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of Traumatic Events
Whether denial or dissociation, avoidance of abuse-related material by the survivor should be respected because it indicates his or her judgment that exploration in that area would exceed the therapeutic window. The role of the therapist at such junctures is not to overpower the client's defenses or in any way to convince him or her that abuse occurred, but rather to provide the conditions (e.g., safety, support, and a trustworthy environment) whereby avoidance is less necessary. Because this latter step can require significant time and skill, the specific enumeration and description of abusive events is far from a simple matter (Courtois, 1995).
Exposure to Abuse-Related Material
The exposure approach suggested here for abuse trauma is a form of systematic desensitization (Wolpe, 1958), wherein the survivor is asked to recall non-overwhelming, but painful abuse-specific experiences in the context of a safe therapeutic environment and the positive effects of emotional discharge. The exposure is sequenced according to the intensity of the recalled abuse, with less upsetting memories being recalled and addressed in therapy before more upsetting ones are considered. The use of exposure or desensitization procedures appears to be effective in the treatment of various types of trauma survivors, including rape victims (Foa, Rothbaum, Riggs, & Murdock, 1991; Frank & Stewart, 1983) and war veterans (Bowen & Lambert, 1986; Keane, Fairbank, Caddell, & Zimering, 1989).
In contrast to more strictly behavioral interventions, however, abused-focused psychotherapy does not adhere to a strict, preplanned series of exposure activities. This is due, in part, to the fact that most survivors in therapy present with a complex history of multiple and chronic abusive and neglectful acts that occurred many years ago as opposed to a single instance of rape or other assault during adulthood. Further, the survivor's ability to tolerate exposure may vary considerably from session to session as a function of his or her level of self-capacities, extent of outside life stressors, level of support from friends, relatives, and others, and the "place" in the therapeutic window that the therapy occupies at any given moment. In addition, the immediate target for desensitization may not be a discrete memory, but rather the more elusive and complex phenomenon of transferentially evoked abuse-relevant thoughts and feelings. In fact, as noted in chapter 4, transference is a frequent and powerful form of abuse re-experiencing, and thus is a potent source of nonspecific but important material that can be desensitized during treatment.
Regarding the last point, the client may be sufficiently stressed by previous therapeutic events or transferential aspects of the therapeutic relationship (e.g., the re-stimulated attachment dynamics described in chapter 5) that his or her ability to handle any further stressful material is limited. Further processing of abuse memories or responses at such times usually leads to avoidance, or even to some level of fragmentation. As a result, the focus of therapy becomes consolidation, arousal reduction (e.g., via grounding), and the shoring up of self-resources as indicated in the earlier "process" section of this chapter. In addition, if exploration of abuse-related issues has led to enduring feelings of revulsion, self-hatred, or helplessness, the client may require interventions that interrupt or contradict cognitive distortions before he or she can move on to more exposure.
As noted by McCann and Peariman (1990), exposure to abuse memories is complicated by the fact that there are probably at least two different memory systems to address: verbal and imagery (although we later refer to the latter as "sensorimotor"). The former is more narrative and autobiographical, whereas the latter involves the encoding and recovery of sensations and nonverbal experiences. McCann and Peariman (1990) note that material from both systems must be desensitized-the first by repeatedly exploring the factual aspects of the event (e.g., who, what, where, and when), and the second by recollection and recounting of the physical environment and bodily sensations associated with the abuse. In my experience, processing of verbal memories is considerably less overwhelming for most survivors than exploration of sensory memories; therefore, the former should usually be addressed around any given memory before the latter is elicited.
The need to process sensory material may be especially relevant because, as indicated by van der Kolk (1994) and others, it is likely that some components of posttraumatic memory are intrinsically sensory or sensorimotor. As a result, therapeutic work that focuses solely on the narrative level (i.e., as is seen in some intellectualized therapies) is unlikely to allow processing of all available posttraumatic material. In contradistinction, good trauma work is both cognitive and affective-addressing not only distorted cognitions and the acquisition of insight, but also the need for emotional expression, processing, and desensitization.
As indicated earlier, for abuse-focused therapy to work well, there should be as little avoidance as possible during the session. Specifically, the client should be encouraged to stay as "present" as he or she can during the detailed recall of abuse memories, so that desensitization is maximized. The extremely dissociated survivor may have little true exposure to abuse material during treatment- despite what may be detailed verbal renditions of a given memory. The therapist must keep the therapeutic window in mind, and not, however, interrupt survivor dissociation that is, in fact, appropriate in the face of therapeutic over-stimulation. This might occur, for example, when the client accesses memories whose affective characteristics exceed his or her self-resources. Conversely, it is not uncommon for dissociative responses to become so over-learned that they automatically (but unnecessarily) emerge during exploration of stressful material. In this case, some level of encouragement of the client to reduce his or her dissociation during treatment is not only safe but frequently imperative for significant desensitization to occur.
Effective abuse-related therapy capitalizes on the positive effects of emotional release. In this regard, crying and other forms of emotional discharge may operate as inborn healing/counterconditioning responses. Specifically, emotional release (e.g., crying, raging, and screaming) may countercondition (neutralize) the pain initially associated with the trauma by pairing the memory with emotional relief, thereby inhibiting its linkage with distress. In other words, the common suggestion that someone "have a good cry" or "get it off of your chest" may reflect folk-wisdom support for ventilation and other emotional activities that naturally desensitize trauma. From this perspective, just as traditional systematic desensitization pairs a formerly distressing stimulus to a relaxed (anxiety-incompatible) state, and thereby neutralizes the original anxious response over time, repeated emotional discharge during nondissociated exposure to painful memories allows the processing of traumatic stimuli in the context of the relatively positive internal states associated with emotional release. Thus, a "good cry" is good because, in the absence of significant dissociation, it tends to allow counter-conditioning of traumatic material.
Although appropriate emotional expression may facilitate the desensitization of abuse-related trauma, such activity is not equivalent to the recently rediscovered notion of "abreaction" of chronic abuse trauma. These more dramatic procedures often involve pressure on the client to engage in extreme emotional discharge, sometimes in response to previously unavailable material, often in the context of an hypnotic state. Unfortunately, such techniques run the risk of greatly exceeding the therapeutic window, with resultant flooding of painful affects. In addition, by their very nature, such interventions encourage dissociated emotional release-a phenomenon that, although easily accomplished by many survivors, is unlikely to be therapeutically helpful. As noted by Cornell and Olio (1991), "~abreactive] techniques may appear to deepen affect and produce dramatic results in the session, but they may not result in the client's sustained understanding of, or connection to, their experience of abuse" (p. 62).
The non-dissociated emotional
processing of abuse-related traumatic response can, therefore, be seen as a natural-albeit
sometimes painful-way to metabolize posttraumatic stress psychologically. The
survivor who remembers her abuse (both narratively and through intrusive sensory
reexperiencing), who cries or rages about it, and who repetitively talks and ruminates
about it is engaging in a natural healing response. For many survivors, this process
may best occur during therapy, where the clinician can provide a safe and organized
structure for the unfolding of each component and can be counted on to keep the
processing well within the therapeutic window. As noted earlier, the survivor's
existing self-resources will determine how much exposure and processing can occur
without overwhelming her and stimulating avoidance responses.
Reflection Exercise #5