus may increase their “buy in” for trigger management activities. As the client increasingly locates triggers in their environment, witnesses their effects, and links them to specific events in their childhood, they are more likely to accept triggering as an important aspect of their posttraumatic difficulties, and be more willing to identify trigger phenomena and intervene when they occur.

Second, once a trigger is linked to a past trauma, the client may develop metacognitive awareness during the triggering process. Described in Chapter 11 and first coined in this context by Teasdale and colleagues (e.g., Teasdale et al., 1995), metacognitive awareness refers to the growing ability to determine that emotions, thoughts, and perceptions are ultimately ‘‘events in the mind, rather than as direct readouts on reality’’ (Teasdale, 1999, p. 147). In the triggering context, trigger–trauma linkage increases the client’s realization that they have been triggered, and thus that any subsequent thoughts, feeling, or sensations may be memories as opposed to real experiences, causing the past to feel like the present. For example, the client who has been triggered by an argument might be able to say to themselves

Finally, trigger–trauma linkage often prompts discussion in the therapy session about previous traumas, and the fact that they can be reactivated by current life experiences. When this occurs in detail, across sessions, additional cognitive and emotional processing may occur.

INTERVENING IN TRIGGERS AND TRIGGERED STATES

Together, growing metacognitive awareness of triggers, and their basis in historical (not solely current) events, can have significant positive impacts on the trauma survivor’s overall level of reactivity, generally by decreasing the perceived reality of flashbacks and activated emotional states. For example, it may be helpful to know that a flashback to combat or early parental rejection is not “real,” and that the associated distress is a trauma response, not evidence of current danger or loss. Jankowski and Holas (2014) refer, in a related context, to this process as reperceiving (p. 66): being able to observe one’s internal mental activities (e.g., intrusive thoughts, memories, and perceptions) without being entirely immersed in them, or necessarily believing them to be true. To the extent that this occurs, intrusive symptoms may be taken less seriously, since, in some ways, there may be little to be upset about in the actual, current environment.

Despite the benefits of a metacognitive perspective, however, such insight is often insufficient, on its own, for those plagued by ongoing, intrusive thoughts, emotions, and sensory activations. For this reason, the next step in trigger management is learning to directly intervene in triggered states.

Trigger Avoidance or Reduction

Following trigger identification, therapy-based trigger management typically involves reducing the number of active triggers in the client’s environment, or at least diminishing their intensity. Notably, the goal of this approach is primarily to increase internal stability, rather than to specifically alter the effects of triggering, per se.

Trigger avoidance or reduction is often most appropriate early in treatment, when the client is easily overwhelmed by triggers in their environment. In such cases, the client may choose to decrease exposure to the most dysregulating triggers in their environment, whether through negotiating certain sexual interactions with partners, avoiding arguments (or argumentative friends), reducing social drinking (e.g., at parties or in bars), or avoiding large groups of people that might trigger unwanted memories (e.g., of mass casualty events). Although trigger reduction does not address the underlying basis of triggering, it can serve to at least temporarily lessen the level of chaos and intrusion in the client’s life. It may also increase their sense of control over at least some aspects of their immediate experience and environment.

Because triggering is not inherently a “bad” thing, to the extent that it supports the intrinsic processing of traumatic memories, it is important that trigger avoidance not be overused to the point that it involves permanent phobic avoidance of challenging experiences. Instead, this trigger management strategy is best viewed as a stop-gap measure, often used early in therapy, that allows the client to reduce their stress levels and increase their immediate sense of self-efficacy and control. As the client’s internal stability increases, other trigger management interventions, including presented below, may become more relevant.

Deescalating Triggered States

Beyond trigger identification and reduction, a critical aspect of trigger management is the deescalation of triggered responses. The central notion is that although triggering can be problematic to the extent it prompts painful reliving and, in some cases, motivates DRBs, clients often can decrease the impact of these phenomena.

Calming behaviors. As described in Chapter 8, the most common form of deescalation involves the strategic use of self-calming behaviors. These activities typically involve the client learning to engage in

grounding,

strategic distraction,

mindful breathing, and

self-soothing behaviors

when triggers lead to heightened distress. Such activities tend to “improve the moment” (Linehan, 1993), thereby reducing the need for avoidance behaviors. Deescalating interventions can be taught in a didactic manner but are best integrated into the client’s coping repertoire when they are practiced in vivo during the therapy session. In this regard, the client might practice breathing exercises or grounding when exposure activities or relational triggering during treatment trigger anxiety or anger. For example, someone triggered in treatment might

identify the trigger,

become aware of what it activates (e.g., inordinate rage or feelings of shame),

potentially link it to a specific trauma,

and then

ground themselves, engage in a breathing exercise, or refocus their attention to a less activating stimulus or activity, so that

the triggered state is reduced in intensity and/or duration.

Self-talk. Deescalation also can be facilitated using positive self-talk and metacognitive statements, especially when what is triggered are cognitive intrusions involving low self-esteem, self-blame, helplessness, and unworthiness. These triggered cognitions can lead to anxiety, depression, posttraumatic stress, and shame (e.g., LeMoult et al., 2017) as well as dissociation and distress reduction behaviors (e.g., Briere, 2019; Nester et al., 2022). Positive self-talk can be used by the survivor to counter these negative self-appraisals, generally by rebutting them with self-statements like the following:

“I can handle this.”

“I’m not a kid anymore, I can do something about this.”

“This isn’t about me, it’s about her sexism/racism/homophobia.”

“There is nothing to be ashamed of.”

“I deserve respect.”

The client may also make meta-cognitive self-statements:

“This is just a flashback; it’s not real.”

“This is my childhood talking.”

“This is the past, not the present.”

“These are just thoughts; they aren’t necessarily true.”

“I’m being triggered. These are just memories from the past.”

“Hi, Mom/Dad.”

Although it is not unusual for clients to resist employing self-talk because it seems simplistic, child-like, or unduly primitive, many eventually find them helpful. In part, this may be because positive self-talk not only provides a countervailing message, it also acknowledges and highlights the triggered negative self-talk process, and thereby increases metacognitive awareness. This metacognitive insight, in turn, can make triggered states more obviously “unreal,” and thus less likely to overwhelm.

Trigger reevaluation. Finally, deescalation can be facilitated by trigger reevaluation. This intervention involves the client analyzing the triggering stimulus or situation until a greater understanding changes their perception and thus terminates the trigger. When this occurs, triggerability, per se, is not affected, but the trigger itself is reinterpreted such that it no longer activates the original memory.

For example, the survivor might

carefully examine the behavior of someone who is triggering posttraumatic fear, and eventually become more aware of the fact that this person is not acting in a threatening manner,

come to understand that a given individual’s seemingly dismissive style does not indicate a desire to reject, abandon, or ignore, as much as interpersonal awkwardness,

realize that a close friend’s seeming critical or demanding behavior does not necessarily represent their negative responses to the client, but rather may arise from insecurity, neediness, or even the friend’s own childhood history of child maltreatment, or

determine that although the client’s boss at work bears a physical similarity to their abusive mother, they are actually not at all like their mother in reality.

INTERVENING IN DRBS

In addition to deescalating triggered states, the client may practice techniques, learned beforehand in therapy, that reduce the likelihood that a triggering will result in a DRB. These interventions tend to work by

teaching emotional tolerance,

fostering habituation of triggered states,

replacing DRBs with other activities, and

changing one’s reactions to one’s reactions, often referred to as urge or emotion surfing.

Delaying DRBs

A common DRB management strategy is to intentionally forestall DRBs as long as possible. In general, this involves encouraging the client to “hold off” on behaviors that they normally would automatically use to reduce distress when triggered (e.g., impulsive sexual behavior, or binging/purging) and then, if the behavior must be engaged in, doing so to the minimal extent possible.

There are at least two important aspects of this strategy. First, many survivors learn that their DRB responses are to some extent habitual or reflexive: Given sufficient attention and thought, they could be delayed or even avoided without too much difficulty. For example, a person whose immediate response upon being triggered into a negative state is to self-injure might discover that, in fact, the upsetting feeling was ultimately tolerable without such behavior.

Second, as noted by Bowen et al. (2011) and others, many triggered emotional states that otherwise would motivate a DRB or episode of substance abuse have a relatively short half-life: If the individual can sit out the activated emotional state, it will tend to decrease over time (habituate), thereby reducing the need for subsequent maladaptive behavior. With continued practice, the period between the initial triggered experience and the actual DRB may be lengthened, the DRB itself may be decreased in severity, and emotional tolerance may be increased.

Notably, although it is usually very difficult to just stop using a DRB (Were it that simple, the client might not require psychotherapy in the first place.), one can delay it as long as possible. For example, to the extent that a client can forestall for 3 minutes a food binge that they otherwise would have engaged in immediately post-trigger, they have, by definition, delayed as long as possible and therefore has succeeded. The next time they attempt to delay this DRB, varying conditions, triggers, activated memories, and internal resources may mean that they (a) are not able to delay as long, (b) are able to keep from acting for an even longer period of time, or (c) are able to avoid the DRB entirely. Thus, the goal is not for complete cessation to occur immediately, only for the client to experiment with extending the pre-DRB period as long as possible, until their emotional tolerance capacities grow and DRBs eventually become less necessary.

Urge surfing. The process of delaying DRBs can be facilitated by urge surfing, briefly described in Chapter 6. Based upon the notion that “you can’t stop the waves, but you can learn to surf” (Kabat-Zinn, 1994, p. 32), urge surfing involves mindfully viewing the urge to engage in a DRB as similar to riding a wave—the urge slowly builds, peaks relatively quickly, and then, if not avoided or hung on to, slowly falls away. If the client can objectify this process by viewing it through a metacognitive lens, it is often easier to experience the need to distress reduce as a temporary phenomenon that will lessen with time, and thereby feel less urgency or desperation to engage in a DRB. Although some clients understand urge surfing intuitively, others may acquire this perspective through meditation and mindfulness training, described in Chapter 11. See Appendix 4 for a brief urge/emotion surfing exercise, from Semple and Briere (2020).

Developing distress tolerance. The process of pausing between urge and action provide opportunities for the client to develop at least some modicum of emotional tolerance. For example, if a survivor is able to forestall binge eating or acting on a sexual compulsion following a triggering situation—if only for a few minutes—two things may happen:

They may be exposed to a brief period of sustained (but temporarily manageable) distress, during which time they can learn that DRBs may be at least briefly forestalled without the assumed catastrophic outcomes.

The impulse to engage in the DRB may fade, because the emotionality associated with the urge to engage in the DRB tends to lessen when not immediately acted upon (Bowen et al., 2011).

Substitution, Reduction, and/or Distraction

Following whatever delay is possible, and assuming the DRB is still impending, the typical next step is to somehow mitigate the need for a full distress-reduction response.

Substitution . Substitution occurs when the client replaces a harmful DRB with a less harmful one. For example, they may replace self-injury with a razor blade with another pain-inducing—but less extreme—action, such as holding ice cubes in their hand until painful, doing pushups or other exercises until they produce significant pain, punching a wall rather than cutting, or holding their breath until oxygen hunger is intense.

Although widely described and endorsed in some self-help environments, we generally recommend that DRB substitution be used only when no other intervention is possible, and only if the new behavior is not, itself, potentially self-endangering. This is because such behaviors not only may be dangerous, they generally do not teach distress tolerance, address attachment issues, or assist in the processing of traumatic memories. Instead, most substitution behaviors continue to support pain induction as a way to deal with painful experience, and may continue to serve as forms of self-punishment, thereby reinforce the validity of internally directed anger or shame.

Reduction. Somewhat similar to replacement, reduction refers to attempts to engage otherwise unavoidable DRBs to the least extent possible (e.g., bingeing for 5 minutes rather than an hour, or trying to limit sexual behavior to flirting as opposed to intercourse), so that the harmfulness of the behavior is reduced. Like substitution, however, reduction can be problematic, and should be used only as an early step in DRB management. This is because such activities, even in a reduced form, may still be dangerous or otherwise ill-advised. Further, in some cases, lower-level involvement in a problem behavior (e.g., eating “just” one cookie or “just” flirting with someone) may trigger even more intense cravings or urges and thereby increase, not decrease, the likelihood or intensity of a DRB.

Distraction. Distraction refers to strategic attempts to direct one’s attention away from activated internal states, ideally until the state fades for lack of attention or reinforcement. Although generally preferable to substitution or reduction, distraction is not so much a solution to DRBs as it is a way to problem-solve activated states in the here and now, at least until more durable interventions are possible. The following are examples of strategic distraction when confronted with triggered distress:

Exercise

Reading

Writing or journaling

Listening to music or a podcast

Conversations with safe/supportive others, including by cell phone or texting

when immediacy is important

Taking a “time-out” in a place or environment that feels safer and is less triggering

Eating, but not bingeing on, a comfort food

Creating art

Interacting with, or cuddling, a pet

Going for a walk

Engaging in yoga or tai chi

Notably, such activities are rarely as effective—at least initially—as classic DRBs. It is important that the client understand that distraction is not intended to fully replace DRBs, but rather to be used as a way to reduce distress to a “handle-able”/survivable level following a triggering event. In fact, the usually incomplete effectiveness of distraction behaviors can be beneficial, since they do not remove all distress and thereby support the development of emotional tolerance skills and, potentially, some level of emotional processing. At the same time, it should be acknowledged that distraction is a form of avoidance, no matter how benign or useful, and thus is best conceived of as a harm-reducing response to immediate, potentially overwhelming triggered states, as opposed to more long-term solutions, like trauma/attachment processing or the acquisition of a broader emotional regulation repertoire.

ReGAIN

A final intervention in triggered trauma/attachment-related states, mentioned in Chapter 6 is an exercise that combines several of the approaches outlined in this and previous chapters. ReGAIN (Briere, 2019; see also Appendix 5) is an adaptation of a mindfulness technique (R.A.I.N.) first developed in the early 2000s by meditation teacher Michele McDonald and later expanded and popularized by Buddhist psychologists Tara Brach (2013, 2019)2 and Jack Kornfield (2008).

Building on R.A.I.N. ( Recognize, Allow, Investigate, and Nurture with self-compassion) (www.tarabrach.com/rain/#rainchange), the ReGAIN approach focuses specifically on triggered states, adds a grounding step between Recognize and Allow, emphasizes titrated access to upsetting feelings, and, as does R.A.I.N. at a different step, calls upon self-compassion.

Steps of ReGAIN. ReGAIN consists of the following steps, although it is not uncommon for someone to follow any given step with an earlier one when necessary.

Recognize that you are triggered

Recognize refers to being aware that something has changed internally as a result of a triggering external event—that one is having emotions, thoughts, sensations, or memories that were not present before and may not relate as much to the current environment as to the traumatic past. It relies on some degree of mindfulness, as described in Chapter 11, that helps the client to identify what is happening internally, and to do so without self-judgment.

Such internal awareness can also have a downside, however, because it may involve increased access to unwanted thoughts, feelings, and memories. The client who is challenged by upsetting internal experiences during Recognize may need to approach this phase of ReGAIN more superficially, initially only labeling or noting a state, but not delving into it.

Ground yourself

Because recognition can be activating, some trauma survivors will benefit from a brief period of grounding before moving onto the Allowing step of ReGAIN. This typically involves activities reviewed in this and previous chapters, including grounding exercises; mindful breathing; “surfing” emotions, thoughts, or urges; engaging in metacognitive self-talk; and using strategic distraction as needed.

As best you can, Allow yourself to experience whatever is happening, with self-compassion.

Allowing involves, to the extent possible, nonresistance to triggered thoughts, feelings, or sensations—not fighting, blocking, or otherwise avoiding intrusive internal states, but instead allowing them to occur unimpeded. By avoiding the suppression effect described in Chapter 4, and supporting emotional processing, Allowing ultimately can lessen posttraumatic distress over time, and thus, potentially, the immediate need for DRBs. This step also includes self-compassion, specifically an appreciation of how difficult it can be to sit with trauma-related emotions, thoughts, and/or memories, and the bravery associated with allowing these experiences to occur.

As is true for Recognition, Allowing can be challenging, especially earlier in treatment. If necessary, the client may choose to titrate their acceptance of potentially overwhelming triggered states, for example, “letting in” grief or fear for a few seconds, and then diverting their attention to less challenging phenomena. This may include returning to Grounding when necessary, for example, using self-talk and breathing techniques.

Investigate how you are triggered, where the thoughts or feelings come from, and why they make you upset.

In this step, the client is invited to identify relevant triggers as they occur and explore trigger–trauma linkages, as described earlier. Generally, this involves asking questions such as

What is triggering me?

What memories are being triggered?

Am I experiencing the present or remembering the past?

How accurate are these thoughts and feelings, in terms of what is really going on right now?

As these and related questions are investigated, the “not real” aspects of triggered states are emphasized, a process that encourages the final, Nonidentification step of ReGAIN, presented below. Investigation allows the client to be more conversant with their triggers and their effects, and to develop a metacognitive perspective on them. As well, by uncovering more accurate reasons for upsetting thoughts, intrusive phenomena, and problematic behavior, Investigation also encourages self-compassion, including the fact that one is not inherently unacceptable or unworthy, but instead, has been attempting to survive the effects of triggered, potentially overwhelming traumatic memories.

Nonidentify with triggered thoughts, feelings, or memories

This final step often arises in response to previous steps (Brach, 2013), especially the metacognitive aspects of Investigation. The term nonidentification is borrowed from Buddhist psychology and refers in the current instance to the insight that triggered emotions, thoughts, or memories generally arise from past experiences and do not necessarily reflect who one is or what is happening in the here and-now. Broadly stated, this view suggests that we receive our internal experiences, but we are not defined by them. As one meditation teacher describes this, “You are not your thoughts; you are the observer of your thoughts” (Ray, 2015). To the extent that the client is able to maintain this perspective, triggered feelings, thoughts, and sensations are likely to become less destabilizing, since the client is able to take them less seriously, seeing them as remnants of the past, not information on the present or harbingers of the future.

Chapter 9

EMOTIONAL PROCESSING

In addition to the cognitive interventions described in Chapter 7, most trauma therapies include some form of emotional processing, which occurs when traumatic memories are activated through therapeutic exposure, and are then contradicted, counterconditioned, and/or updated. Classically, emotional processing was thought to arise, in large part, as a function of habituation, whereby fear associated with activated trauma memories, once triggered, naturally fades (is extinguished) over time (Foa & Kozak, 1986).

As we will see later in this chapter, however, recent research suggests that

habituation is less relevant to emotional processing than previous thought,

conditioned fear is not the only cognitive-emotional phenomena affected by treatment,

trauma memories may not be “extinguished” as much as contradicted by new memories and thereby rendered inactive, and

classic therapeutic exposure may not be the only way in which emotional processing can occur.

Whatever the underlying mechanism, emotional processing typically involves exposure to trauma-related material in the session, which then activates memories, emotions, and cognitions that were encoded at the time of the trauma but (a) are not reinforced and (b) are counterconditioned by positive aspects of the therapeutic relationship. The disparity between activated memories and safe therapeutic conditions may result in new learning, including that

danger is typically not present, despite the presence of a trigger;

activated emotions, sensations, or cognitions generally do not reflect here-and-now concerns or experiences;

upsetting feelings can be tolerated without dire consequences; and

some relationships can be trusted.

These experiences may change the emotional valence of the memory by contradicting and inhibiting the original memory–emotion association. Specifically, verbalizing trauma typically activates associated conditioned emotional responses (e.g., fear, horror, anger) and simple cognitions (e.g., self-blame or helplessness). These activated states are not reinforced in the safety of the session, however, and may be influenced over time by the positive feelings engendered by the therapeutic relationship and activities that calm or ground the survivor. As a result, after sufficient trauma processing, exposure to trauma triggers is less able to produce posttraumatic distress and/or trauma-related cognitive distortions.

Things are not always this straightforward, however—any given “trauma memory” is likely to encompass a collection of separate, yet interlinked, memories of that traumatic event. Further, evocation of these memories and associated conditioned emotional and cognitive responses may trigger recollections of other traumas and other conditioned responses (Briere, 2019). Such trigger linkage can lead to a highly complicated cascade of internal associations and activated states or experiences, involving a range of implicit and explicit, sensory, emotional, and verbally mediated, memories.

Linked memories may be activated and processed within and outside of therapy. A reminiscent event in the environment (e.g., for example, a critical comment by a loved one) may trigger a memory or cluster of memories of previous traumatic experiences (e.g., instances of physical and verbal abuse by a parent), which may activate emotional or cognitive responses (e.g., expectations of danger, intrusive fear, or anger). If these responses are not supported in the environment (e.g., the loved one is reliably not abusive or dangerous), or a similar process occurs in therapy (e.g., the therapist provides safety, support, and positive regard), these abuse-era responses may be inhibited by newer learning.

Notably, not all of this processing occurs on a verbal level. LeDoux (1998) and others note that emotional (and simple cognitive) responses can be triggered “without the involvement of the higher processing systems of the brain, systems believed to be involved in thinking, reasoning, and consciousness” (p. 161). LeDoux has demonstrated that this subcortical route transmits sensory information directly from the thalamus to the amygdala—as opposed to the cortical route that transmits from the thalamus to both the cortex and the hippocampus—where it is integrated with more contextual and often verbal information and then sent to the amygdala.

In other words, trauma memories may be processed on noncognitive as well as cognitive levels and can include nonverbal learning that certain responses are no longer relevant to formerly triggering stimuli: what Craske and colleagues (2014) refer to as expectancy violation. Although emphasis is often placed on clients’ verbal processing of cognitions as they seek to understand and resolve traumatic experiences, it is also true that considerable trauma activation and processing occurs at implicit, nonverbal, often relational, levels.

REEXPERIENCING AS TRAUMA PROCESSING

Before describing how trauma memories can be addressed during treatment, we must expand on the notion of intrinsic processing through reexperiencing, first introduced here in Chapter 4. This idea suggests that reexperiencing of trauma-related memories, whether in therapy or out, is often an inherent ingredient of recovery from trauma. When intrinsic processing occurs naturally (e.g., outside of therapy), it typically involves the mind’s repeated presentation of upsetting memories to itself (e.g., through flashbacks, nightmares, and intrusive thoughts or memories), as a way to prompt cognitive accommodation to the reality of the traumatic event (Horowitz, 1990) and to extinguish trauma-related responses by invoking them after the trauma has passed and trauma-based responses are no longer relevant. This mechanism may, in part, explain why some people recover—at least to some extent—from posttraumatic stress disorders within months of the trauma (Bryant & Harvey, 2000; Lai et al., 2021), even in the absence of therapy. In such cases, early traumatic stress responses may represent, in part, self-healing algorithms as much as symptoms of an emerging stress disorder. Importantly, trauma therapy can be viewed as harnessing intrinsic processing, albeit in a structured and focused way that more efficiently processes trauma-conditioned emotions and thoughts.

Avoidance

Some traumatic memories are so upsetting (e.g., those associated with major child abuse, early abandonment or loss, severe disattunement, torture, or rape), however, that they cannot be easily processed. As well, some people are sufficiently compromised by other psychological or social phenomena (described later) that they are unable to undergo trauma processing without being overwhelmed by painful emotions. This relatively unresolvable distress may then motivate the various avoidance responses described in Chapter 2 and elsewhere, which then block the emotional activation necessary for processing. For example, the individual whose negative emotional responses to a triggered trauma memory exceed their capacity to tolerate such feelings may be forced to use dissociation, substance abuse, distress reduction behaviors, thought suppression, distraction, or other avoidance responses to maintain internal equilibrium. In such a case, processing is likely to be derailed, resulting in continuing posttraumatic distress without recovery.

This perspective has significant implications for trauma therapy. It suggests that some level of avoidance may be adaptive—even necessary—for individuals who have especially aversive trauma memories and/or significant difficulties in regulating the associated negative emotions. It also implies that overly enthusiastic or heavy-handed attempts by the therapist to prematurely remove such avoidance, denial, or dissociative symptoms may represent a threat to the client’s internal equilibrium.

This presents a therapeutic conundrum—some individuals, especially chronic trauma survivors, are unable to tolerate the emotional activation associated with remembering trauma in therapy, and thus cannot easily process such material (Ford et al., 2005). As described later in this chapter, the solution often lies in finding ways to monitor and control the level of the client’s emotional activation while still providing sufficient exposure to trauma memories. In other words, the clinician attempts to provide enough therapeutic exposure that memory inhibition or counterconditioning can eventually occur, but not so much that the client becomes overwhelmed and has to invoke avoidance strategies that block processing.

In fact, part of the therapist’s role in treatment may be to take on the “job” of intrinsic processing by replacing the client’s intrusive reexperiencing with careful, less overwhelming therapeutic exploration of trauma memories. In contrast to naturally occurring trauma processing, therapy provides a relatively controlled environment in which the therapist can adjust or titrate the level of memory exposure (and resultant emotional activation) within the session in order to accommodate the reduced emotional capacities or excessively upsetting memories of some trauma survivors.

THE COMPONENTS OF TRAUMA PROCESSING

Outlined below are a series of steps or components of trauma processing, which ideally occur in the context of a positive therapeutic relationship, safety, and ongoing attention to the pace and intensity of treatment. Expanded from previous versions of this text, they are

Evaluation for contraindications to exposure

Prebriefing

Exposure

Activation

Disparity/New information

Interspersal and counterconditioning

Extinction/Inhibition

Debriefing/Closure

Reconsolidation

These components do not always follow a linear progression. In fact, in some cases, interventions at a later stage may lead to further work at an earlier stage. In other instances, certain components (e.g., counterconditioning) may be less important than others (e.g., disparity). And, finally, as described in Chapter 6, the therapy process may require the client to learn emotional regulation techniques that down-regulate distress when emotional responses inadvertently become overwhelming.

1. Evaluation for Contraindications to Exposure

As noted, exposure to trauma memories and the attendant distress can sometimes be challenging. In most instances, this process is tolerable to the extent that it occurs in a safe context in which the client’s defenses are honored. In some cases, however, almost any level of memory processing can be overwhelming, irrespective of the clinician’s efforts. When this occurs, it is usually because (1) the trauma is so recent or severe that activation is inherently overwhelming; (2) the client has insufficient emotional regulation capacities; and/or (3) they suffer from such high levels of comorbid emotional distress or negative cognitive preoccupation that the additional (especially trauma-related) distress is not tolerable.

For these reasons, early exploration of traumatic material may or may not be appropriate. As noted by various authors (e.g., Bryant & Harvey, 2000; Najavits, 2002; Pitman et al., 1991), early therapeutic exposure to trauma memories may be contraindicated for clients experiencing the following:

Extremely distressing memories (e.g., of horrendous or debilitating traumas)

Very high anxiety (including easily triggered panic attacks)

Severe dissociation

Major depression

Acute psychosis

Major suicidality (i.e., high risk of suicide attempts)

Overwhelming guilt and shame associated with the traumatic event

Especially impaired emotional regulation capacity

Very recent and substantial trauma exposure

Chronic substance intoxication

Importantly, although some version of therapeutic exposure is an important aspect of several modern trauma therapies, treatment outcome studies indicate that, on average, it is not necessarily more effective for treating posttraumatic stress than other validated therapies and may have some unwanted side effects (Powers et al., 2010).

This is especially true of what many consider the “gold standard” treatment, prolonged exposure (PE), in which the client is instructed to repeatedly remember and recount upsetting or painful memories in detail, and stays with the attendant distress for relatively long periods of time—as much as 45 to 90 minutes per session (Foa & Rothbaum, 1998). Yet, Steenkamp et al. (2015) note in a widely cited article in the Journal of the American Medical Association (JAMA),

When exposure therapy appears to be contraindicated, either because of interfering conditions or because it is not well tolerated, the clinician may choose to use one or more of the various other interventions outlined in this book, including relational processing (Chapter 10), emotional regulation skills development (Chapter 6), cognitive (as opposed to emotion-based) interventions (Chapter 7), and/or psychotropic medication (Chapter 15). Fortunately, several evidence-based therapies for trauma that are not primarily exposure-based are nevertheless quite helpful for trauma survivors.

Interpersonal therapy (IPT; Weissman et al., 2018), for example, has no major exposure component, and has been shown to be at least as effective as PE in the treatment of PTSD and likely even more effective for comorbid depression (Bleiberg & Markowitz, 2019). Similarly, cognitive processing therapy (CPT; Resick & Schnicke, 1992) is a cognitive—not primarily exposure-based—intervention yet has documented efficacy in the treatment of posttraumatic stress (Asmundson et al., 2019), as has Seeking Safety (Najavits, 2002, 2009), which eschews exposure almost entirely, and WET, which involves a brief series of shorter exposure periods. Even Eye Movement Desensitization and Reprocessing (EMDR; Shapiro, 2018), described later in this chapter, although likely a form of exposure therapy, does not require the client to verbally recount traumatic events, is often conducted over relatively short periods of time, with exposure periods as brief as 20 to 50 seconds (EMDR Institute, http://www.emdr.com/frequent-questions), and yet typically is as effective as PE in treating PTSD (Department of Veterans Affairs & Department of Defense, 2017). In fact, even a common control condition in treatment outcome studies, Present-Centered Therapy—which is intentionally not trauma centered and, in fact, was not initially intended to be a therapy—appears in some cases to be as effective as PE in the treatment of PTSD (e.g., Steenkamp et al., 2015).

Taken together, the literature suggests that although therapeutic exposure has a long track record of effectiveness for some traumatized people, PE is not always well tolerated by a subset of trauma survivors and may not necessarily be more helpful than other validated trauma therapies (Powers et al., 2010). For this reason, exposure therapy (perhaps especially PE) should not be automatically assumed to be the treatment of choice for any given client. Instead, the client should be assessed for potential risk factors and treatment-interfering conditions, and a range of treatment options considered.

2. Prebriefing

Assuming that constraining conditions are not in force, or that they have been sufficiently addressed, therapeutic exposure is often indicated in some form. However, although exposure is widely understood by clinicians to be helpful, the trauma survivor can be forgiven for not necessarily wanting to remember and recount painful events and sit with the attendant feelings. Prior to therapy the survivor may have devoted considerable time and effort to control their symptoms by avoiding people, places, and, significantly, conversations about their prior trauma. In fact, avoidance of reminders of the trauma is a central aspect of PTSD and other stress responses. In this context, exposure techniques in which the client is asked to intentionally experience events that they have been avoiding may seem counterintuitive.

For this reason, an important aspect of trauma therapy is prebriefing: explaining the rationale for emotional processing, and its general methodology, prior to the onset of formal treatment. Without sufficient explanation the process and immediate effects of exposure may seem so illogical and stressful that the client will automatically resist and avoid. On the other hand, if the client can understand and accept the reasons for this procedure, it usually is not hard to form a positive client–therapist alliance and a shared appreciation of the process.

Although the way in which exposure is introduced may vary from instance to instance, the clinician should address as many of the following content areas as possible when preparing clients for exposure work:

Reexperiencing is not only a source of upsetting symptoms but also evidence of the mind’s attempt to process painful memories.

Although the client understandably would like to not think about what happened and may have been avoiding upsetting feelings about the trauma, such avoidance often serves to keep the symptoms alive.

If the client can talk enough about what happened, the pain and fear associated with the trauma is likely to decrease. Do not, however, promise recovery.

By its nature, exposure is associated with some level of distress and some people who undergo exposure experience an increase in flashbacks, nightmares, and distressing feelings between sessions. Such responses are normal and usually not a bad sign. In fact, they signal that emotional processing is occurring. At the same time, the client should inform the clinician when such phenomena occur, so that they can monitor whether exposure has been too intense.

The clinician will work to keep the discussion of these memories from overwhelming the client, and—in general contrast to a PE approach—they are encouraged to stop talking about any given memory if it becomes too upsetting. However, the more that the client can remember, think, feel, and talk about, the more likely significant improvement will occur.

3. Exposure

In the current context, exposure refers to any activity or experience engaged in by the therapist or the client that provokes or triggers client memories of previous traumatic events. Therapeutic exposure has been described, for example, as “repeated or extended exposure, either in vivo or in imagination, to objectively harmless but feared stimuli for the purpose of reducing anxiety” (Abueg & Fairbank, 1992, p. 127). From a trauma perspective, the objectively harmless stimuli are memories of prior trauma that are, by definition, not currently occurring, and the anxiety is the triggered emotional response to these trauma memories.

Prolonged exposure revisited . As noted earlier, several types of exposure-based therapies have been used to treat traumatic stress, one of which—PE—is often considered to be a first line treatment for the effects of trauma, most notably sexual assault and combat. This approach involves extended recall and discussion of the full force of a traumatic memory until the associated anxiety is believed to fade through habituation.

In the PE context, habituation refers to the tendency for triggered fear states to diminish when the client is able to stay with them for extended periods of time without significant avoidance. As fear habituates, erroneous trauma-related perceptions, beliefs, and expectations (what Foa & Kozak [1986] call “pathological fear structures”) and conditioned emotional responses are thought to extinguish. Because habituation takes time, however, it has been assumed that the exposure process also must be prolonged—often up to 90 minutes per session, until the client’s fear (sometimes measured by “subjective units of distress” [SUDs]) decreases by at least 50 percent within a given session (Peterman, 2019).

Notably, however, the habituation construct has lost some of its credibility of late as the primary underlying driver of therapeutic exposure effects. Research indicates that exposure therapy outcomes are not affected to any significant extent by whether fear habituates within—or sometimes even across—sessions (e.g., Baker et al., 2010; Prenoveau et al., 2013; van Minnen & Foa, 2006). The reduced importance of habituation—the most cited reason for extended exposure—to clinical outcomes raises the question of whether exposure must be prolonged in the first place, especially given that (a) it can be aversive or intolerable for some (e.g., Morris, 2015); (b) it runs the risk of overwhelming some survivors with limited emotional regulation capacities (Levitt & Cloitre, 2005); and (c) can motivate avoidance responses that undercut treatment effectiveness, including premature drop-out (Najavits, 2015).

Probably apropos of the reduced role of habituation in successful emotional processing, recent studies indicate that exposure periods of 30 minutes or less are just as effective as more prolonged exposure in reducing posttraumatic stress (e.g., Nacasch et al., 2015; Sloan et al., 2018; van Minnen & Foa, 2006), and thus do not rule out the possibility that exposure periods could be even significantly shorter without sacrificing efficacy. Although these findings do not mean that PE should be avoided in all cases (e.g., Peck et al., 2018), they do suggest that—especially for clients with low distress tolerance or very high traumatic stress—there may be equally effective alternatives to habituation-based (and therefore prolonged) exposure approaches.

In this regard, Foa and McLean (2016) conclude that “the fact that within-session fear reduction does not predict treatment outcome suggests that the length of PE sessions can be shortened without compromising efficacy” (p. 11). Apropos of this, several exposure-related treatments, for example EMDR and WET, appear to be as effective as PE, yet involve short exposure periods. Ultimately, with the continuing shrinkage of exposure length the semantic boundary between “prolonged” exposure and other less extended exposure-based treatments may become moot.

Titrated exposure . In light of these concerns, as well as clinical experience with complex trauma survivors, we suggest that therapeutic exposure can be modified to increase its tolerability without reducing (in fact, potentially increasing) its efficacy. This generally involves at least three changes to traditional PE:

Reduce, when necessary, the duration of exposure periods.

Because classic PE can be challenging and does not appear to have special efficacy over other validated trauma therapies (see the meta-analysis by Powers et al., 2010), we recommend the use of shorter exposure periods when appropriate. Especially when the client is involved in behaviors that indicate emotional tolerance problems—for example chronic substance abuse, major dissociation, or ongoing involvement in serious DRBs—5 to 10 minutes (or even less) of exposure at a time may be more appropriate, assuming therapeutic exposure is indicated at all. Other clients may be able to benefit from longer periods, including the 30 minutes that Foa and McLean (2016) now recommend. Importantly, as noted, recent research indicates that the development of new information and associations during processing—for example, learning that triggers do not necessarily signal ongoing danger or loss, and experiencing trauma-related distress in the context of a positive therapeutic relationship—is likely more important than habituation, per se (Craske et al., 2014). As a result, a major goal of treatment is new learning that inhibits previous trauma memories, as opposed to exposure to prolonged, trauma related distress until it fades. In this regard, the point may not be to insist on any specific exposure duration, but rather to use exposure as a way to provide new learning and associations that counter previous trauma-related assumptions or expectancies. This may require repeated, titrated exposure to memories, but does not implicitly necessitate extended duration of any given exposure period.

Adjust exposure intensity when indicated.

Therapeutic exposure is generally most tolerable when it is adjusted to the client’s existing emotional regulation capacities. Referred to as working within the “therapeutic window” (Briere, 1989, 2019), this usually involves limiting exposure to whatever the client can tolerate—being careful to not exceed their emotional regulation abilities while, at the same time, providing as much processing as possible. Such exposure is sometimes (but not inevitably) graduated according to the intensity of the recalled material, with less challenging memories being recalled and verbalized before more upsetting ones. However, the approach advocated here usually does not involve a strict, preplanned series of extended exposure activities. This is because the client’s ability to tolerate exposure may vary considerably as a function of outside life stressors and threats, level of support from friends, relatives, and others, and, most important, the extent of emotional regulation capacities available to them at any given point in time.

Allow multiple exposure targets, under the client’s control.

In general, exposure involves the client recalling and discussing traumatic events with the therapist, or, on occasion, writing about them and then reading them in the session. In the classical PE approach, the client is asked to pick a single trauma, often the most upsetting one, and then focus on that memory for extended periods of time, over a number of sessions, until it loses its ability to produce distress. If the client moves to a different memory during this time, they are often gently redirected by the therapist to the prechosen memory, so that “adequate exposure” can occur. Such redirection or refocusing is deemed necessary because it is not unusual for a trauma survivor to move from one memory to another within a given session. For example, a client might start with a rape experience, switch to an instance of childhood maltreatment, and then, perhaps, to a memory of intimate partner violence, or from a memory of hand-to-hand combat to, 10 minutes later, an instance of homophobic bullying during adolescence.

The broader exposure methodology described in this book acknowledges this complexity, as opposed to eliminating it through a single-trauma focus. This is done by, among other things, “following the client” through what may be multiple trauma memories within a given session. Although they may come to treatment in order to address a recent assault experience, it may soon become apparent that either (1) an earlier trauma is actually more relevant to their ongoing distress, or (2) their posttraumatic stress is due to the interacting effects of multiple traumas. A sexually exploited youth, for example, might seek treatment for the effects of a sexual assault, and soon discover that this rape activates memories of the vast collection of other distressing experiences they undergo on a regular basis, as well as the childhood abuse experiences that may have contributed to their involvement in prostitution in the first place. In such instances, insisting that the client focus exclusively on a single predetermined trauma during therapy, or even on just one trauma at a time, can be problematic, if not counterintuitive.

Instead of necessarily constraining the client to discussion of a single agreed-upon adverse event, we suggest that they be encouraged to discuss—and thereby expose themself to—whatever trauma seems important at a given time, or whatever memory—or part of a memory—is triggered by any other memory. As noted, many clients have experienced multiple traumas and attachment disruptions in their lives, the memories of which interact with one another and, cumulatively, better predict posttraumatic outcomes than single-event traumas. In such contexts, multitarget processing may be more efficient than a series of separate, extended exposure interventions for each of a large number of distressing memories. As well, as noted by Linehan (1993), such client control over the treatment process “may itself be therapeutic and render future exposure less frightening” (p. 352).

Written Homework

As noted in the previous chapter, therapeutic exposure sometimes includes homework assignments. This typically involves the client writing about the traumatic event outside of therapy and then reading aloud what they have written in the next session (see Briere & Lanktree [2012] for a detailed discussion). Along with providing additional opportunities to examine and process cognitions initially associated with the event, this activity requires that the client access the original trauma memory in order to write about it, and thus provides significant therapeutic exposure. This exposure is then repeated when the client reads the narrative aloud to the therapist.

Adapting from Resick and Schnicke’s (1992) assignment for a rape survivor, albeit with titrated processing in mind, the therapist might suggest something like the following:

Typically, the client is asked to repeat this writing exercise on several different occasions over the course of treatment, potentially for different traumas, and to read their writing each time to the therapist. The specific appropriateness and timing of these writing and reading exercises may vary according to (1) the client’s level of safety at home, (2) their current capacity for written expression, (3) their readiness to directly confront the trauma, and (4) their immediate stability and emotional regulation capacity. The therapist’s response to hearing the client’s story should be characterized by support, validation, and appreciation for the client’s willingness to engage in such a potentially difficult task.

Obviously, this approach is not possible for those who are unable to read and write fluently in a shared language, who are too cognitively debilitated (e.g., by extreme posttraumatic stress, psychosis, intellectual impairment, or severe depression), or those without a safe (or any) home in which to do the work. In cases where language, literacy, and instability are not issues, however, this exercise can be initiated at some point after the first few sessions and then repeated several times throughout treatment. The total number of times this exercise is done may increase if there are several different traumas in need of emotional processing. In general, the clinician may find that these written renditions become more detailed and emotionally descriptive upon repetition, and that the client’s emotional responses when reading the assignment aloud become less extreme over time.

Written Exposure Therapy (WET)

In some ways like written trauma homework, WET (Sloan & Marx, 2019) involves writing about a traumatic event, typically for 30 minutes, for a total of five sessions. Significantly, there are little postexposure debriefing or cognitive interventions. As per Pennebaker’s research on expressive writing (Pennebaker & Beall, 1986), WET effects may be due to the repeated activation of cognitive fear structures in safe contexts over time (Thompson-Hollands et al., 2019). Despite its brief format, WET has been shown in several studies to be at least as effective as PE or CPT, even at 60-week follow-up (Thompson-Hollands et al., 2018) and to have a considerably lower drop-out rate.

Eye Movement Desensitization and Reprocessing (EMDR)

In EMDR (Shapiro, 2018), the client is asked to recall a traumatic event, and then to focus on visual images, negative beliefs, bodily sensations, and emotional responses associated with the memory. At the same time, the client visually tracks the therapist’s finger as it moves back and forth across their visual field, or the client is exposed to dichotic tapping, auditory tones, or moving or flashing lights. This is repeated on multiple occasions during a given session.

Several meta-analyses suggest that EMDR reduces posttraumatic stress symptoms to the same degree demonstrated for classic therapeutic exposure methods (e.g., Bisson et al., 2013; Powers et al., 2010). Interestingly, in contrast to earlier questions about the specific importance of the eye movement component of EMDR (see Lee & Cuijpers, 2013), recent research offers neurobiological support for the impacts of eye movement on (a) the frontoparietal cortical representation of traumatic memories (Harricharan et al., 2019, p. 1) and, if results can be generalized from mouse research, (b) the superior colliculus and mediodorsal thalamus circuit involved in fear extinction (Baek et al., 2019).

Most of the outcome literature on EMDR involves the treatment of relatively “simple” posttraumatic stress, especially single incident events that occurred in adulthood and resulted in PTSD. In contrast, beyond a few case studies (e.g., Korn & Leeds, 2002), there is less empirical research regarding its effects on more complex trauma effects, especially childhood maltreated-related problems such as emotional dysregulation, distress-reducing behaviors, attachment disturbance, or relational disturbance (although see Shapiro & Brown, 2019). Perhaps apropos of this, van der Kolk and colleagues (2007) found that EMDR was considerably more effective in eliminating PTSD symptoms among those with adult-onset traumas than among those who had experienced childhood trauma, which tends to confer more wide-ranging and complex effects.

Yet, at the same time, EMDR has multiple components that are relevant to more complex trauma, including stabilizing interventions; support for self-compassion; attention to interlinked memories and cognitive distortions such as shame or guilt; and alternation between desensitization and access to internal resources, which likely serves therapeutic window-like functions. Further, although EMDR tends to focus on explicit trauma memories, some writers, not without controversy, suggest that it can be adapted to address implicit, attachment-level memories as well (e.g., Parnell, 2013). Likely for these reasons, EMDR has been integrated into other therapies, including relational and complex trauma-specific ones (Shapiro & Brown, 2019). In the current context, EMDR may be helpful in supporting “hot spot” processing (i.e., targeted attention to discrete, especially distressing aspects of a trauma) during longer-term relational therapy (e.g., Korn, 2009). As noted on the EMDR Institute website in 2004, this procedure, like other exposure therapies, requires that the client have “adequate methods of handling emotional distress and good coping skills, and [is in] a relatively stable state. If further stabilization is required, or if additional skills are needed, therapy focuses on providing these.”

4. Activation

As opposed to exposure, which involves directing the client’s attention to, and engagement in, traumatic memories, activation occurs when remembering trauma(s) triggers posttraumatic emotions (e.g., fear, sadness, disgust, or horror), sensations (i.e., flashbacks), and/or cognitions (e.g., intrusive negative self-perceptions, guilt, or helplessness) conditioned to the original event. Other, related memories and their associated affects and cognitions also may then be triggered, as described earlier in this chapter (and by Briere, 2019) as trigger linkage.

Exposure antedates activation, but both must occur for emotional processing to happen. For example, a client who is asked to describe an instance of child abuse undergoes exposure to the extent that they recall and describe aspects of that event during the therapy session. If these memories trigger emotional responses (e.g., fear, anger, or disgust) conditioned to the original abuse stimuli, or associated cognitive intrusions (e.g., self-blame or shame), or stimulate further memories (e.g., of other abuse experiences, or another aspect of the trauma triggered by remembering certain aspects of it), activation is said to have taken place. In most cases, activation involves implicit, nonverbal memories or conditioned emotional responses. For example, the client’s perception of therapist disattunement may expose them to attachment-era memories of parental disengagement or neglect, which then activates memories of insecure attachment, with associated fear, expectations of abandonment, and anger (see Chapter 10 for a detailed discussion of such relational activations).

Activation is critical to trauma processing—in order to lessen the power of emotional-cognitive associations to a given traumatic memory, they must be (a) activated, (b) not reinforced, and ideally (c) contradicted by the therapeutic process. For this reason, therapeutic interventions that consist solely of the narration of trauma-related memories, without emotional activation (e.g., describing painful experiences while dissociated or intoxicated), will often fail to reduce symptoms (Foa & Kozak, 1986; Samoilov & Goldfried, 2000). Generally, for optimal activation to occur, there should be as little avoidance as safely possible during the exposure process. On the other hand, too much activation is also problematic because it generates high levels of distress, potentially linking memory to current emotional pain, rather than to safety or positive feelings.

The Therapeutic Window

As described earlier, in order for therapeutic activation to contribute to trauma processing, the thoughts and feelings activated by exposure must not be excessive. Although it should be distressing enough to serve as a target for treatment, such activation should not be so intense that it exceeds the client’s emotional tolerance and overwhelms—referred to as working within the therapeutic window. The therapeutic window refers to a psychological midpoint between inadequate and overwhelming activation of trauma-related emotion during treatment (Briere, 1989); it is a hypothetical “place” where therapeutic interventions are thought to be most helpful. Interventions within the therapeutic window are neither so trivial or nonevocative that they provide inadequate memory exposure and processing, nor so intense or prolonged that the client’s balance between acceptable memory activation and overwhelming emotion is tipped toward the latter. In other words, interventions that take the therapeutic window into account are those that activate trauma memories and promote processing but do not overwhelm internal protective systems and motivate unwanted avoidance responses.

Overshooting and undershooting. Interventions that undershoot the therapeutic window are those that either completely and consistently avoid traumatic material or are focused primarily on support and validation with a client who could tolerate greater exposure and processing. Undershooting is rarely dangerous—it can, however, waste time and resources in instances when more effective therapeutic interventions are possible. Overshooting the window, on the other hand, occurs when the clinician inadvertently provides too intense or prolonged memory exposure and emotional activation relative to the client’s existing emotional regulation resources, or is unable to prevent the client from flooding themself with overwhelming traumatic distress. Interventions that are too fast paced or prolonged may overshoot the window because they do not allow the client to adequately accommodate and desensitize previously activated material before triggering new memories. When therapy consistently overshoots the window, the survivor typically must engage in avoidance maneuvers in order to keep from being overwhelmed by the therapy process. For example, they may increase their level of dissociation through disengagement or “spacing out” during the session or interrupt the focus or pace of therapy with arguments, by “not getting” obvious therapeutic points, by distracting the therapist with various behaviors (e.g., aggressive or sexualized responses), or by changing the subject to something less threatening. In the worst case, they may drop out of treatment.

Although therapists may view these behaviors as “resistance,” such avoidance often represents appropriate self-protective responses to therapist process errors. Unfortunately, the regular need for avoidance can easily impede treatment by decreasing the client’s exposure to memory material and the ameliorative aspects of therapy. In contrast, effective trauma therapy provides titrated exposure to traumatic material while maintaining the safety necessary to eventually neutralize conditioned emotional responses. By carefully adjusting the amount of therapeutic exposure so that the associated emotional activation does not exceed the survivor’s emotional capacities, treatment within the therapeutic window allows the client to slowly process trauma memories without being retraumatized and needing to shut down the process.

Intensity control. Intensity control refers to the therapist’s awareness of and relative control over the level of emotional activation occurring within the session. We recommend that—especially for those clients with impaired emotional regulation capacities—emotional intensity be highest at around (or slightly before) midsession, whereas the beginning and end of the session should be at the lowest intensity (see Figure 9.1). Ideally at the beginning of the session, the client gradually enters the process of psychotherapy; by the middle the focus has shifted to relatively more intense activation and processing; at the end of the session, they are sufficiently dearoused that they can reenter the outside world without needing later avoidance activities. Notably, the relative safety of psychotherapy sessions may allow some clients to become more affectively aroused than they would outside of the therapeutic environment. As a result, it should be the therapist’s goal to leave the client in as calm an affective state as is possible—ideally no more emotionally aroused than they were at the beginning of the session.

Figure 9.1 Therapeutic Intensity Over Time During Session

Because activated cognitive-emotional responses are, to some extent, the crux of trauma work, we describe in the following sections several interventions aimed at controlling the level of activation during treatment. The goal, in each case, is to work within the therapeutic window—to support emotional and cognitive activation that is neither too little nor too much for optimal processing.

Increasing activation . The therapist typically seeks to increase activation in instances when, despite available emotional regulation capacity, the client unnecessarily blocks some portion of their emotional responses to the traumatic material. It is not uncommon for avoidance responses to become so overlearned that they automatically, but unnecessarily, emerge during exposure to stress. In other instances, gender roles or occupational socialization (i.e., in action-oriented professions) may discourage emotional expression in an individual who could otherwise tolerate it, as described in Chapter 4. In such cases, a reduction in avoidance during treatment is not only likely to be reasonably safe, but also is usually necessary for significant processing to occur. When avoidance is not required for continued emotional homeostasis, yet appears to be blocking trauma processing, several interventions may be appropriate. In each case, the goal is increased awareness and, thus, increased activation—not criticism or, necessarily, even symptom identification.

First, the therapist may ask questions that can only be answered in a less avoidant state. These include the following:

“What were you feeling/how did it feel when that happened?”

“What are you feeling now?”

“Are you aware of any thoughts or feelings when you describe [the trauma]?”

In such cases, the avoidance may decrease, yet never be acknowledged—an outcome that is entirely appropriate, since the primary intent is to keep activation at a reasonable level, not to label the client’s reaction as problematic.

Second, the clinician can indirectly draw attention to the avoidance, without stigmatizing it, and ask the client to increase their level of contact during the process of activation. This is often most effective when the client’s avoidance, or the power of the memories to overwhelm, has previously been identified as an issue in therapy. This may involve encouraging suggestions such as

“You’re doing well. Try to stay with the feelings.”

“Hang in there. You’re doing great. Stay with it if you can.”

“I can see it’s upsetting. Can you stay with the memory for just a few more minutes? We can always stop if you need to.”

In other cases, however, for example, when dissociation is just one possibility, or when the client is more prone to a defensive response, the therapist may intervene with a question-statement combination, such as

“How are you doing? It looks like maybe you’re spacing out a little bit?”

“It looks like you’re going away a little bit right now. Is that true?”

Although calling direct attention to avoidance is sometimes appropriate, it tends to break the process of exposure/activation, and generally should be used only when less direct methods of encouraging activation (and thus reducing avoidance) have not been effective.

The clinician can increase activation not only by intervening in cognitive or emotional avoidance but also by increasing the emotional experience. Often, this involves requesting more concrete details about the traumatic event and responding in ways that focus the client on emotional issues. As the client provides more details, the opportunity for greater activation increases—both because greater details often include more emotionally arousing material, and because greater detail reinstates more of the original context in the client’s mind, thereby increasing the experience of emotions that occurred at the time of the trauma.

Decreasing activation. In general, the intensity of activation is determined by (1) the level of exposure, (2) the aversiveness of the trauma memory (that is, the extent of negative emotionality and cognition conditioned to it), and (3) the amount of emotional regulation capacity available to the client. If the therapist encourages too much activation or is unsuccessful in keeping the client’s emotional activation to a tolerable level, the therapeutic window likely will be exceeded. As suggested earlier, those with reduced emotional regulation capacities typically should not be exposed to especially upsetting memories until their ability to regulate negative emotions improves. This may mean that the therapist redirects the client to less upsetting material when the client becomes too activated, introduces a relaxation exercise (an example of which will be referred to as interspersal later in this chapter), or directs the conversation to less emotionally charged aspects of the event. In such cases, emotional regulation skill development (see Chapter 6) may receive priority over especially intense trauma processing, and supportive interventions and responses may predominate over exploratory ones. When avoidance is more extreme, for example when the client becomes highly dissociated in the session, the therapist will generally stop the exposure/activation process and focus stabilizing interventions on whatever is producing the avoidance.

This titrated approach might appear to deprive the client of the opportunity to address major traumas, since it does not require the prolonged exposure advocated by some. We believe, however, that such restraint is one of the responsibilities of the therapist. If the clinician suspects—based on observation of the client or their previous history in treatment—that activation is likely to exceed the therapeutic window in any given circumstance, it is important that they ensure safety by reducing the intensity and pace of the therapeutic process. This does not mean that the clinician avoids trauma processing altogether; only that processing should proceed slowly and carefully or be temporarily delayed.

Fortunately, the need for such a conservative approach is often transient. As traumatic material is slowly and carefully processed, progressively fewer trauma memories will have the potential to activate overwhelming distress, and, as described in Chapter 6, the client’s overall capacity to tolerate painful emotional states will likely grow. The primary issue, overall, is one of time: the individual with good emotional regulation capacities, less than extremely distressing trauma memories, and no interfering comorbidities may be able to tolerate higher levels of activation without exceeding the therapeutic window, and thus may respond relatively quickly to treatment. Those with difficulties in one or more of these areas, however, may require titration to lower levels of activation during trauma processing, and thus may have to be in therapy for a longer period of time before major symptom improvement occurs.

Unfortunately, not all activation is visible to the therapist. There may be occasions when the client overshoots the therapeutic window during treatment yet may not appear to be especially overwhelmed. This may occur because

the client feels relatively safe in the controlled environment of the therapist’s office and does not fully experience the overwhelming nature of the exposure until they leave the session;

they are concerned about therapist approval and do not show distress in the session so as to appear strong, healthy, or in control; or

they are dissociating or cognitively suppressing upsetting internal processes.

Such nonapparent overshooting, whether or not it is acknowledged by the client, may cause elevated anxiety, reexperiencing, or shame after the session ends—negative experiences that may then result in DRBs (e.g., self-injury), substance abuse, or other avoidance activities. In some cases, the client may make emergency calls to the therapist, may miss the next therapy session, or may arrive late to it.

In trauma work, missed sessions and lateness sometimes represent avoidance of the distress associated with previous therapeutic exposure to traumatic material. In such instances, the client’s behavior may reflect their fear of further emotional activation in subsequent sessions. Once a session is missed, further missed sessions may follow. When a client repeatedly misses appointments, we recommend that the therapist explore this issue with them, by phone or in person, in a nonjudgmental, nonblaming manner, assessing what aspects of the therapeutic process or content is motivating avoidance and assuring the client that the therapist is not angry and will not be punitive. Often, a permissive attitude toward “no-shows” is more necessary in trauma work than in other forms of psychotherapy. By accepting, discussing, and normalizing the underlying motivation for nonattendance—as opposed to confronting and criticizing it—the therapist has a better chance of decreasing the likelihood of future missed sessions.

Remediating window errors . Obviously, it is important to avoid exceeding the therapeutic window whenever possible. Given the delicate nature of exposure work, however, and the sometimes-obscuring effects of client emotional avoidance, it is often impossible to entirely avoid overactivation. As a result, part of the clinician’s job in therapy is to intervene when overactivation occurs and to work to repair the effects of such experiences.

When it is apparent that the therapeutic window has been significantly exceeded, the therapist is advised to consider the following:

Reducing the duration and intensity of the current activation, through relaxation or breathing exercises, cognitive (as opposed to emotional) interventions, and, generally, a shift in focus away from overly activating topics

Taking some responsibility for the client’s overactivation while, at the same time, not disparaging one’s own work or abilities

Supporting and validating the client’s emotional responses, including suggesting that they are indicative of doing “good work” as opposed to engaging in avoidance

Discussing and reframing major activation after it occurs, so that the client understands their reactions as a normal reaction to the power of the triggering memory, and does not pathologize them

Problem-solving with the client in ways in which

the therapist can detect the client’s escalating distress (this is especially relevant if the client habitually uses emotional avoidance defenses in the session)

the client can communicate distress at the time it occurs

the therapist and client can work to bring the activation level back into the therapeutic window

Making supportive and validating statements that convey cautious optimism that the “emotional rollercoaster” of early trauma sessions may gradually abate over time in treatment.

5. Disparity/New Information

Exposure and activation are not, in and of themselves, sufficient in trauma treatment. As noted earlier, there also must be a disparity between what the client is feeling (e.g., activated fear associated with a trauma memory) or thinking (e.g., that they are about to be rejected or abandoned) and the current state of reality (e.g., the manifest absence of immediate danger). For conditioned associations to traumatic memories to be diminished or inhibited over time, they must be consistently contradicted by distress-antithetic experiences in the current environment.

As discussed earlier, safety should be manifest in at least two ways. First, the client should have the opportunity to realize that they are safe in the presence of the therapist. This means safety not only from physical injury and sexual exploitation, but also from criticism, punitiveness, boundary violation, inadvertent microaggressions, or underappreciation of the client’s experience. Because the survivor of interpersonal violence, maltreatment, or exploitation tends to overidentify danger in interpersonal situations, the absence of danger in the session must be experienced directly, not just promised. In other words, for the client’s anxious associations to trauma memories to lose their power, they must consistently not be reinforced by current danger or maltreatment in the session, however subtle or unintended.

Second, safety in treatment includes some degree of protection from overwhelming internal experience. As noted earlier, such states may occur because one or both of two things are present: (1) the memory is so traumatic and has so much painful emotions (e.g., anxiety, rage) or cognitions (e.g., guilt or shame) associated with it that untitrated exposure produces considerable distress; and/or (2) the survivor’s emotional regulation capacities are sufficiently compromised that any major reexperiencing is overwhelming. In each instance, safety—and therefore disparity—can only be provided within the context of the therapeutic window. Because processing within the window means, by definition, that exposure to memories does not exceed the client’s ability to tolerate those memories, reexperiencing trauma in this context ideally is not associated with overwhelming negative affect, identity fragmentation, or feelings of loss of control.

The processing of conditioned responses to trauma memories operates in a manner similar to the processing of fear in behavioral treatments for phobias. The ongoing activation of fear and other negative emotional responses during the repetitive recounting of traumatic material in the absence of any discernible reason for such responses during the session means that trauma-related emotions are activated but contradicted by current therapeutic experiences and activities. Eventually, responses that are both not reinforced and actively updated tend to fade. Possible reasons for this phenomenon range from traditional extinction theories to cognitive models involving the experience-based modification of cognitive fear structures.

Especially relevant to trauma processing, however, are newer developments in what is referred to as inhibitory learning theory. Recent research indicates that, in contrast to prior scientific belief, therapy-based extinction may not primarily involve the actual erasing or deleting of associations between triggering stimuli and conditioned trauma related responses (Craske et al., 2014). Instead, these responses typically remain in memory even if they are no longer easily activated (Bjork & Bjork, 1992). As Jacoby and Abramowitz (2016) note, “Once they are learned, such associations don’t fade over time; rather access to them does” (p. 30).

The continuing presence of old (i.e., trauma-related) memories aside newer versions of them (e.g., updated with new insights gained in therapy or the contradictory experience of positive relational feelings while discussing upsetting events), is an important aspect of inhibitory learning theory (Lang et al., 1999). It suggests that therapy-based learning—for example, that contact with people in some way similar to one’s perpetrator does not always lead to danger, or that memories are just that, not necessarily information on current reality—must compete with “old” but still potentially available expectancies, for example those formed in the context of trauma, abuse, or insecure attachment experiences. The difference between inhibitory learning and earlier habituation perspectives has significant implications for trauma processing. For example, it suggests that repeated experiences of safety, connection, and support in therapy while recalling painful events in the past probably do not extinguish associations between childhood maltreatment and current relational stimuli through habituation. Instead, they create new learning that, if successful, overrides or inhibits older conditioned responses. Thus, part of the goal of trauma therapy is to increase the likelihood that new memories will successfully inhibit old ones, a process that may “deepen extinction” (Craske et al., 2014) and reduce the activatability of trauma-based assumptions or associations.

Regardless of the underlying mechanisms, the role of disparity in trauma recovery is clear. The environment in which trauma activation occurs must reliably not reinforce the client’s original trauma- or attachment-related associations but should actively and simultaneously contradict them with antithetic experiences. If this does not occur, it is likely that the client’s conditioned responses to negative experiences will remain strong, perhaps even increase.

6. Counterconditioning

Not only is it important that there be a manifest absence of danger during trauma processing, in the best circumstances there also should be counterconditioning—the simultaneous presence of positive phenomena that are antithetic to physical or psychological danger and distress. Thus, for example, a person in therapy for problems related to unremitting abuse as a child initially may expect or perceive their therapist to be critical or rejecting, if not physically or emotionally dangerous. When their fears not only are met with the absence of those things in treatment (the disparity associated with therapeutic safety), but occur in the presence of acceptance, validation, and nurturing, the activated distress may diminish in intensity because it is at least partially incompatible with the positive feelings that arise in therapy. As a result, the emotional associations to memories of being abused are not only not reinforced, but they are also inhibited by contradictory, positive feeling states.

Neurobiology. Counterconditioning of trauma memories likely includes the effects of attachment neurobiology, involving inborn neurochemical reinforcement systems that reward sustained and intimate human connection. Probably based on the evolutionary need for the child to maximize attachment with, and physical/emotional support from, caretakers (Bowlby, 1982), attachment bonds appear to be rewarded by triggered oxytocin and related (e.g., dopamine) release (Strathearn, 2011). These neurochemicals, in turn, tend to increase a sense of well-being, openness, and trust in others, and reduce stress and anxiety (Kirsch et al., 2005; Kosfeld et al., 2005). Thus, to the extent that therapy activates attachment neurobiology, the client is likely to experience the classic counterconditioning scenario: exposure to memories in the presence of distress-reducing positive emotional states, decreased defensiveness, and reduced anxiety.

Emotional expression . Neurobiological counterconditioning likely also occurs when an individual cries or engages in other forms of emotional release while remembering traumatic events in safety. Not only can crying, for example, be cathartic and self-soothing, recent research suggests it triggers oxytocin and—especially in the presence of a caring, supportive other—decreases stress and improves mood (e.g., Gračanin et al., 2014; Hendriks et al., 2007). Other forms of expressed emotionality during treatment also have been found to decrease chronic distress (see a review by Kennedy-Moore & Watson, 2001), presumably because emotional expression can lead to relief, which may then countercondition simultaneously present painful memories.

This process may be facilitated by the absence of the suppression effect, as described earlier. From this perspective, emotional exploration and expression is the antithesis of emotional suppression, and thus would be expected to correlate with symptom reduction, as appears to be the case (e.g., Lumley et al., 2017; B. L. Thompson & Waltz, 2010). As summarized by Whelton (2004), there is growing evidence that “the in-session activation of specific, relevant emotions” (p. 58) predicts positive therapeutic outcome. In this context, the common suggestion that someone “have a good cry” or “let it all out” may reflect cultural support for emotional activities that naturally countercondition activated trauma-related distress.

Taken together, research on the neurobiology of the therapeutic relationship and the effects of emotional expression during treatment comports with the tenets of counterconditioning theory. Just as traditional systematic desensitization typically pairs a formerly distressing stimulus to a relaxed, anxiety-incompatible state in an attempt to neutralize the anxious response over time (Wolpe, 1958), emotional expression in the context of a caring therapeutic relationship pairs traumatic material with relatively positive internal states. For this reason, trauma therapy is often most helpful when it includes (a) a caring, attuned, therapeutic relationship that triggers positive attachment responses, and (b) gentle support for—and reinforcement of—expressed emotionality during exposure activities.

Interspersal. As noted, a central notion in counterconditioning is that processing may be assisted by having the client experience painful memory in the context of relatively distress-incompatible states. Beyond the activation of positive attachment neurodynamics and support for emotional release, counterconditioning may also occur when there is interspersal (Briere, 2019) of nondistressing, calming, or grounding activities between periods of therapeutic exposure. For example, a client might undergo 10 minutes of exposure to an especially distressing trauma memory, followed by 5 minutes of a grounding exercise, then perhaps another exposure period, followed by a brief breathing exercise. Among the interspersal activities that may be employed to increase counterconditioning are

Relaxation exercises

Deep breathing

Mindfulness activities

Discussions that increase feelings of closeness (e.g., therapist encouragement, praise, support, reflection on progress, or caring statements)

Episodic discussion of nonupsetting topics

Specific emotional regulation activities

Importantly, as opposed to the counterconditioning effects of the therapeutic relationship, these activities generally do not take place during exposure, but rather before and after it. As such, they are less subject to the criticism that activities which reduce full activation of memory-related distress constrain the effectiveness of emotional processing. Such concerns are often expressed based on research suggesting that the use of “safety” activities (behaviors that reduce fear during exposure) reduces the effectiveness of emotional processing (Helbig-Lang & Petermann, 2010). Other studies, however, indicate that safety activities may not impede processing (e.g., Meulders et al., 2016), and may, in fact, increase the tolerability of exposure and contribute to the client’s sense of self-efficacy. More relevant to interspersal, recent research indicates that mindfulness or relaxation exercises prior to exposure do not lessen the effectiveness of subsequent emotional processing (e.g., Treanor, 2011; Tyron, 2005), and may have neuropsychological effects that facilitate recovery from posttraumatic stress (e.g., Treanor, 2011).

There is also little research indicating that distress-reducing activities after exposure undercuts emotional processing. Instead, they may be helpful in reducing unresolved exposure-based distress (e.g., Peck et al., 2018), and support the client’s ultimate capacity to move in and out of distressing states without feeling overwhelmed, potentially increasing their sense of control and self-efficacy (Linehan, 1993; Meulders et al., 2016).

These findings, along with clinical experience, suggest that clients who experience difficulties with exposure treatments may gain from interspersal to

keep exposure-based distress under control,

provide positive, relatively distress-incompatible states that promote counterconditioning, and

help the client develop emotion de-escalation skills and increased sense of self-efficacy.

7. Extinction/Inhibition

Together, the process of remembering painful (but not overwhelming) events in the context of safety, relatedness, emotional expression, and interspersal can alter the connection between traumatic memories and associated negative emotional responses; a process traditionally referred to as extinction—although, as discussed, this may not always be the best term.1 However the process is labelled, environmental and internal events that trigger memories of traumatic experiences can, over time, no longer produce the same level of negative emotionality, for at least two interrelated reasons:

Triggered distress in the presence of a positive therapeutic relationship, feelings of safety, and interspersed periods of relaxation or grounding, countercondition negative emotional associations

Within-session learning—for example, that posttraumatic distress need not be overwhelming when activated, or that people in authority are not necessarily dangerous or rejecting—inhibits older abuse/trauma-related associations

Once trauma memories are processed in this manner, stimuli that formerly triggered emotional distress are less able to do so. As a result, the client becomes less “traumatized”—although some aspects of the original conditioned distress likely still exists in memory (Lang et al., 1999), it is less accessible, even when cued or triggered by reminiscent stimuli in the current environment. In the case of the multiply-traumatized person, the process may not end with just decreased triggerability of a given emotional/cognitive memory. Instead, other memories, often those associated with even greater distress, may become more available (less avoided), at which point the process continues with this new material.

Deepening extinction. The fact that many trauma-era memories do not actually disappear, but just are made less accessible by virtue of later contradictory learning means that previously processed trauma associations can become active again or fail to extinguish in the first place. For example, treatment outcome studies often report that, despite initial treatment success, some clients relapse into significant posttraumatic stress at follow-up, sometimes referred to as “return of fear” (ROF; Craske & Mystkowski, 2006). This is especially common when the individual has experienced a new trauma or stressor, or they are triggered in situations that are dissimilar from the conditions of psychotherapy. In response to this problem, Craske and colleagues (2014) suggest ways in which contradictory learning can be “deepened” or made more enduring. Specifically, it may be possible to increase the chances that the effects of trauma processing will persist and continue to inhibit trauma-related associations.

Craske and colleagues (2014) provide a list of a number of ways to deepen inhibitory learning, albeit in the context of treating obsessive-compulsive behavior. Two of their suggestions are especially relevant to trauma therapy: highlight expectancy violation and process memories in a variety of ways and from different perspectives.

Highlight expectancy violations. In the current context, expectancy violation refers to times in therapy when, based on traumatic experiences, the client expects one outcome but, instead, another outcome ensues. For example, they might expect rejection or harm from the therapist, yet encounter therapeutic safety and support, or might assume that strong painful feelings lead to overwhelmingly negative outcomes, and yet discover that activated states are tolerable, perhaps even associated with relief. More basically, they may expect that the presence of a trigger signals a returning trauma.

Such mismatches between expectation and outcome are common when trauma therapy occurs in the context of safety, support, and compassion. Importantly, this discrepancy should be repeatedly demonstrated and noted, so that new learning is maximized. For example, Craske and colleagues (2014) suggest that

In trauma therapy, expectancy violation can be highlighted by frequently asking the client, for example, to discuss what they expect will occur if they encounter a trauma-reminder/trigger, attempt to discuss upsetting material in the context of reduced avoidance, open themself a bit more to the therapeutic relationship, or try a new behavior that challenges old learning. When there is subsequent evidence that the client’s expectations are incorrect (e.g., triggered fear does not mean current danger, distress is tolerable, the session is safe, and new behaviors are either successful or, at least, not dangerous), the disparity can be gently highlighted. In other words, the more the expectancy is challenged by experience, and the client is consciously aware of this fact, the more these expectancies can be inhibited by new learning.

It should be noted that expectation disconfirmation targets a different processing goal than does the habituation model. Habituation-focused interventions seek to expose the client to trauma-related fear until it lessens significantly within a given session, and, ultimately across sessions, whereas “(i)n an inhibitory learning model, exposure continues for the length of time predetermined as an adequate test of a stated expectancy and continues for the number of occasions necessary for expectancies to be lessened” (Craske et al, 2014, p. 6).

This approach leads to a different question during therapeutic exposure: not “has this activated state habituated,” but rather “has exposure to trauma memories in safety sufficiently highlighted the disparity between what was expected or assumed versus what actually is true.” This latter goal may not require as prolonged an exposure period, since habituation probably is not especially relevant, but rather multiple opportunities to experience expectation disconfirmation within a given session. It also may not require repeated focus on a specific memory over time, but rather access and exposure to multiple memories that disconfirm the same general belief. For example, a client might process an instance of sexual assault when they were 11, then an occasion of bullying by an assumed friend at work, both of which, in the context of antithetic therapeutic experiences, might repeatedly teach that (a) they are not to blame for people hurting them, (b) the lack of safety they experienced in these situations do not mean that all relational closeness is risky, and (c) activated distress doesn’t have to be intolerable and overwhelming.

Process memories in a variety of ways and from different perspectives. The inhibitory learning literature suggests that contradictory learning is more persistent when memories are processed in a variety of different contexts, perspectives, and situations, and at variable levels of intensity and duration (Craske et al., 2014). In other words, multiple discussion of multiple traumas from multiple “angles” is more likely to generalize into wider, abuse-contradictory schema that are relevant to a broader range of triggers and situations. For example, exposure to different aspects of a victimization experience—in many cases via a range of activated implicit and explicit memories and contexts—can facilitate more generalized learning, which, in turn, can be applied in different situations.

In this regard, the failure of some exposure-based learning to sustain, causing painful memory to reinstate over time (i.e., the “return of fear” mentioned earlier), may be lessened when therapy addresses different aspects of the trauma, and, potentially, other similar traumatic events. For example, titrated exposure to multiple memories, revisited on multiple occasions during variable exposure periods, potentially increases the generalizability of extinction/inhibition, and thus deepens the unavailability of past (trauma-related) learning. A wide range of exposure targets means that multiple schema, fear structures, and conditioned responses are activated and processed within and across treatment sessions, such that multiple expectancies are contradicted and counterconditioned by safety, support, and new information.

Because the goal is to process trauma memories in a variety of ways, it may be helpful to employ more than one exposure methodology. For example, the use of homework, WET, or trauma-focused group or family therapy simultaneous with regular trauma psychotherapy may allow the client to address trauma memories across several different modalities, a process that likely provide additional pathways to exposure, activation, and generalization.

The therapist may find a variety of others ways to increase the generalizability of exposure therapy effects. Some examples are

Inviting the client to discuss a given trauma in the context of other ones they have experienced, and to explore whether the “message” of different traumas seem to converge on common themes—for example, that one deserves or asked for maltreatment, is bad or shameful, or is helpless to resist victimization—and yet, how these themes may be incorrect

Encouraging the client to bring photos of themself, taken around the times of previous trauma(s), to further trigger implicit memories that can be processed in therapy

Introducing art therapy exercises that involve renditions of trauma-related memories

If appropriate, referring the client to a therapy or support group where they can discuss their trauma(s) with others

Encouraging the client to write (but typically not deliver) detailed letters to their perpetrator(s) regarding the impacts of their actions on the client, which can then be read to the therapist

Having the client “talk” to their earlier, victimized self in role-play sessions, offering themselves perspective, encouragement, and advice

Helping the client to more deeply reinstate the context of specific trauma memories, so that more aspects can be processed, and learning is more generalized. This may include describing peripheral aspects of a given trauma (e.g., what time of day it happened, where it occurred, who else was present) as well as details of the event that might otherwise be overlooked (e.g., what they thought, saw, heard, or smelled at the time, what happened afterward)

8. Debriefing/Closure

One of the last aspects of trauma processing is the notion of closure. In the current context, closure refers to the completion of activated, but unresolved mental processes (Lewin, 1935), including trauma memories. One of Lewin’s students, Zeigarnik (1927), outline a theory of “psychic tension” thought to arise from incomplete or interrupted processes, causing memories to stay active in consciousness until some resolution occurred. One implication of the “Zeigarnik effect” is that when distressing memories are activated either by triggers in the environment or by exposure in the therapy session, but are not sufficiently processed, they will continue to intrude into awareness as symptoms like flashbacks or sudden distress (see Rachman, 1980, for a more contemporary discussion of this phenomenon).

In trauma therapy, closure activities are especially recommended when—as often is the case—the client has experienced activated memories that are incompletely processed within the session. When closure activities are successful, the client ideally will leave the session in no more arousal than when they entered it, and, in many cases, with a greater sense of meaning or understanding. Major sources of closure in trauma therapy include transitioning, debriefing, and rituals.

Transitioning occurs as the session predictably winds down, slowly shifting from exposure and cognitive-emotional processing to the “here-and-now” of the session’s end. In some cases, clinicians inadvertently skip this transition, meaning that the session stops relatively abruptly without a felt sense of completion. Per the Zeigarnik effect, the result may be client’s lingering preoccupation with and perseveration on session-activated trauma memories, sometimes including exacerbated posttraumatic stress. For this reason, we recommend that the last 5 to 10 minutes of any given session be devoted to “coming back” from memory processing to current experience, and transitioning to the outside world.

Debriefing occurs when the client has the opportunity to discuss what occurred earlier in the session, so that any unresolved details or emotional states can be addressed and any meaning, lessons, and/or expectancy violations can be highlighted and discussed. This process can support the development of a more dispassionate, coherent narrative (Amir et al., 1998) of the session. It also provides an opportunity to reframe within-session challenges in ways that emphasize bravery, strength, and hope. Whenever possible, the goal is for the client to view the just-ending session in a positive, coherent manner that encourages further involvement in treatment. When they have trouble doing so, it may fall on the therapist to provide this perspective.

Finally, many therapists have discovered that ending rituals (Linehan, 1993) can support a sense of closure. This may include specific behaviors such as walking the client to the door, noting the next appointment time, and offering, if appropriate, a handshake or elbow bump that signals a positive end of the session. Such activities not only demarcate the end of the session, but they can also contribute to feelings of safety and containment associated with reliable, predictable, and supportive therapist responses.

9. Reconsolidation

The final aspect of trauma processing is not a therapeutic activity, per se. Instead, it explains how exposure and counterconditioning can result in durable psychological changes. Research on memory reconsolidation suggests that there is a golden window of time, measured in hours, during which an activated memory can be destabilized (i.e., deconsolidated) and updated with new information or altered emotional connections, then reconsolidated back into neural tissue (Tronson & Taylor, 2007). Notably, the alterations or updates to memory are of its implicit characteristic (e.g., the originally encoded fear or self-blame), not the autobiographical explicit aspects of the memory. Thus, for example, trauma memories reconsolidated in therapy are not changed in terms of the who/what/where details of what happened, but rather the previous conditioned emotional or cognitive aspects of the memory are less able to be triggered. In other words, the trauma memory can be narratively recalled as always, but may be less associated with the original negative emotional or cognitive states that produce posttraumatic symptoms.

From this perspective, as noted by Lane and colleagues (2015) “the essential ingredients of therapeutic change include: (1) reactivating old memories; [and] (2) engaging in new emotional experiences that are incorporated into these reactivated memories via the process of reconsolidation” (p. 1). When this occurs, a trauma memory “can change its emotional valence in a short time frame and be reconsolidated with new emotional valence as part of personal memory” (Högberg & Hällström, 2018, p. 2).

Reconsolidation, then, is often a critical aspect of trauma therapy, since it represents the conversion of therapeutic processing into something that sustains beyond treatment.

In this way, reconsolidation explains how emotional and cognitive processing works:

Trauma memories are activated in the context of the disparity and counterconditioning associated with a safe, positive therapeutic relationship, as well as therapy-based insights and new information associated with cognitive processing of the memory. Reconsolidation research suggests the importance of detailed memory activation (we would add within the constraints of the therapeutic window) and explicit contrasts between the activated memory and current experiences and understandings that contradict that memory.

This leads to changes in the client’s overall schema, fear structure, and emotional associations to the memory, since reconsolidation creates a “new” version of the memory based on new experiences (e.g., safety in an important relationship) and new information (e.g., insight) derived from therapy.

The resultant memory gestalt is encoded into brain tissue, where it inhibits previous conditioned responses, cognitive distortions, and the emotional valence of the prior trauma memory. When this occurs, future triggering of this updated and reconsolidated memory will be less associated with negative cognitive-emotional states.

EMOTIONAL PROCESSING AND SUBSTANCE USE

Most of the cognitive-behavioral principles called upon in modern trauma therapy were developed in the context of treatment-outcome research that excluded those involved in problematic substance use (Spinazzola et al., 2005). As a result, there is less known about using exposure and other emotional processing approaches with those who suffer from both posttraumatic stress and involvement in substance abuse. This is unfortunate, since, as described in Chapter 2, a substantial number of substance abusers have trauma histories, and many experience significant posttraumatic stress.

The usual suggestion for treating comorbid trauma symptoms and substance use has been to first treat the chemical dependency and then, once abstinence has occurred, treat trauma-related symptoms (e.g., Chu, 1988). The primary rationale for this treatment sequence is that premature exposure to trauma memories may intensify substance abuse, trigger relapses, or otherwise challenge diminished emotional regulation capacities. Perhaps apropos of these reasonable concerns, one of the best known and most effective treatment approaches to comorbid PTSD and problematic substance use (“Seeking Safety”; Najavits, 2002) initially eschewed any form of therapeutic exposure to, or exploration of, trauma memories (although see Najavits [2024], Creating Change, a new, past-focused approach to trauma and addiction that includes some degree of exposure).

Despite these concerns, however, there are several problems with using an “abstinence first” approach in general clinical practice. These include

the fact that a high proportion of those presenting for trauma treatment have significant substance abuse issues—blocking their access to treatment would mean underserving the majority of treatment-seeking trauma survivors,

in most urban mental health contexts, competent and readily available chemical dependency services are rarely immediately available—waiting lists are often many months long, and specialized programs for substance abusing trauma survivors are rare, and

research indicates that treatment for substance use is considerably less effective for those who also experience major posttraumatic stress (Ouimette et al., 2003)—in other words, successful “pretreatment” of substance use before trauma treatment may in some cases be empirically, if not logically, inconsistent.

In light of these problems, some clinicians and researchers advocate combined trauma and substance use treatment (see the Expert Consensus Guideline Series, 1999). Further, several studies suggest that classic trauma therapy, including therapeutic exposure, can be effective with some substance dependent trauma survivors (e.g., Killeen et al., 2015). In basic agreement with this perspective, we suggest that the most useful and inclusive approach to trauma-substance use comorbidity is to treat posttraumatic stress in substance abusing survivors generally as outlined for others in this book. However, given what is known about this comorbidity, and the problems associated with problematic substance use in general, we suggest several potential modifications to regular trauma processing.

1. Some substance abusing trauma survivors are noteworthy for their diminished emotional regulation skills and coping capacities (e.g., Estévez et al., 2017). For this reason, the clinician should consider delaying major emotional processing of trauma memories for some clients until they have benefited from the stress reduction and emotional regulation interventions outlined in Chapter 6.

2. If some level of trauma processing is possible, either because emotional regulation is adequate or as a result of successful intervention in this area, therapeutic exposure and activation can be initiated. Nevertheless, it should be approached with caution. The clinician should especially ensure that processing occurs within the therapeutic window when significant substance use is present. Most important, exposure to traumatic memory should follow the dictum “Start low and go slow”: Traumatic material should be explored and processed in small increments and exposure should be terminated if it appears to overly challenge existing emotional regulation capacities.

3. Trauma therapy generally should not take place if the survivor comes to treatment in an intoxicated state. Instead, the focus should be on client safety (e.g., did they drive to the session, and can they get home safely?), and on managing any clinical issues that might be present (e.g., suicidality, aggression, intoxication-related agitation). Further, the next session should include a nonblaming discussion of the client’s reason for previously coming to treatment intoxicated, reiteration that intoxication automatically means that therapy is not possible, and exploration of ways in which the client can regain abstinence or at least ensure sobriety at the time of future sessions. Although therapists may vary on this point, typically we do not require sustained substance abstinence in trauma clients. We do, however, ask that the client not use recreational drugs or alcohol in the day of their session, so that they do not arrive in an altered state.

4. Whenever possible, the client should consider some sort of outside group, self-help or clinician-guided, that focuses on substance use issues. Alcoholics Anonymous or other 12-step programs may serve this purpose, to the extent that their precepts are psychologically and spiritually acceptable to the client.

5. Trauma treatment, as outlined in this book, should be augmented, when possible, with effective substance use treatment techniques. The reader is referred to Najavits’ 2002 and 2024 treatment manuals and Ouimette and Brown’s (2003) edited volume for coverage of specific PTSD-SUD approaches.

SEQUENCE AND SESSION-LEVEL STRUCTURE OF MEMORY PROCESSING

The current and previous chapters have described various techniques and approaches for the cognitive and emotional processing of traumatic memory. In this last section we suggest an overall context in which these interventions might best occur. Although the actual processing of traumatic memory will vary in degree from session to session, generally all such sessions should adhere to a basic structure. This framework allows the therapist to assess the client’s current needs, provide relevant processing activities as needed, reassess the client’s current state, deescalate session-level arousal if needed, and provide end-of-session closure. We suggest some version of the following, divided into four time periods. The length of these periods will vary according to the client’s emotional regulation and tolerance capacities, the presence of recent traumas and dysregulating life events, and their overall trauma history.

Opening

Inquire about any changes in the client’s life since the last session.

– Have there been any new traumas or victimization?

– Is the client suicidal or have they engaged in dysfunctional or self-destructive behaviors?

If any of the foregoing is of concern, work to assure or increase the client’s ongoing physical safety. Do this before (or instead of) formal trauma processing.

Check with the client regarding their internal experience since the last session. Have intrusive or avoidance symptoms increased significantly? If yes, normalize the experience and validate symptoms as intrinsic trauma processing. If the intrusions or avoidance responses are substantial, consider (a) decreasing the intensity of exposure and activation in the current session and (b) focusing more on emotional regulation activities and, potentially, longer interspersal periods.

Midsession

When appropriate, encourage emotional and cognitive memory processing, staying within the therapeutic window whenever possible. Especially if the client has significant emotional regulation difficulties, or experiences severe within-session emotional activations, consider limiting exposure periods and increasing the number and/or duration of interspersal periods.

If significant processing is contraindicated, revert to psychoeducation, cognitive interventions, general discussion, or a focus on less upsetting events in the client’s life.

Later in the session

Debrief, normalize, and validate any memory processing that occurs.

about the client’s subjective experience during processing, as well as any thoughts or feeling they have. Support the development of a hopeful, positive coherent narrative about the session.

Provide cognitive interventions, as needed, for cognitive distortions that emerged during processing (see Chapter 7) and highlight any assumption violations or new information.

If the client’s level of activation remains high, work to deescalate their emotional arousal. This may include grounding, per Chapter 6, an increasing focus on nonemotional issues, and/or further cognitive (but not emotional) processing.

Ending

Remind the client (as necessary) of the potential delayed effects of trauma processing, including occasionally increased flashbacks, nightmares, and a desire to engage in avoidance activities such as substance use or distress reduction behaviors.

Provide safety planning (if necessary) regarding dangers identified in the session, or any possible self-destructive behavior. Make concrete suggestions about what they might do when this occurs.

Encourage or provide closure statements, activities, or rituals.

Explicitly refer to the time and date of the next session.

Descriptions of Images and Figures

The X-axis represents the timeline of the session, divided into "Beginning of session," "Mid-session," and "End of session." The Y-axis represents "Activation." The curve starts at a low point, rises to a peak at mid-session, and then declines back to a low point by the end of the session, forming an arch shape.

Chapter 10

INCREASING IDENTITY AND RELATIONAL FUNCTIONING

As described earlier, trauma can produce chronic problems in identity and interpersonal relatedness, above and beyond the posttraumatic stress, cognitive distortions, and emotional dysregulation often associated with a history of ongoing and severe childhood abuse and neglect (Bigras et al., 2015). These problems are sometimes viewed by clinicians as evidence of a personality (especially borderline) disorder. As noted in Chapter 2, although there is a significant link between trauma and some forms of enduring psychological difficulties, not all problems in this area necessarily relate to personality disturbance, per se. In many cases, they represent reactions, accommodations, or coping strategies developed in the face of chronic childhood maltreatment and associated attachment disturbance (Ford & Courtois, 2021; Levy et al., 2015). For example, notions of disturbed self-organization (DSO; Bachem et al., 2021) or altered self-capacities (ASC; Briere & Runtz, 2002) emphasize the impaired self-reference, negative self-perceptions, and relational difficulties often associated with early abuse, neglect, and disattunement, often without reference to a personality disorder.

With a few exceptions (e.g., Cloitre et al. 2002; Linehan, 1993) most cognitive-behavioral trauma therapies focus solely on treating cognitive or posttraumatic stress symptoms. However, many survivors of multiple, complex traumas present with significant—often highly distressing—difficulties in identity and interpersonal functioning. As a result, we recommend interventions that address these areas as well.

IDENTITY PROBLEMS

Survivors of early and severe childhood trauma often demonstrate problems associated with an inability to access a stable sense of self (Berman, 2016). This may present, for example, as problems in determining one’s own needs or entitlements, maintaining safe boundaries in interpersonal interactions, or marshaling sufficient self-support in the context of harsh treatment by others. Some of these difficulties overlap with the adversity-based low self-esteem described in Chapter 2. However, the identity problems outlined in this chapter more reflect the fact that early, repeated experiences of danger (whether physical or psychological) can lead to other-directedness: the tendency to define oneself based on others’ judgments and responses (Briere, 2002b). In the absence of sufficient self-reference, for example, the client may come to assume that their value or validity is whatever others believe it to be. When faced with abuse, neglect, or early social maltreatment, they may have few options other than to believe that they are intrinsically bad, unacceptable, inadequate, or even hate-worthy, and that any boundaries against maltreatment and intrusion are determined by others, as opposed to themself.

As noted, such difficulties are typically thought to develop in the earlier years of life, when the parent–child attachment relationship is disrupted by caretaker aggression or neglect (Hesse et al., 2003). In addition to possible negative impacts on the developing child’s psychobiology (e.g., reducing the orbitofrontal cortex’s capacity to regulate cortical and autonomic processes associated with self-functioning [e.g., Siegel, 2012]), childhood abuse and neglect can interfere with the child’s development of a coherent sense of self (Penner et al., 2019).

Later adversities also can impact identity at this level by overriding what otherwise might be more benign self-perceptions—for example when older children are consistently criticized or devalued. Similarly, survivors of pervasive social maltreatment may be deprived of positive internal models and repetitively experience negative models of self, and thus come to view themselves as they are described or treated by hostile others, leading to, for example, internalized homophobia (Newcomb & Mustanski, 2010), transphobia (Nadal & Mendoza, 2014), racism (Jones, 2000), and sexism (Capodilupo et al., 2010).

Although the reasons for identity problems in survivors of childhood trauma are complex, probable etiologies include hypervigilance, early dissociation, and the absence of benign interactions with others. The hypervigilance needed by the endangered child to ensure survival means that much of their attention is directed outward, a process that detracts from internal self-awareness and understanding. In this context, when introspection (which is probably necessary for the development of self-awareness; Stern, 1985) occurs, it is punished, since (1) such inward focus takes attention away from the environment and, therefore, increases danger, and (2) greater internal awareness means—in the context of ongoing trauma—greater awareness of emotional pain.

The need to avoid ongoing adversity-related distress early in life also can support the development of dissociative defenses. As described in Chapter 2, dissociation generally reduces awareness of psychological pain, which is advantageous when one is being regularly hurt or neglected. Unfortunately, it also tends to block the survivor’s awareness of their internal state at the very time that a sense of self is thought to develop in children.

Finally, most theories of identity development stress the role of benign others in the child’s development of a viable internal model of self (Bowlby, 1988). One may have to interact with positive others in order to form a coherent and positive sense of oneself. This occurs when the loving and attuned parent or caretaker reflects back to the child what the child appears to be feeling or experiencing (e.g., smiling when the infant smiles, or appearing concerned when the infant cries), responds to the child’s needs in a way that reinforces the child’s legitimacy and safety, and treats the child in such a manner that they can infer positive self-characteristics (Cassidy & Shaver, 2016). As the child develops into an adolescent, and then an adult, the growing complexity of their interactions with the social environment ideally bestows a growing sense of self in the context of others. Unfortunately, this progression into increasingly coherent identity may be less possible for those who were deprived of positive parenting or living in disconfirming environments.

Intervention

Because much of self-development appears to involve interactions with caring others, the therapeutic relationship can be a powerful environment within which the client’s sense of identity may evolve. In this context, the clinician works to provide safety, support self-validity, and encourage self-exploration.

Provide safety . Introspection is, ultimately, a luxury that can only occur when the external environment does not require hypervigilance. For this reason, the clinical setting should promulgate those aspects of safety previously outlined in this book. Not only should the client feel physically safe from the therapist and (at least temporarily) from the world, they should experience psychological safety—the clinician should be psychologically noninvasive, careful to honor the client’s boundaries (regardless of whether the client is yet aware of them), reliable enough to communicate stability and security, and willing to explicitly condemn unjust treatment of the client by others. When these conditions are met, the client is more likely to trust the clinical environment enough to explore their thoughts, feelings, and experiences and, as noted later in this chapter, form a more positive attachment to the therapist. The process of actually discovering that one is safe in treatment, however, may be protracted. Many survivors of severe childhood or adult adversities may have to be in treatment for some time before they are able to accurately perceive the safety and nonjudgement inherent in the session. Even then, this sense of relative safety may wax and wane.

Support self-validity. Also helpful is the therapist’s visible acceptance of the client’s needs, perceptions, and intrinsic worthiness, and the therapist’s communication to the client regarding the client’s basic relational entitlements (Herman, 1992a). To some extent, this generalized acceptance might appear to contradict the need to challenge the client’s negative self-perceptions and other cognitive distortions. However, the approach advocated in this book is not to repeatedly argue with clients regarding their misperceptions about self, but rather to work with them in such a way that they are able to perceive incorrect self-assumptions and reconsider them in light of their current (therapy-based) relational experience. Although the therapist will not validate the client’s self-condemnation (e.g., the belief that one does not deserve respectful and caring treatment by others), they will provide a therapeutic experience that ideally contradicts such thoughts, including nonargumentative statements that validate and support, and that explicitly identify unfair treatment in the survivor’s life. This is, in some ways, a form of the disparity described in earlier chapters: Although the client may view themself as “bad” or not having rights to self-determination, these self-perceptions are contrary to the experience of acceptance and positive regard experienced in the session. Such cognitions, when not reinforced by the clinician, are likely to decrease over time. Equally important, as the message of self-as-valid is repeatedly communicated to the client by the therapist’s behavior, client notions of undeservingness and unacceptability are relationally contradicted.

This general focus on the client’s entitlements can help to reverse the other-directness the survivor learned in the context of abuse or neglect. In many instances of childhood abuse, attention is focused on the abuser’s needs, the possibility that they will be violent, and, ultimately, on the abuser’s view of reality. In such a context, the child’s needs or reality are irrelevant, if not dangerous, when asserted. In a client-focused environment, however, reality becomes more what the client needs or perceives than what others demand or expect. In such an environment, the client is more able to identify internal states, perceptions, and needs, and discover how to “hang on to” these aspects of self even when in the presence of meaningful others. By stressing to the client that their experience is the ultimate focus, and by helping them to identify and label their (intrinsically valid) feelings and entitlements, the therapist helps the client to build a coherent and positive model of self—much in the way early caretakers would have, had the client’s childhood been more safe, attuned, and supportive.

Encourage introspection and self-exploration. By facilitating self-exploration and self-reference, therapy can allow the survivor to gain a greater sense of their internal topography. Increased self-awareness may be fostered particularly when the client is repeatedly asked about their ongoing internal experience throughout the course of treatment. This may include multiple, gentle inquiries about the client’s early perceptions and experiences, their feelings and reactions during and after victimization experiences, how they interpret social micro- or macroaggressions directed against them, and what their thoughts and conclusions are regarding their interactions with the therapist.

Equally important is the need for the client to discover, quite literally, what they think and feel about current things, both adversity related and otherwise. Because the other-directedness necessary to survive victimization generally works against self-understanding, the survivor should be encouraged to explore their own likes and dislikes, views regarding self and others, entitlements and obligations, marginalization experiences, and related phenomena in the context of therapeutic support and acceptance. This broader, less specifically trauma-focused intervention is, to some extent, “identity development”: providing the survivor with the opportunity to discover what they think and feel, as distinct from what others (including the clinician) think and feel.

The therapist’s consistent and ongoing support for introspection, self-exploration, and self-identification, and unambiguous rejection of unjust social messages, allows the client to develop a more articulated and accessible internal sense of self that is less easily subverted by the views and actions of others. Ultimately, the therapist takes on the role of the supportive and engaged attachment figure whose primary interest—beyond symptom resolution—is nurturing the client’s internal life, self-acceptance, and self-determinism. This process, although less anchored in specific therapeutic techniques or protocols, can be one of the more important aspects of treatment.

RELATIONAL DISTURBANCE

The perspective offered in this book is that many of the relationship problems experienced by traumatized people arise from early learning about—and accommodation to—a harsh interpersonal world. Although such difficulties may occur as a result of chronic interpersonal traumas in adulthood (e.g., ongoing intimate partner violence, torture, microaggressions, or living in a chronically dangerous environment), they are seen far more often in the context of earlier childhood maltreatment. One of the earliest impacts of abuse and neglect is thought to be on the child’s internal representations of self and others based on how they are treated by their caretakers (Bowlby, 1988). In the case of abuse or neglect, these inferences are likely to be especially negative. For example, the child who is being maltreated may conclude that they must be intrinsically unacceptable or malignant to deserve such punishment or disregard, or may come to see themself as helpless, inadequate, or weak. As well, this negative context may mean that the abused or neglected child comes to view others as inherently dangerous, rejecting, or unavailable.

These early inferences about self and others often form a generalized set of expectations and assumptions, sometimes described as internal working models (Bowlby, 1982) or relational schemas (Baldwin et al., 1993). Such core understandings are often relatively nonresponsive to verbal information or the expressed views of others later in life, since they are encoded in the first years and thus are preverbal in nature. For example, the individual who believes, based on early learning, that they are unlikable or unattractive to others, or that others are not to be trusted, will not easily change such views based on other people’s declarations that the person is valued by them or that they can be relied upon.

As described in earlier chapters, such memory is often implicit, involving largely nonverbal, sensory, and experiential memories that cannot be recalled, per se, but can be triggered by reminiscent stimuli in the current environment. As a result, most people have amnesia for these early relational memories—although such memories can trigger cognitions and conditioned emotional responses, they cannot be consciously recalled as part of the past (Siegel, 2012).

The quality and valence of these core schemas are thought to affect the individual’s later capacity to form and maintain meaningful connections and attachments with other people (Bowlby, 1982). As a result, formerly abused or neglected individuals may find themselves in conflictual or chaotic relationships later in life, may have problems with forming intimate adult attachments, and may engage in behaviors that are likely to threaten or disrupt close relationships. These core schemas are often related to attachment styles (Platts et al., 2002). The reader is encouraged to read modern texts on attachment theory (e.g., Cassidy & Shaver, 2016) and at least one of Bowlby’s classic works (e.g., Bowlby, 1988), since the lessons learned by the child during early parent–child attachment are clearly relevant to dysfunctional interpersonal behavior in traumatized adolescents and adults.

Because relational schema—or internal working models—are typically encoded at the implicit, nonverbal level, and are primarily based in safety and attachment needs, they may not be evident except in situations where the survivor perceives interpersonal threats similar to the abuse, such as rejection, abandonment, criticism, or physical danger. When this occurs, these underlying cognitions may be triggered with resultant negative emotions and interpersonal difficulties (Simpson & Rholes, 2015). For example, an individual who experienced early separation or abandonment may relate relatively well in a given occupational or intimate context until they encounter stimuli that suggest (or are in some way reminiscent of) rejection, empathic disattunement, or abandonment. These perceived experiences, by virtue of their similarity to early trauma, may then trigger memories, emotions, and cognitions that, although excessive or out of proportion in the immediate context, are appropriate to the feelings and thoughts of an abused or neglected child. This activation may then motivate behavior that, although intended to ensure proximity and to maintain the relationship, is so characterized by archaic responses and demands, and so affectively laden that it challenges or even destroys that relationship.

The most dramatic example of chronic relational trauma activations may occur in what is referred to as borderline personality disorder. As noted in Chapter 2, individuals with so-called borderline personality features are often described as prone to (1) sudden emotional outbursts in response to minor or imagined interpersonal provocation; (2) self-defeating cognitions; (3) feelings of emptiness and intense dysphoria; and (4) “impulsive” distress-reducing behaviors that are triggered by perceptions of having been abandoned, rejected, or maltreated by another person (American Psychiatric Association, 2000, 2013). A fair portion of such behavior and symptomatology can be seen as arising from attachment disturbance, in combination with triggered maltreatment-related memories, generally in the context of reduced emotional regulation capacities (Godbout et al., 2018; Miljkovitch et al., 2018). People in this situation, upon having abuse memories triggered by stimuli in adult relational contexts, may then attempt to avoid the associated distress by engaging in activities such as substance abuse, inappropriate proximity seeking (e.g., neediness or attempts to forestall abandonment), or involvement in DRBs (Briere, 2019).

Intervention

The interventions for relational disturbance parallel, to some extent, those outlined in Chapter 9. In the relational context, however, the various components of trauma processing occur more directly as a function of the therapeutic relationship. Because most disturbed relatedness appears to arise from maltreatment early in life, and is often triggered by later interpersonal stimuli, it is not surprising that the most effective interventions for relational problems may be relational as well (Courtois & Ford, 2012). As stated by a trauma survivor in Kohlenberg and Tsai (1998), “If bad relationships messed me up, then it follows that I need good relationships to help me heal” (p. 305). Far from being the nonspecific placebo effect or inert ingredient suggested by some advocates of short-term therapy, the relationship between client and therapist can be seen as directly and specifically curative.

Among other things, the therapeutic relationship is a powerful source of interpersonal triggers. As the connection between client and therapist grows, the client’s increasing attachment to the therapist can trigger implicit memories of attachment experiences in childhood. For many clients, these early attachment memories include considerable abuse or neglect, which may be reexperienced in the form of maltreatment-related thoughts and feelings during therapy. Such “relational flashbacks” do not contain contextual information that they represent the past, and thus are often misperceived as being feelings related to the current therapist–client relationship (the source attribution errors described earlier). Once activated and expressed, such cognitions and emotions can be discussed and processed in the context of the safety, support, and compassion associated with a positive therapeutic relationship.

As in work with more “simple” or explicit traumatic memories, the therapeutic processing of relational memories and their associations can be seen as involving the exposure, activation, disparity, and counterconditioning described in the previous chapter.

Exposure: In the session, the client reexperiences implicit memories of earlier interpersonal traumas in response to therapeutic stimuli that are in some way similar to those early experiences.

Therapy stimuli that can trigger exposure to relational memories, by virtue of their similarity to the original trauma, include the clinician’s physical appearance, their age, sex, or race, and the power differential between client and therapist, including client feelings of vulnerability. Even positive feelings associated with the therapeutic relationship can trigger distress—the client’s loving feelings toward the therapist, or perception of similar feelings from the clinician, can activate sexual feelings or fears, and perceptions of therapist caring and acceptance can trigger fears of losing such experiences, that is, of being abandoned by an attachment figure. As well, therapists are inevitably prey to the vagaries of normal human experience, including momentary lapses in empathic attunement, distraction by personal problems, fatigue, or, as described in Chapter 4, the triggering of their own issues by some aspect of the client’s presentation—any of which may inadvertently expose the client to memories of earlier maltreatment or neglect.

Beyond these discrete triggers, the therapeutic relationship itself—by virtue of its ongoing nature and importance to the client—may replicate stimulus conditions similar to those of early important relationships, including the client’s childhood need for attachment. To the extent that the earlier relationship was characterized by trauma, the current therapeutic relationship is likely to trigger negative relational memories.

Just as noted in previous chapters for simpler trauma processing, exposure must occur within the context of the therapeutic window. In this regard, the clinician may have to work actively to ensure that their stimulus value or the characteristics of the therapeutic relationship do not produce so much inadvertent exposure to negative relational memories that the client becomes overwhelmed. Just as the therapist treating posttraumatic stress may titrate the amount of exposure the client undergoes regarding a traumatic memory, the clinician treating relational traumas ideally seeks to ensure that reminiscent aspects of the therapeutic environment are not overwhelming.

For example, as noted in Chapter 4, clients with easily accessible schemas arising from punitive parenting may require treatment that especially avoids any sense of therapist judgment. Similarly, the client who has been physically or sexually assaulted may require (1) special, visible attention to safety issues, (2) therapist responses that stress boundary awareness and respect, or even (3) a greater-than-normal physical distance between the client’s chair and that of the therapist’s. A client with abandonment issues arising from early psychological neglect, on the other hand, may be more comfortable when the clinician is especially attuned and psychologically available to the client. On a more general level, therapists of chronically traumatized clients may need to devote even greater attention than usual to avoiding behaviors that in some way appear to involve intrusion, control, or narcissism.

Unfortunately, some characteristics of the therapist may be such powerful triggers that useful therapy is not always possible. Probably the best example of this is therapist gender. For example, a person who has been recently sexually assaulted by a man or men may have considerable difficulty working in therapy with a clinician identifying as male. Regardless of the therapist’s personal qualities and best intentions, his masculine stimulus value may trigger overwhelming exposure to trauma memories of assault by a male, thereby exceeding the therapeutic window and negating the possibility of meaningful intervention (Briere, 1996). In such cases, the best solution may be to refer the client to a therapist who does not present as male. Similar scenarios may occur when the therapist’s ethnic or racial identity is the same as the client’s perpetrator, or where the therapy location (e.g., a hospital) overwhelmingly triggers trauma memories in the client (e.g., of being tortured in a similar facility in their country of origin). More generally, to the extent that the therapist shares characteristics with those of the dominant culture, people who have been injured by that same culture may be broadly triggered.

Fortunately, in many cases triggering aspects of the therapist or the therapeutic relationship can be negotiated to the extent that referral is not necessary. This may involve extended discussion (and clinician nondefensiveness) around the implications of the therapist’s gender, age, race, sexual orientation, cultural history, and social position/privilege, so that the client’s concerns and responses can be taken seriously, and the therapist can examine and hopefully reduce triggering qualities of their social stimulus value.

Activation: As a result of therapeutic exposure, the client experiences emotions and thoughts that occurred at the time of the relational trauma(s).

Activated emotional responses to early relational memories are often notable for the suddenness of their emergence, their intensity, and their seeming contextual inappropriateness. Intrusive negative cognitions about self or the therapist may be activated, or attachment-related schema involving submission, childlike perceptions, or dependency may suddenly appear. In some cases, this activation may also trigger sensory flashbacks and dissociative responses.

Such cognitive-emotional activation can be easily understood by both client and therapist when it occurs in the context of explicit trauma memories, such as those of an assault or disaster. When activation occurs in the context of triggered relational stimuli, however, the actual “reason” behind the client’s thoughts and feelings may be far less clear. Because the original trauma memories may have been formed in the first years of life, and therefore are not available to conscious awareness, neither client not therapist may know exactly why the client is feeling especially anxious or angry, or why they are suddenly so distrustful of the clinician. In fact, in instances where such activations are dramatic, they may appear so irrational and contextually inappropriate that they are seen as evidence of significant psychopathology, perhaps even psychosis. Ultimately, however, these activations are logical, in the sense that they represent conditioned cognitive-emotional responses to triggered relational memories.

Relational activation is especially relevant to longer-term, more intensive psychotherapy, wherein the triggering of client attachment responses (both positive and negative) is more likely. An example of the activation of relational trauma memories and associated negative schema is presented in Briere (2002):

In this example, the seemingly benign relationship between client and clinician contains stimuli (e.g., the growing feeling of emotional intimacy as treatment progresses) that trigger childhood abuse memories and activate trauma-specific responses. In agreement with many psychodynamic theorists, we suggest that activation of relational memories and feelings (often referred to as transference) should be expected when treating those with childhood (and extended adult) traumas and is, in fact, often necessary for the successful resolution of chronic interpersonal problems. Absent such relational activation, therapy might be easier to conduct but would be unlikely to activate the very material that has to be processed before the client’s relational life can significantly improve.

Disparity: Although the client thinks and feels as if maltreatment or abandonment is either happening or is about to happen, in reality the session is safe and the therapist is not abusive, rejecting, or otherwise dangerous.

Although this component is often critical to trauma processing, those who have been victimized interpersonally—especially if that victimization was chronic—may find disparity difficult to fully accept at first, let alone trust. There are a number of reasons for this.

First, those exposed to chronic danger often come to assume that such danger is inevitable. The combat veteran, prostituted person, or survivor of systemic racism, for example, may find it difficult to accept that the rules have suddenly changed and that they are safe. This is especially true in situations that bear some similarity to the original (dangerous) context, such as in a relationship with a powerful other, especially if that other shares certain characteristics (e.g., gender, social status, or a similar interactive style) with previous perpetrators.

Second, in many cases, the original perpetrator(s) of violence promised safety, trustworthiness, caring, and support as a way to gain access to the victim (Winters et al., 2020). As a result, reassurance or declarations of safety may seem like just more of the same, if not a warning of impending danger.

Finally, therapy implicitly requires some level of intimacy, or at least vulnerability from the client; a requirement that—from the survivor’s perspective—can be a recapitulation of past experience of intimacy demands and subsequent injuries.

For these and related reasons, not only must disparity/safety be present, but the client must be able to perceive it. This sometimes means that considerable time in therapy is necessary before sufficient trust is present to allow extensive relational processing. For example, the survivor of chronic child abuse, torture, warfare, or gang violence may require months of therapy before letting down their guard enough to fully participate in trauma therapy. Similarly, the therapist should be prepared in such cases for client disbelief or immediate rejection of statements like “You are safe here.” or “I won’t go away.” This does not mean that the clinician shouldn’t make such statements when they are accurate, expressed in a nonintrusive, nondemanding way, but rather should understand that such declarations, alone, rarely alter cognitions that have been repeatedly reinforced by prior adversity.

Especially for those hypervigilant to danger in interpersonal situations, disparity cannot just be verbally communicated; it also must be repeatedly demonstrated. As noted earlier, therapist statements that they should be trusted can actually have the opposite effect on traumatized clients—because they have heard similar promises or protestations from ill-meaning or chaotically conflicted people in the past, such statements may make them feel less safe, not more. Instead, when working with chronic relational trauma survivors, the therapist typically must behave in a reliably safe and nonexploitive way over time, until the client can truly extrapolate safety into the future and imagine disparity.

The exposure/activation/disparity process may proceed in a stepwise fashion for the relational trauma survivor: early in therapy, they may occasionally (and often inadvertently) reveal some small degree of vulnerability or suffering to the therapist, and then reflexively expect a negative consequence. When this vulnerability is not, in fact, punished by the therapist and (as noted in the next section) is met with support and visible caring, the client may slowly lower their psychological barriers (including their avoidance strategies) and express more thoughts or feelings. As these responses are likewise supported, and not exploited or punished, the client’s willingness to process pain in “real time” (that is, directly, in the presence of the therapist) generally increases. It should be stressed that this may take time, and therapist expressions of impatience may subvert the process by communicating criticism, rejection, or even narcissism.

In other cases—for example, when the client has experienced less extreme or less chronic relational trauma, when the conditions surrounding the victimization are clearly quite different (and perceivable as such by the client) than the current ones in therapy, or when there were supportive people in the client’s environment in addition to the perpetrator(s)—disparity may be considerably easier to establish, and trauma processing may be more immediately possible. In any case, however, this is an assessment issue, as opposed to something that can be automatically assumed.

Counterconditioning : Not only is the client able to perceive safety in the therapy session, but they also experience positive, fear-diminishing emotional states in the context of the therapeutic relationship.

When counterconditioning was described in Chapter 9, the healing aspect of this phenomenon was described as the simultaneous presence of both (1) the activated distress associated with traumatic memory exposure and (2) the positive feelings engendered by a supportive, caring therapy environment. When major relational trauma is being processed, counterconditioning is potentially even more important. In this regard, activated negative relational cognitions (e.g., “She doesn’t like me.” “He will hurt/abandon me.” or “I’ll be taken advantage of if I become vulnerable.”) and feelings (e.g., fear of authority figures or intimacy) are directly—and, therefore, potentially more efficiently—contradicted by positive relational experiences in therapy. In other words, there may be something especially helpful about experiencing nonoverwhelming fears and expectations of maltreatment in the specific context of nurturance and acceptance. In the language of earlier psychodynamic theory, such real-time contradiction of activated schemas and feelings may provide a corrective emotional experience (Alexander et al., 1946).

There is also a potential downside to the juxtaposition of negative expectations and positive experiences in therapy, however. Just as positive experiences in therapy may contradict earlier held beliefs about close relationships, it is also true that activated, negative relational cognitions can at least temporarily prevent the client from identifying and accessing the positive relational phenomena that occur in therapy. Fortunately, this is rarely an all-or-none experience; in most cases, even distrustful or hypervigilant clients will slowly come to reevaluate negative relational cognitions when therapist support and validation are visibly and reliably present. As is the case for client difficulties in perceiving therapeutic safety, the incremental process of “letting in” therapeutic caring and positive regard (and, thereby, positive attachment experiences) may require considerable time in treatment.

As noted earlier, clients involved in longer-term psychotherapy may experience an even more powerful form of counterconditioning than therapist support and caring. This is often described as a sense of deeper warmth and connectedness between client and therapist: an affective state that seems to be especially supportive of trauma processing. Although this phenomenon is difficult to quantify or identify empirically, it is likely that such responses represent the activation of relatively inborn, attachment-level neurobiology.

Beginning relatively soon after the birth of a child—in the absence of intervening problems—both parent and infant typically experience very positive emotions toward one another. As noted earlier, these feelings and their associated cognitions likely constitute an evolutionarily derived survival function (Bowlby, 1982). Not only does the child seek proximity to the parent in order to avoid the pain of separation, but also to experience biologically based positive feelings associated with activated attachment neurochemistry (Szymanska et al., 2017). Similarly, the parent maintains attachment to the child because, among other reasons, separation from the child hurts, whereas proximity to the child produces positive feelings. This mutual desire for parent–child proximity maximizes the likelihood that the child will be fed and protected, thereby supporting the ongoing survival of the species (Bowlby, 1982).

Research indicates that positive attachment experiences tend to specifically activate oxytocin and dopamine reward systems (Schneiderman et al., 2012; Strathearn, 2011). It is likely that these physiologic systems of reward for intimacy and connectedness are available to humans throughout their lives and can be triggered in contexts where there is sustained proximity to a caring and nurturing person (Buchheim et al., 2009; Carter, 2017). When activated in parent-child dyads, major friendship, or sexual relationships, this phenomenon is usually referred to as love. A similar feeling may be present when such activation occurs in nurturing, longer-term psychotherapy—something that psychoanalysts consider a form of transference and that we will describe as, for lack of a better phrase, attachment activation.

To the extent that attachment activation occurs during the process of ongoing psychotherapy, several outcomes are likely. First, the positive and sustained feelings engendered by triggered inborn attachment responses are likely to be especially effective in counterconditioning negative thoughts and feelings associated with previous traumatic experiences. Second, attachment activation may trigger other childhood-specific thoughts, feelings, and behaviors in the client—responses that must be monitored carefully for their impacts on treatment. For example, the client may become more dependent and childlike as the therapeutic relationship continues and deepens. They may begin to request more contact with the therapist, make more phone calls to them, and in other ways seek greater proximity. Third, those clients whose early attachment experiences were especially insecure or otherwise problematic may find that the therapeutic relationship becomes a powerful trigger for reliving of these early relational traumas.

In some cases, this type of transformation may appear problematic, as the client “regresses” to a seemingly more basic level of relational functioning with the therapist. However, it is important that the therapist understand this as attachment-level reliving, in the same way as emotionally processing an assault in the session is reliving. As described earlier, the goal is to work within the therapeutic window—providing sufficient relational contact, support, and positive regard that the client has the opportunity to reexperience implicit childhood memories in the context of a distress-diminishing, nurturing state. At the same time, however, the clinician must not provide so much quasi-parental support that early trauma-related distress is too strongly activated, or the client’s dependency needs are reinforced in a way that is detrimental to growth. The latter is probably best prevented by the therapist’s continuous examination of their own needs to protect and/or rescue the client. In addition, obviously, the possible emergence of attachment-level feelings in the therapist requires special vigilance to the possibility of inappropriate sexualization or romanticization of the client or use of the client to meet the therapist’s unmet attachment (including parenting) needs. Any such countertransference (referred to here as counteractivation), if acted upon, both reduces disparity (i.e., eliminates safety) and reinforces or augments trauma-related memories and associated emotions and cognitions.

Extinction/inhibition: The client’s repeated exposure to relational trauma memories, triggered by their relationship with the therapist, in combination with the reliable nonreinforcement and counterconditioning of their negative expectation and feelings by the therapeutic relationship, leads to a contradiction of earlier learned connections between relatedness and danger.

As described in Chapter 9, the process of exposure, activation, disparity, and counterconditioning, when repeated sufficiently in the context of the therapeutic window, can lead to the processing and inhibition of trauma memories. This probably involves a series of processes, including the following:

Some degree of inhibition of nonreinforced emotional responses, via disparity

Counterconditioning, wherein triggered trauma/attachment-related responses occur in the presence of positive, distress-reducing states (e.g., those associated with support and caring)

The creation of new learning that contradicts and inhibits previously learned assumptions and associations

Reduction in the capacity of relational stimuli to trigger trauma memories

Briere,Regarding the last point, positive therapeutic experiences may change the tendency for relationships or interpersonal intimacy to automatically trigger early abuse memories, since relationship, per se, is no longer perceived as necessarily dangerous and therefore is less reminiscent of childhood abuse or neglect.

However this occurs, the overall effect of the progressive activation and processing of implicit relational memories and their cognitive and emotional associations, in the context of therapeutic acceptance and support, is to change the client’s reaction to their interpersonal world. Successful therapy, in this regard, means that the client is more able to enter into and sustain positive interpersonal relationships, because connection with others no longer triggers the same levels of fear, anger, distrust, and negative or avoidant behaviors. As a result, the client’s interpersonal life can become more fulfilling and less chaotic—a source of support rather than of continuing suffering.