In addition to post-traumatic symptomatology, clients often experience intense affect, including anxiety, fear, depression, shame, hopelessness, and rage. When they begin to focus on their traumatic experiences, these feelings may intensify.
Counselling interventions for such affective responses include helping the client to identify and label his or her feelings, to understand the relationship between these feelings and the trauma that they experienced, and to experience feelings without evaluating or rejecting them. In this phase of counselling, clients often need to learn to express feelings verbally or through other means, such as writing, art, and music (Chu, 1998). Counselling interventions at this stage are aimed at the healthy expression of emotion in general, rather than the evocation of trauma-related affect. If clients gain a sense of control over their emotional responses prior to the exploration of abuse, they will be better equipped to tolerate distressing affect when such exploration begins. Additionally, if clients are informed about how emotional responses are related to healing, and are assured of the coun�sellor's support and availability, they may feel less overwhelmed by their reactions when they begin exploratory work.
Clients and counsellors can devise an action plan specifying what the client will do if he or she becomes at risk for engaging in self-harm. For example, non-suicide contracts detailing actions to be taken in the event of suicidal ideation can be helpful. Action plans may include: self-control techniques (e.g. becoming involved in some activity), calling the counsellor or a hotline, or going to the emergency room of a hospital in the event of imminent danger. Designing such explicit agreements demonstrates the counsellor's concern for the client's safety while giving the client responsibility for his or her actions by devising specific guidelines for managing self-destructive urges. Cognitive-behavioural approaches for dealing with continuing suicidal ideation and self-mutilation, such as those outlined by Meichenbaum (1994), Beck (1994), and Linehan (1993), may be indicated.
Counsellors may help clients anticipate and prepare for aggressive impulses that might arise when they begin to explore abuse issues. Aggression may be a special concern for male survivors. Bruckner and johnson (1987), who conduct group therapy with male sur�vivors, reported that group members have often expressed intense anger following disclosure. This anger was sometimes accompanied by plans for retribution, including physical assault on offenders. Counsellors need to assess the potential of harm to others, while validating the client's angry feelings.
Anger management training, in which clients are taught to express anger verbally and constructively, may be indicated for some clients. Meichenbaum (1994) described a stress inoculation training programme for anger control and conflict management that includes: increasing the chent's awareness of his or her anger; education regarding the components and function of anger; learning time-out procedures and relaxation and visual coping skills; cognitive restructuring; the use of humour; and skill�building (communication skills, assertiveness training).
Clients may present with a variety of addictive behaviours, including substance abuse, eating disorders, and sexual compulsivity; these behaviours may also represent long-standing coping mechanisms used to deal with intolerable affect related to earlier trauma and must be addressed prior to exploratory work. Some counsellors may have the training and expertise to deal with such problems in their own practices; others may refer the client to self�help groups, specialized treatment programmes, or practitioners who specialize in these issues. Structured treatment manuals and therapy guidelines that address chemical dependency (Brower et al., 1989; Brown and Fromm, 1986; Meichenbaum, 1994), eating disorders (Friedman and Brownell, 1996; Gamer and Carfinkel, 1997), and sexual compulsivity (Schwartz and Masters, 1993) are available.
Sexual abuse survivors may be particularly resistant to involvement in self-help groups such as Alcoholics Anonymous. Several counselling interventions are recommended to deal with this resistance (Skorina and Kovach, 1986). The first step of an AA programme is the admission of powerlessness over alcohol and life, a terrifying prospect for survivors of sexual abuse. Counsellors may discuss the difference between being powerless over a substance and being powerless over one's body or psyche, stressing that admission of powerlessness over a substance is actually a way of gaining control. Because another block to survivors' participation in an AA programme is lack of trust, coun�sellors can recommend finding home groups and sponsors (i.e., peers from AA with a history of sobriety who provide personal support) who are sensitive to abuse issues. If the survivor is a woman, the choice of an all-female group and a female sponsor may be helpful. Further, the invitation to 'tell one's story' in an AA meeting may be experienced as intrusive by the survivor; counsellors may help the survivor prepare for this in advance.
Trotter (1995: 100) expressed concern that 'over focusing either on rigid sobriety while ignoring post-trauma symptoms or on issues secondary to serious addiction can create for the recovering person the potential for relapse'. She proposed a developmental model for recovery for the chemically dependent trauma survivor, based in part on Gorski's (1992) recovery-from-addiction model. In the five stages of the model (transition, stabilization, early recovery, middle recovery, and ongoing recovery) issues related to dynamics of trauma, the nature of addiction, and the relationship between trauma and addiction are addressed. For example, during the stabilization phase, the symptoms of postacute with�drawal from alcohol (e.g. inability to think clearly, memory problems, emotional reactions or numbness, sleep disturbances) can mimic the symptoms of PTSD; clinicians are advised, there�fore, to refrain from making a psychological diagnosis until the chemical withdrawal is completed. In the model, the 12 steps of Alcoholics Anonymous are interwoven with the stages of trauma recovery. Special attention is paid to relapse prevention by identi�fying and managing warning signs.
Survivors who are not self-destructive in one of the ways discussed above may have a tendency to neglect their general self�care needs (e.g. poor eating habits, neglect of health care, lack of pleasurable activities). This neglect may be due to feelings of low self-worth that stem from the early abuse.
Constructing a self-care plan may be something as simple as agreeing to treat oneself to a desired article of clothing or to take a warm bubble bath after a particularly difficult session; it may be as comprehensive as a nutrition and exercise plan to accompany the counselling process. Clients may need a medical evaluation if they have neglected their health-care needs. Providing for self�care typically becomes easier when survivors are further along in the healing process. Making a commitment to a reasonable plan early in treatment, however, suggests to clients that they can take action to tolerate the painful aspects of the counselling process.
Clients may present with disturbed interpersonal relationships that must be addressed prior to beginning exploratory work. They may be isolated and without social support, or may be involved in relationships that are stormy and abusive. Courtois stated that: 'Much therapeutic time must be spent identifying and unlearning the "relational rules of abuse and victimization" and replacing them with skills and attitudes necessary for healthy, interdepen�dent connections with supportive others' (1999: 200).
For some clients, social skills training may be indicated so they can begin to seek out sustaining social activities and relationships. Structured educational groups may be useful for this purpose. If the client is currently involved in an abusive relationship, this must be addressed in this phase of counselling.
Because the client may attempt to re-enact old relational patterns with the therapist, the formation of a therapeutic alliance that is mutual and collaborative is necessary. Chu stated, 'The therapy helps to introduce mutuality and collaboration in rela�tionships, rather than control, aggression, abandonment, and betrayal that formed the core experiences of the patient's early life' (1998: 85).
(Lionel Richie - "Truely")
