In addition to the cognitive interventions described in the last chapter, most trauma treatments include some form of therapeutic exposure.
Therapeutic exposure refers to a procedure wherein the client is exposed, during therapy, to memories of a traumatic event, and then the emotional responses that emerge are desensitized or habituated over time until they no longer can be activated by the memory. A specific type of therapeutic exposure, titrated exposure, can be defined as therapeutic exposure that is controlled so that the activated emotions do not exceed the client’s affect regulation capacity, and thus do not overwhelm the trauma survivor . In this context, the Self-Trauma Model refers to the therapeutic window and intensity control, both of which are described below.
The Therapeutic Window
The therapeutic window represents the psychological midpoint between inadequate and overwhelming activation of trauma-related emotion during treatment. It is a hypothetical “place” where therapeutic interventions are thought to be most helpful (Briere & Scott, 2012). Interventions within the therapeutic window are not so trivial or nonevocative that they provide inadequate memory exposure and processing, or so intense that they become overwhelming. In other words, interventions that consider the therapeutic window are those that trigger trauma memories (i.e., through therapeutic exposure) and promote processing, but do not overwhelm internal protective systems and motivate unwanted avoidance responses. Because many traumatized adolescents with complex posttraumatic outcomes have affect regulation problems, the therapeutic window is an important aspect of ITCT-A.
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 waste time and resources, however, when more effective therapeutic interventions would be possible. Overshooting the window, on the other hand, occurs when the clinician either (1) inadvertently provides too much therapeutic exposure and, therefore, too much emotional activation relative to the client’s existing affect regulation resources, or (2) is unable to prevent the client from flooding himself or herself with overwhelming traumatic distress. Interventions that are paced too quickly may overshoot the window because they do not allow the adolescent to adequately accommodate and desensitize previously activated material before triggering new memories. When therapy consistently overshoots the window, the survivor must engage in avoidance maneuvers in order to keep from being overwhelmed by the therapy process. Most often, the youth will increase his or her level of dissociation (e.g., through disengagement or “spacing out”) or cognitive avoidance during the session. The youth may interrupt the focus or pace of therapy with arguments, “not get” obvious therapeutic points, distract the therapist with various dramatic, sexualized, or aggressive behaviors, or change the subject to something less threatening. In the worst case, he or she may drop out of treatment. Although the clinician may interpret these behaviors as “resistance” or “borderline behavior,” such avoidance often represents appropriate protective responses to therapist process errors. Unfortunately, the client’s need for avoidance can easily impede treatment by decreasing his or her exposure to memory material and the ameliorative aspects of therapy.
In contrast, effective therapy for traumatized adolescents provides titrated exposure to traumatic material while maintaining the safety and support necessary eventually to extinguish trauma-related 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 refers to the therapist’s awareness and relative control of the level of emotional activation that occurs within the session. It is recommended that – especially for adolescents with affect regulation difficulties – emotional intensity be highest at around mid-session, whereas the beginning and end of the session should be at the lowest intensity. Ideally, at the beginning of the session, the youth gradually enters the process of psychotherapy; by the middle of the session, the focus has shifted to relatively more intense processing and activation; at the end of the session, the client is sufficiently de-aroused that she or he can re-enter the outside world without needing later avoidance activities. 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 he or she was at the beginning of the session.
The need for the adolescent to experience upsetting feelings and thoughts during trauma-focused treatment requires that the therapist carefully titrate the level of emotional activation the client experiences, at least to the extent that this is under the therapist’s control. From the therapeutic window perspective, intense affect during treatment pushes the client toward the outer edge of the window (i.e., toward an increased possibility of being overwhelmed), whereas less intensity (or a more cognitive focus) moves the client toward the inner edge (i.e., toward reduced exposure and emotional processing). The goal is to keep the survivor near the “middle” of the window – to feel neither too little (i.e., to dissociate or otherwise avoid to the point that abuse-related emotional responses and cognitions cannot be processed) nor too much (i.e., to become flooded with previously avoided emotionality that overwhelms available affect regulation resources and is retraumatizing).
The Components of Titrated Exposure
Assuming that none of the constraining conditions presented above are in force, or that they have been sufficiently diminished, formal titrated exposure can be initiated. For the purposes of this treatment guide, the processing of traumatic memory within the therapeutic window will be divided into five components: exposure, activation, disparity, counterconditioning, and desensitization/resolution . These components do not always follow a linear progression. In fact, in some cases interventions at a “later” step may lead to further work at an “earlier” step. In other instances, certain steps (e.g., counterconditioning) may be less important than others (e.g., disparity). And, finally, as described in Chapter 7, the therapy process may require the client to learn (or invoke previously learned) affect regulation techniques in order to down-regulate distress when emotional responses inadvertently become overwhelming.
In the current context, exposure refers to any activity engaged in by the therapist or the client that provokes or triggers client memories of traumatic events. Several types of exposure-based therapies are used to treat traumatic stress. The approach described in this guide asks the client to recall non-overwhelming but moderately distressing traumatic experiences in the context of a safe therapeutic environment. This approach usually does not adhere to a strict, pre-planned series of extended exposure activities. This is because the youth’s ability to tolerate exposure may be quite compromised, and may vary considerably as a function of outside life stressors, level of support from friends, relatives, and others, and, most importantly, the extent of affect regulation capacities available to him or her at any given point in time. In Self-Trauma language, the “size” of the therapeutic window may change within and across sessions.
In general, therapeutic exposure involves the adolescent recalling and discussing traumatic events with the therapist, and, in some cases, writing about them at home and then reading them aloud in the next session. Although some other forms of trauma therapy focus on memories of a single trauma (e.g., of a motor vehicle accident or physical assault), and discourage much discussion of other traumas, the approach advocated in ITCT-A is considerably more permissive. It is quite common and acceptable for trauma survivors to “jump around” from one memory to another, often making associations that are not immediately apparent to the therapist – or even, in some cases, the client. Especially for youth with histories of multiple, complex, and extended traumas, the focus of a given session may move from a rape experience to earlier childhood maltreatment to an experience of violence during an arrest. A young man caught in prostitution may begin the session with a memory of being assaulted by a john (customer), and find himself, 20 minutes later, describing being physically abused by his father when he was a child.
The broader exposure activities of the therapy described here reflect the complexity of many trauma presentations. Although an adolescent may come to treatment in order to address a recent assault experience, it may soon become apparent that either (a) an earlier trauma is actually more relevant to his or her ongoing psychological distress, or (b) the distress is due to the interacting effects of multiple traumas. A young heroin user, for example, might seek treatment for the effects of a violent rape by an acquaintance, and soon discover that this rape activates memories of a number of other distressing experiences, as well as the childhood incest experiences that may have partially determined his or her current addiction. In such instances, insisting that the survivor focus exclusively on a single trauma during therapy, or even on just one trauma at a time, may be contraindicated, or not well appreciated by the client. As well, recollections of early trauma are often fragmented and incomplete, if not entirely nonverbal in nature, precluding the youth’s exposure to a discrete, coherent memory, per se. Instead of being limited to discussions of a single trauma, it is suggested that the adolescent be allowed to explore – and thereby expose himself or herself to – whatever traumatic material seems important at a given time, or whatever memory – or part of a memory – is triggered by any other memory.
Explaining the value of titrated exposure
Although exposure is widely understood to be a powerful treatment methodology by clinicians, the adolescent may respond negatively to the idea of revisiting traumatic memories. Prior to therapy, the survivor may have spent considerable time and energy controlling his or her distress by avoiding people, places, and situations that trigger posttraumatic intrusions, and by trying to suppress or numb trauma-related distress. As a result, exposure techniques, wherein the client is asked to intentionally reexperience events and emotions that he or she has been avoiding, may seem counterintuitive, if not anti-survival.
For this reason, an important aspect of trauma therapy is pre-briefing: explaining the rationale for therapeutic exposure, 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 adolescent client may automatically resist and avoid, including, in some cases, terminating therapy. On the other hand, if exposure can be explained so that he or she understands the reasons for this procedure, it usually is not hard to form a positive client-therapist alliance around this approach and a shared appreciation for the process.
Although the way in which exposure is introduced may vary from instance to instance, the clinician should cover the following main points when preparing clients for exposure work (Briere & Scott, 2012):
- Unresolved memories of the trauma often have to be talked about and reexperienced, or else they may not be fully processed and will be more likely to keep coming back as symptoms or unwanted feelings.
- Although the adolescent understandably would like to not think about what happened, and may have been avoiding upsetting feelings about the trauma, such avoidance (a) is usually impossible to maintain (hence the presence of symptoms), and (b) often blocks processing and thus, ironically, serves to keep the symptoms alive.
- If the client can talk about what happened enough, in the safety of treatment, the pain and fear associated with the trauma is likely to decrease. The clinician cannot, however, promise that this will occur.
- By its nature, exposure is associated with some level of distress, and some people who undergo exposure experience a slight increase in flashbacks, nightmares, and/or distressing feelings between sessions. This is normal and usually not a bad sign. At the same time, the youth should inform the therapist when this occurs, so that he or she can monitor whether exposure has been too intense.
- The clinician will work to keep the discussion of these memories from overwhelming the client, and the client can choose to stop talking about any given memory if it becomes too upsetting (an option usually not offered in more classic, prolonged exposure approaches). The youth need only talk about as much traumatic material as he or she is comfortable with. However, the more he or she can remember, think, feel, and talk about non-overwhelming memories during therapy, the more likely it is that significant improvement will occur. Because therapeutic exposure can exceed the therapeutic window, the therapist should “check in” with the client on a regular basis during this process, making sure that he or she is feeling in sufficient control and is not becoming overwhelmed.
As noted in the last chapter, trauma therapy sometimes includes “homework” assignments for clients who can tolerate between-session exposure exercises. This adjunct to session-based treatment typically involves the client writing about the traumatic event when at home (or wherever might be safe), and then reading it aloud in the next session. Along with providing additional opportunities to examine and process cognitions initially associated with the event (per Chapter 9), 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 (1993) book on cognitive processing for rape victims, the therapist is invited to copy the handout found in the Appendix (Written Homework About My Trauma) and provide it to the client, saying something like:
Here is the homework sheet we discussed. Try to write down answers to all the questions about the