Chapter Ten – Titrated ExposureTreatment-Guide-Chapter-10

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

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

[rape/shooting/abuse incident/etc.] and what happened afterwards. Include as much detail about it as you can remember, and be as specific as possible. After you’re done writing, read it to yourself at least once before our next session. If it is too upsetting to read all at once, try reading as much as you can, and then read the rest later, when you are ready.

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.


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.


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.


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.


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.