The adolescent may be asked to repeat this writing exercise on several different occasions over the course of treatment, either completing the exercise for a different trauma on each occasion, or repeating the exercise on multiple occasions for the same trauma. The specific timing and frequency of these writing and reading exercises may vary according to (a) the adolescent’s capacity for written expression, (b) his or her readiness to directly confront the trauma, and (c) his or her immediate emotional stability and affect 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 a potentially difficult task. He or she should also be prepared to provide grounding or other stabilization techniques in the event that this exercise (especially reading the homework out loud) produces significant emotional distress.

Obviously, this approach is not possible for those unable to read and write, for non-English speakers, or for who are too cognitively debilitated (e.g., by psychosis, severe depression, or hyperarousal). 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. It should be reiterated, however, that “homework” involving exposure to trauma memories (and thus the associated feelings and thoughts) is only indicated for those adolescents who are unlikely to be overwhelmed by such activities. In many cases, it is probably best to discuss this activity to the client, and to get his or her opinion about whether it would be possible and useful, rather than just prescribing it. As with any other exposure intervention, the client has the absolute right to refuse to engage in exposure homework.

On occasion, the clinician may choose to augment (or even replace) the “homework about my trauma” with other exercises, such as writing (but typically not sending) a letter to the perpetrator or others involved in the trauma, or writing about trauma-related thoughts and feelings in a journal, and then reading this material to the clinician in the following session. Typically, the more opportunities the client has to put his or her experiences into written form, the more chances he or she has to recall (and thus expose himself or herself to) the painful past in a safe, more structured and constrained way.

Activation

If treatment is to be effective, some degree of activation must take place during exposure. Activation refers to emotional responses that are triggered by trauma memories, such as fear, sadness, or horror, and trauma-specific cognitive reactions, such as intrusive negative self-perceptions or sudden feelings of helplessness. Other related memories and their associated affects and cognitions may be triggered as well. A young woman who is asked to describe a childhood sexual abuse experience, for example, undergoes therapeutic exposure to the extent that she recalls and describes aspects of that event during the therapy session. If these memories trigger emotional responses conditioned to the original abuse stimuli (e.g., fear or disgust), or associated cognitive intrusions (e.g., “I am so gross”), or stimulate further memories (e.g., of other traumas, or other aspects of the abuse triggered by remembering certain aspects of it), therapeutic activation can be said to have taken place.

Activation is usually critical to trauma processing – in order to extinguish emotional-cognitive associations to a given traumatic memory, they must be (a) activated, (b) not reinforced, and, ideally, (c) counterconditioned. As a result, therapeutic interventions that consist solely of the narration of trauma-related memories without emotional activation will often fail to produce symptom relief. In order for optimal activation to occur, there should be as little avoidance as is reasonably possible during the exposure process. On the other hand, as noted throughout this guide, too much activation is also problematic because it generates high levels of distress (thereby linking memory to current emotional pain, rather than to safety or positive feelings) and motivates avoidance (thereby reducing further exposure and processing).

Because activated cognitive-emotional responses are, to some extent, the crux of trauma work, the following sections describe 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. It is important to note that the interventions described hereafter relate to verbal – as opposed to written – therapeutic exposure. Although activation upon reading previously written trauma narratives is possible, it is typically less overwhelming, and somewhat more difficult for the therapist to modulate during the session.

Increasing activation

The therapist typically seeks to increase activation in instances when, despite available affect regulation capacity, the client appears to be unnecessarily blocking some portion of his or her emotional responses to the traumatic material. It is common for avoidance responses to become so overlearned that they automatically, but unnecessarily, emerge during exposure to stressful material. In other instances, gender roles or socialization may discourage emotional expression in an individual who could otherwise tolerate it. 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.

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

• “What were you feeling/how did it feel/ when that happened?”
• “What are you feeling now?”
• “Are you having 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 his or her level of contact during the process of activation. This is often most effective when the client’s avoidance, or the power of the triggered emotions 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,”
• “Don’t go away now. You’re doing great. Stay with it.”
• “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, 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 little bit, right now. Are you?”

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

A third way that the clinician can increase activation is by increasing the intensity of the emotional experience. Often, this involves requesting more details about the traumatic event, and responding in ways that focus the youth 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

If the therapist inadvertently triggers too much activation, or is unsuccessful in keeping the client’s emotional activation to a tolerable level, the therapeutic window will be exceeded. This can be problematic because, as noted earlier, clients with reduced affect regulation capacities typically should not be exposed to especially upsetting memories until their ability to regulate negative emotions improves. In general, when material exceeds the therapeutic window, the appropriate response is to either redirect the client to a less upsetting topic, or, more subtly, directing the conversation to less emotionally charged, typically more cognitive, aspects of the trauma. Once the client’s emotionality has returned to baseline, careful exposure activities may be resumed, if appropriate.

Occasionally, overactivation (overshooting the window) may produce responses that are not sufficiently addressed by changing the focus or intensity of the therapeutic conversation. For example, the youth may experience a transient dissociative response, engage in an angry emotional outburst, or begin to cry in a withdrawn manner. When such responses are extreme, the therapist should generally stop exposure-activation and focus stabilizing interventions (e.g., breathing exercises, grounding, placing the process in perspective) in order to reduce the impacts of whatever is engendering the response. In fact, if overshooting appears to be relatively common with a given client – despite the clinician’s ongoing attempt to titrate emotional exposure – it may be appropriate to focus on affect regulation development and/or cognitive processing for a number of sessions, returning to emotional processing when the client’s capacity to tolerate the distress associated with exposure-based procedures has notably increased.

Therapist activities that decrease activation might appear to deprive the client of the opportunity to address the emotional sequels of major trauma. Such restraint, however, is one of the responsibilities of the therapist. If the clinician suspects – based on observation of the client – that activation is likely to exceed the therapeutic window in any given circumstance, it is important that he or she ensure safety by reducing the intensity and pace of the therapeutic process. This does not mean that the clinician necessarily avoids trauma processing altogether; only that the work should proceed slowly and carefully, or be temporarily delayed. Fortunately, the need for such a conservative approach is usually transient. As the traumatic material is slowly and carefully processed, progressively fewer trauma memories will have the potential to activate overwhelming affect, and, as described in Chapter 7, the client’s overall capacity to tolerate distress will grow. And, as a side effect, the client-therapist attunement and communication often associated with this process tend to reinforce the therapeutic relationship, thereby providing further stabilization.

Disparity

Exposure and activation are typically not, in and of themselves, sufficient in trauma treatment. There also must be some disparity between what the client is feeling (e.g., activated fear associated with a trauma memory) and what the current state of reality actually is (e.g., the visible absence of immediate danger). For conditioned emotional responses to traumatic memories to be diminished or extinguished over time, they must consistently not be reinforced by similar danger (physical or emotional) in the current environment.

As described earlier, safety should be manifest in at least two ways. First, the adolescent should have the opportunity to realize that he or she is safe in the presence of the therapist. This means safety not only from physical injury and sexual exploitation, but also from harsh criticism, punitive responses, boundary violations, or under-appreciation of the client’s experience. Because the client may tend to over-identify 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 not be reinforced by current danger or maltreatment in the session, however subtle.

Second, safety in treatment includes protection from overwhelming internal experience. The client whose trauma memories produce destabilizing emotions during treatment may not find therapy to be substantially different from the original experience. As noted earlier, overwhelming emotion may occur because one or both of two things are present. First, the memory is so traumatic and has so much painful affect (e.g., anxiety, rage) or cognitions (e.g., guilt or shame) associated with it that unmodulated exposure produces considerable psychic pain, or second, the survivor’s affect 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 is not associated with overwhelming negative affect, identity fragmentation, or feelings of loss of control.

It should be noted that it is not enough that disparity be present in the session; it also must be perceived as such. Thus, for example, although the 15-year-old incest survivor may be safe from abuse or exploitation during the psychotherapy session, he or she may not easily perceive that to be true. Instead, the hypervigilance associated with posttraumatic stress, or characteristics of the clinician that are similar to those of the abuser (e.g., gender, age, race, appearance) may cause the client to believe that he or she is in danger. In many cases, it is only after repeated experiences of safety in such contexts that the client will come to reevaluate his or her impressions and truly note disparity. Because highly traumatized youth may reflexively view interpersonal situations as dangerous, and may have a myriad of potential triggers that can produce fear, it may take considerable time in therapy before the curative aspects of disparity are able to unfold. As a result, the multi-traumatized “street kid,” the survivor of severe and chronic child abuse, or the refugee child previously sold into the sex trade may require consistent, reliable treatment that far exceeds the parameters of classic short-term trauma therapy.

Counterconditioning

Not only is it important that there be a visible absence of danger during trauma processing, in the best circumstances there also should be positive phenomena present during therapy that are relatively antithetical to the experience of physical or psychological danger. Thus, for example, a teenager in therapy for problems related to ongoing domestic violence may expect her therapist to be critical or rejecting. When her fears are met not only with the absence of those things in treatment (i.e., the disparity associated with therapeutic safety), but occur, in fact, in the presence of acceptance, validation, and nurturing, the activated distress may diminish in intensity because it is incompatible with the positive feelings that arise in therapy. As a result, the emotional associations to memories of being battered are not reinforced, but instead are weakened by contradictory, positive feeling states that are present as the memories are evoked.

It is in this domain that a caring therapeutic relationship is most important. The more positive and supportive the relationship, the greater the amount of positive emotionality available to counter-condition previous negative emotional responses. For example, as the chronically unloved adolescent survivor interacts with a reliably caring therapist, the negative associations to relatedness, intimacy, interpersonal vulnerability, and attachment figures are repeatedly elicited and then, in a sense, contradicted by the ongoing experience of affection and protection within the therapeutic process. In this regard, it is often not enough that the therapist does not hurt or exploit; it is also important that attunement and caring be present. Such clinician responses must, of course, be carefully monitored and constrained so that they do not involve any level of intrusion, boundary violation, or self-gratification – any of which may convert counterconditioning into an absence of disparity.

A second form of counterconditioning may be the experience of safe emotional release. Crying or other forms of emotional expression in response to upsetting events typically produces relatively positive emotional states (e.g., relief) that can counter-condition the fear and related affects initially associated with the traumatic memory. In other words, the common suggestion that someone “have a good cry” or “get it off of your chest” may reflect cultural support for emotional activities that naturally counter-condition trauma-related emotional responses (Briere, 2002). From this perspective, just as traditional systematic desensitization often pairs a formerly distressing stimulus to a relaxed, anxiety-incompatible state in an attempt to neutralize the anxious response over time, repeated safe and validated emotional release during exposure to painful memories may pair the traumatic stimuli to the relatively positive internal states associated with emotional expression in a protected environment. For this reason, optimal trauma therapy typically provides gentle support for – and reinforcement of – expressed emotionality during exposure activities. The level of emotional expression in such circumstances will vary from person to person, partially as a function of the client’s affect regulation capacity, personal history, and socialization. The therapist should not “push” for emotional expression when the client is unable or unwilling to engage in such activity, but should support it when it occurs.

Desensitization/resolution

Together, the process of remembering painful (but not overwhelming) events in the context of safety, positive relatedness, emotional expression, opportunities for introspection, and minimal avoidance can serve to break the connection between traumatic memories and associated negative emotional and cognitive responses. As this occurs, environmental and internal events that trigger memories of traumatic experiences will no longer produce the same level of negative response. Once processed, traumatic memories become, simply, memories. Their ability to produce great distress is significantly diminished. In the case of the multiply trauma-exposed person, however, the process usually does not end with the resolution of a given memory or set of memories. Instead, other memories, often those that are associated with even greater distress, tend to become more available for discussion – at which point the process may begin anew.