The primary goal of trauma resolution and integration is for the patient to gradually face and make sense of the abuse/trauma and to experience associated emotions at a pace that is safe, manageable, and not overwhelming.
The solicitation of memories or the intense re-experiencing of early trauma is not the goal of this stage of treatment. As Cold and Brown (1997: 184) argued, 'Neither the clinical nor the research literature on CSA [childhood sexual abuse] and its treatment suggest that remembering is the crux or culmination of effective therapy for this population'. The purpose of recounting abuse experiences is to allow for the processing, desensitization, and integration of traumatic memories that return as fragmentary intrusive experiences. Dissociated memories are translated into a coherent narrative. Traumatic material is 'told and retold' until it becomes an integrated aspect of the self and takes on new meaning 'as part of a socially shared autobiographical history' (Brown et al., 1998: 481). According to Brown et al.: 'Recovery of memories is not about gathering information about the past. It is about mastery over what has been unclear or avoided in memory, making meaning out of one's personal history, and achieving integration' (1998: 481).
The emotional expression (e.g. crying) that accompanies exposure to trauma-related material contributes to desensitization (Briere, 1996). The positive emotional experience of the discharge of emotions in the context of a supportive relationship serves to inhibit and counter-condition the fear associated with the trauma. Catharsis pairs the positive experience of emotional disc arge with trauma stimuli, thereby counter-conditioning traumatic stress.
Counsellors should discuss the rationale for this phase of treat�ment in terms clients can understand and appreciate. Abuse survivors have often had the experience of describing their experiences to others - only to have them respond with disbelief or excessive interest based on curiosity rather than concern. Clients should, therefore, be active participants in the decision to pursue this phase of treatment, and should explicitly agree to engage in exploratory work.
The pacing of exploratory work is crucial for therapeutic success. The counsellor should proceed at a pace consistent with the clients' ability to tolerate painful affect. Briere discussed the con�cept of the therapeutic window, a heuristic used to guide explora�tory work. The therapeutic window is:
that psychological place during treatment wherein appropriate thera�peutic interventions are cast. Such interventions are neither so nondemanding as to be useless nor so evocative or powerful that the client's delicate balance between trauma and avoidance is tipped toward the former. (1996: 146)
Counsellors 'undershoot' the therapeutic window if they avoid exploration of childhood trauma or provide only support and validation for clients who have the capacity to engage in explora�tory work (Briere, 1996). The trauma is not processed and the client continues to employ avoidance or dissociative defences. On the other hand, interventions that 'overshoot' the therapeutic window are too intense or fast-paced to allow for adequate processing of traumatic material. The client will become overwhelmed with affect and experience increased defensive dissociation. In some instances, counsellors inaccurately label this dissociation as ,resistance'. If the client's defences are not adequate, he or she may become overwhelmed by intrusive symptomatology and resort to soothing, but self-destructive, behaviours, such as self�mutilation or substance abuse. Other clients may flee treatment. Maintaining the therapeutic window, therefore, involves titrating discussion of traumatic material so that clients experience the exposure necessary for desensitization without provoking unwanted avoidance.
Cole and Barney addressed the concept of the therapeutic window, which they believe is characterized by moderate distress and manageable symptomatology. They claimed that the coun�sellor's task is to 'judge carefully the amount and exposure to ... memories and affects the survivors can tolerate. That is, the therapist should monitor the "dosage" of intensity and duration so that it is of therapeutically manageable proportions' (1987: 603). Once clients understand the concept of the therapeutic window, the counsellor may periodically 'check in' with them to see if they believe they are working within the window.
Working within the therapeutic window requires a balance between interventions of exploration and interventions of con�solidation (Briere, 1996). Exploratory interventions involve an examination of traumatic material, both cognitively and affec�tively. Consolidation interventions focus on safety, support, and stability. Effective therapy requires a balance between these types of intervention, based on the counsellor's ongoing assessment of the client's changing internal state. Clients who are emotionally overwhelmed or functioning poorly will benefit from a greater focus on consolidation; clients who are emotionally stable will profit from a focus on exploration.
Counsellors also need to control the intensity of affect provoked within each session (Briere, 1996). Exploratory work should begin gradually. The intensity of affect should peak in the middle of the session, and time should be left for clients to regain a sense of control and composure before they leave the counsellor's office.
Exploratory work involves a gradual re-exposure to the affect and stimuli associated with traumatic material within the context of a well-established therapeutic relationship. Exploratory work is a form of systematic desensitization in which less upsetting memories are discussed and desensitized before moving on to fnore painful ones (Briere, 1996). Kluft (1996) recommended pro�cessing traumatic material 'from the top down'. The client is asked to describe consciously available material first. Unavailable material will often emerge naturally in the course of these discussions.
Because abuse memories are coded both verbally and through the sensorimotor system, exposure and desensitization must include both of these systems. Factual, verbal memories are generally processed first, as they tend to be less overwhelming than sensory memories (physical sensations and affects). Clients are asked first about 'facts' of the abuse (the who, what, when, where) and later about associated affective and perceptual experiences.
The constricted affective lives of many sur�vivors can be attributed to defensive processes stemming from the abuse, as well as from growing up in dysfunctional family systems where feelings were not respected. Many survivors will initially appear emotionless when describing their abuse experi�ence (Hall and Lloyd, 1989). When asked, these individuals are often unable to identify or express their feelings.
Male survivors may have special difficulty expressing, naming, and understanding feelings. As Johanek (1988: 112) states, 'Most men with whom we deal have learned to avoid experiencing and displaying emotions at all costs. They tend to describe events and their reactions to those events without using emotional terms'. Men may feel especially threatened when asked to explore their feelings in counselling.
Clients may experience different feelings at varying degrees of intensity when exploring the sexual abuse. Sgroi (1989a), for example, suggested that fear, anger, and perception of loss of control are primary responses that occur when survivors begin to acknowledge the reality of the abuse. Survivors learn that these responses are painful but tolerable. Secondary responses such as guilt, shame, and a sense of damage are subjected to what Sgroi (1989a) refers to as contemporary denial - i.e., the denial of current responses to the abuse experience. Although survivors have acknowledged the reality of the abuse, they minimiz e its importance in order to block the pain of these secondary responses.
Blake-White and Kline (1985) also differentiated the varied feelings experienced by survivors of childhood sexual abuse. They suggested that feelings of guilt and shame are often acknowl�edged by survivors spontaneously; anger and sadness are often just under the surface and discussion of these feelings can be facilitated by the counsellor. The stronger emotions of terror, despair, abandonment, fear of pain, and fear of being alone may continue to be denied.
Counsellors should first validate expressed emotions so that survivors can learn to trust and accept their feeling states and then work toward increasing the survivors' awareness of deeper, repressed emotions. There are several interventions that can be used to facilitate this process. First, counsellors may ask clients to name and describe feelings. When survivors do respond with feeling statements, counsel�lors can acknowledge the feelings with empathic responses.
Third, when working with clients whose families, or society, discouraged the expression of feelings, counsellors may address this dynamic.
As mentioned previously, most trauma experts have suggested that repressed memories, or otherwise unavailable material, will emerge gradually throughout the course of treatment as the client's capacities to tolerate painful material increase and defensive dissociation decreases. The use of specialized memory recovery techniques is generally unnecessary.
Brown et al. (1998) argued, however, that there are some cases where memory retrieval techniques may be appropriate: 'Special�ized memory recovery techniques are sometimes indicated when . . . the patient is suffering from a more pervasive or extreme an-tnesia for trauma ... that has not been reversed by the previous methods designed to minimize memory accuracy errors, such as free narrative recall' (1998: 483-4).
These authors recommended that if it is necessary to use specific interventions to facilitate memory retrieval, a step-wise approach be used. Techniques with the lowest likelihood of causing memory errors, such as free narrative recall, are used first. If these approaches do not reverse the amnesia, techniques that involve a mild increase in memory error rates, such as trans�ference interpretations and context reinstatement combined with free recall (having the client focus on a period of time in which the abuse probably occurred) should be tried. If these are not successful, state-dependent recall techniques (focusing on trauma�associated affect or using techniques to amplify affect), which are associated with a mild to moderate increase in memory error rates, might be considered. A modest increase in memory error rates 1 associated with specialized memory recovery techniques such as hypnosis or age regression; these techniques should be used with extreme caution only by counsellors who are well trained in their use. A high increase in memory error rates is associated with interrogatory and coercive interviewing, includ�ing the supplying of false or misleading information; these methods are always ill-advised.
Exploring the abuse experience often provokes a period of grief and mourning as survivors come to terms with the reality of the abuse and the losses and missed opportunities associated with it (Chu, 1998; Courtois, 1999; Herman, 1992). Survivors may mou the loss of their childhood; their psychological and, in some casi physical integrity; and the capacity to trust others:
The telling of the trauma story thus inevitably plunges the survivor into profound grief. Since so many of the losses are invisible or unrecog�nized, the customary rituals of mourning provide little consolation. The descent into mourning is at once the most necessary and the most dreaded task of this stage of recovery. (Herman, 1992: 188)
Herman suggested that resistance to mourning may take the form of fantasies of revenge, forgiveness, or compensation. During this time, the survivor may be at increased risk of suicide. Positive memories of caring others in the survivor's life, or the survivor's own capacity for compassion, may serve as 'a lifeline during the descent into mourning' (1992: 194).
(Lionel Richie - "Truely")
