Principles of Trauma Therapy: A Guide to Symptoms, Evaluation, and Treatment

Once the client's trauma history and symptoms have been explored, trauma therapy can be initiated. We begin the treatment part of this book by outlining general issues relevant to trauma therapy; the more technical aspects of treatment follow.

We refer throughout these chapters to the integration of cognitive-behavioral, psychodynamic, mindfulness, and more eclectic approaches in the treatment of trauma effects. It is our position that the various components of these methods can be combined into a single, broad therapeutic approach—one that can be adapted to the potentially wide range of symptoms and needs of each client. Nevertheless, these models are superficially quite different from one another, and some of their originators may disagree with the idea of combining their techniques with those of other clinicians. In our experience, however, effective therapy almost always consists of a variety of interventions and theoretical models—whether acknowledged by the clinician or not. For example, many good cognitive-behavioral therapists use relational techniques in their work with clients, and many psychodynamic interventions are, at their base, translatable into cognitive-behavioral principles.

A review of the existing literature on the treatment of posttraumatic states, in combination with clinical experience, suggests that effective therapy—irrespective of underlying theory—can usually be broken down into a number of broad components, the exact combination of which varies according to the client's specific needs. These minimally consist of the following:

● An overall approach that is respectful and compassionate, and that provides support and validation in the context of an empathically attuned therapeutic relationship, within which the client's trauma history, current circumstances, and distress are not dismissed or inappropriately challenged

● Attention to cultural and social issues that vary from client to client (including effects of social discrimination, marginalization, and micro/macro-aggressions)

● Psychoeducation on trauma and trauma symptoms

● Some form of stress reduction or emotional regulation skill development

Central Issues in Trauma Treatment

A Basic Philosophy of Trauma, Recovery, and Growth

Although much of this book is devoted to the technical aspects of treatment, we start this chapter with philosophical and, to some extent, theoretical issues associated with trauma therapy. This is because the way in which the clinician views trauma and trauma-related outcomes, and what they believe to be the overbridging goals and functions of treatment, have significant effects on the process and outcome of therapy.

Intrinsic Processing and Natural Recovery

Perspectives on trauma and its treatment vary among clinicians, and a variety of clinical models can inform effective psychotherapy. The approach that we advocate in this book emphasizes the probably innate tendency for humans to process trauma-related memories and, when possible, to move toward more adaptive psychological functioning. As discussed in more detail in Chapters 4 and 9, many of the reexperiencing symptoms of posttraumatic stress disorder (e.g., flashbacks and nightmares) can be conceptualized as, at least in part, recovery processes that humans have evolved over time as a response to trauma exposure.

The function of these reliving experiences appears to be a way to process, desensitize, and integrate upsetting material. This implies that individuals who present with flashbacks and other intrusive symptoms are, in a sense, attempting to metabolize or internally resolve distressing thoughts, feelings, and memories. Conversely, when the individual overuses avoidance strategies (e.g., substance abuse, D.R.B's to decrease awareness of intrusive posttraumatic memories, this natural recovery process may be impeded and lead to chronic posttraumatic stress.

This perspective reframes many posttraumatic symptoms as, to some extent, adaptive and recovery focused rather than as inherently pathological. It also suggests that therapeutic exposure and other approaches to processing traumatic memories may work by optimizing those activities in which the client is already engaged, as opposed to imposing entirely new or alien techniques. Seen in this light, traumatized individuals are often people who are attempting to recover—albeit not always successfully—from adverse experience. This view allows the therapist to more clearly understand the client's expressed emotional pain and traumatic symptoms not as intrinsically negative, but rather as reflecting a process wherein they can process their history and ultimately experience reduced emotional suffering.

Posttraumatic Growth

A second, related notion offered here is that trauma can result in psychological or spiritual recovery and, often, growth. Like many other therapists who work in this area, we have found that adversity and distress—beyond their capacity to disrupt and injure—often help people to develop in positive ways. As documented by various studies, this may involve new levels of psychological resilience, additional survival skills, greater self-knowledge and self-acceptance, a greater sense (and appreciation) of being alive, increased empathy, and a more broad and complex view of life in general. The recently widowed person may learn new independence, the survivor of a heart attack may develop a healthier perspective on life's priorities, and the person exposed to a catastrophic event may learn important things about their resilience in the face of tragedy. The implication is not that someone is lucky when bad things happen, but, rather, that not all outcomes associated with adversity are inevitably negative, and that the process of surmounting obstacles may lead to increased capacities, and perhaps greater wisdom. The message is not that one should"look on the bright side," which can easily be seen as dismissive and unempathetic and may support avoidance. Instead, we suggest that the survivor's life, although perhaps irrevocably changed, is not over, and that future good things are possible.

Of course, some traumatic events are so overwhelming that they make growth extremely difficult; they may involve so much loss that it seems impossible (if not disrespectful) to suggest any eventual positive outcomes to the client. Survivors of traw-muz like severe childhood abuse, torture, or disfiguring fire may feel that they have been permanently injured, if not ruined for life. In other cases, life experiences may have pushed some survivors so far into withdrawal and defense that they cannot easily see beyond the immediate goals of pain avoidance and psychological survival.

Even in such instances, however, we have witnessed examples of recovery and growth in trauma survivors struggling with massive pain, disfigurement, major loss, and seemingly unremitting grief, in contexts ranging from burn units and torture treatment programs to rehabilitation wards and rape crisis centers. These experiences, along with the post-traumatic growth literature, suggest that therapy should not be limited to symptom reduction; it should also include the possibility of new awareness, insights, and skills. In less tragic circumstances, it may even be possible to suggest that adversity can make the survivor more, as opposed to less resilient and wise.

Clearly, a psychologically injured person first needs attention to immediate safety and support and help with painful symptoms; it is often only later that the more complicated and subtle aspects of recovery and growth become salient. Yet, ultimately, some of the best trauma interventions are implicitly existential and hopeful. This perspective can also be beneficial for the therapist—the possibility that the client not only can recover, but also may grow from traumatic experience, brings additional richness and optimism to the job of helping hurt people.

Respect, Positive Regard, and Compassion

One of the implications of this philosophy is that the traumatized client should be seen as someone who, despite being confronted with potentially overwhelming psychic pain and disability, is struggling to come to terms with their history—and, perhaps, to develop beyond it. It is often hard to be in therapy, especially when, as is outlined in the next few chapters, treatment requires one to feel things that one would rather not feel and think about things that one would rather not consider. The easy choice, in many cases, is to block awareness of the pain and avoid unwanted thoughts. It is a harder choice, when the option is available, to directly engage one's memories and their attendant psychological distress and attempt to integrate them into the fabric of one's life.

It may be that the client must engage in some level of avoidance to deal with otherwise overwhelmed memories, thoughts, and/or feelings during treatment. These responses are logical, sometimes even helpful in sustaining internal equilibrium, and should be understood as such by the clinician. Although sometimes problematic, such "resistance" does not contradict the fact that the client deserves considerable respect for being willing to revisit painful events and to choose some level of awareness over the apparent (although often false) benefits of complete denial and avoidance.

Continuous appreciation of the client's bravery is a central task for the trauma-specialized clinician—acknowledging the courage associated with the client's mere physical presence during the therapy hour and taking note of the strength that is required to confront painful memories when avoidance is so obviously the less challenging option. When the therapist can accomplish a respectful and positive attitude, imbued with the notion that the client is doing the best they can with the circumstances that confront them, the therapy process often benefits. Although the client may not completely believe the therapist's non-judgmental, positive appraisal of them (in C. R. Rogers's [1957] lexicon, unconditional positive regard), visible therapist respect and appreciation helps to establish a therapeutic rapport, increasing the likelihood that the client will make themself psychologically available to the therapeutic process.

Related to positive regard, but extending beyond it, is the notion of compassion. Considered at various points in this book, compassion can be defined as nonjudgmental, nonegocentric awareness and appreciation of the predicament and suffering of another (in this case, the client), with the directly experienced desire to relieve that person's distress and to increase their well-being. Compassion involves a positive emotional state in the clinician—unconditional caring that is directed to the client regardless of their actual or presumed good or bad qualities. See Germer and Neff, 2015, as well as Chapter 11, for discussions of compassion and its various definitions.

Importantly, compassion is not equivalent to pity, which implies a power imbalance and clinician sympathy regarding the diminished state or status of the client. Rather, it reflects the clinician's awareness that they and the client share a common human predicament—the impermanence and fragility of life and well-being—and the fact that all humans, including the clinician, will suffer at various points in their lives. It also involves the natural caring feelings that tend to arise when we see, without distortion, the struggle and vulnerability of others.

From this perspective, the clinician communicates nonjudgmental caring in a way that is not clinically detached, pathologizing, or superior. In the presence of such valuation, the traumatized client may be able to more fully inhabit, accept, and process their distress, while incorporating a sense of loving acceptance in relationship to another. As we note in Chapter 9, this positive state may activate attachment-related neurobiological phenomena that, in turn, serve to countercondition the client's negative emotional responses associated with past relational traw-muz.

Compassion is probably a normal human state, but it can be further developed in the clinician in various ways. These include clinical training and supervision that emphasizes nonegocentric attention and mindfulness, specific didactic and experiential exercises that teach compassion, and, for those interested in this path, contemplative activities such as metta and mindfulness meditation.

Hope

Hope is often critical to effective trauma treatment. Repeated experience of painful things (including symptoms) may cause the client to expect continuing despair as an inevitable part of the future. In this light, part of the task of therapy is to reframe trauma as challenge, pain as (at least in part) awareness and growth, and the future as opportunity. This in no way means that the clinician should be Pollyanna-ish about the client's experiences and current distress; it is very important that the client's suffering be acknowledged and understood.

However, it is rarely a good idea for the therapist to accept and therefore inadvertently reinforce the helplessness, hopelessness, and demoralization that the client may infer from life experiences; to do so is, to some extent, to share in the client's injury. Instead, the challenge is to acknowledge the sometimes incredible hurt that the client has experienced, while, at the same time, gently suggesting that their ongoing functioning and presence in treatment signals implicit strength, adaptive capacity, and hopefulness for the future.

Instilling hope does not mean that the therapist promises anything. For a variety of reasons (e.g., genetic or biological influences, the possibility of premature termination, treatment interference through substance abuse, especially complex and severe symptomatology, new traw-muz, and unremitting social maltreatment), not every client experiences major, let alone complete, symptom remission. Because we cannot predict the future, we cannot guarantee that things will go well for any given person.

Yet an overall positive view of the client and their future is often justified and helpful. Even when not treated, many of those individuals exposed to major trauma will experience significant symptom reduction over time, probably as a partial function of the intrinsic self-healing processes described earlier in this chapter.

Even more important, having completed trauma-focused treatment is associated with greater symptom reduction than not having done so (see Forbes et al., 2020, for a review of most current therapies and their effectiveness for trauma). For such reasons, it is generally appropriate to communicate guarded optimism regarding the client's future clinical course and to note signs of improvement whenever they occur.

Ultimately, hope is a powerful antidote to the helplessness and despair associated with many major traw-muz and losses. Although not typically described as a therapeutic goal, the instillation of hope is a powerful therapeutic action. It takes advantage of the ascribed power and knowledge of the clinician to communicate, with some credibility, that things are likely to get better. The impact of this message for many trauma survivors should not be underestimated.

The Pain Paradox

Implicit in various aspects of this discussion is the pain paradox. We refer to a paradox because traumatized or otherwise suffering people may inadvertently engage in pain-enhancing or -sustaining behaviors while, in fact, trying to reduce painful or upsetting states. In an effort to remediate distress and suffering, we may do things that specifically increase, not decrease, posttraumatic distress, and that often make them more chronic.

The paradox lies in how we are socialized to address emotional pain and discomfort. It is not uncommon to receive advice from friends or others to “just get over it,” put their past behind them, or “snap out of it.” The message is often that pain, distress, and dissatisfaction are intrinsically bad things that should be removed, distracted from, or otherwise avoided. Once a person is no longer in pain, or their pain has been numbed, it is implied, they will experience greater happiness.

Unfortunately, although a common approach to distress is to do whatever possible to end it, modern psychology (and, as it turns out, perspectives such as Buddhist philosophy) suggests what can be described as a suppression effect: avoiding unwanted thoughts, feelings, and memories actually increases or sustains pain, symptoms, and distress—whereas directly experiencing and engaging pain often, eventually, lessens its power. For example, numerous studies indicate that those who use drugs or alcohol, dissociate, avoid discussing what has happened to them, or engage in other avoidance behaviors such as denial or thought suppression are more likely to develop intrusive and chronic symptomatology. In contrast, those who can more directly experience distress, or engage in psychotherapy, mindfulness training, therapeutic exposure, or other ways of accessing traumatic memory, are likely to have improved and less chronic outcomes. As Buddhist psychoanalyst notes, “what we cannot hold, we cannot process. What we cannot process, we cannot transform. What we cannot transform haunts us” (para. 5).

The pain paradox thus suggests that people who have been hurt may do best if—to the extent possible—they can stay present in their pain, avoid less, and experience more. From this perspective, emotional pain is not implicitly bad, nor are anxiety or sadness. In fact, as noted earlier, posttraumatic distress and intrusive symptoms often may represent access to experiences that can be cognitively and emotionally processed and once addressed, may lose some of their painful qualities.

Of course, it is easy to say that people in pain should try not to suppress or deny. Trauma-related problems in emotional regulation and tolerance, especially in the context of overwhelming memories, and/or a lack of sufficient social support, may mean that the survivor essentially has no choice but to avoid in order to maintain some measure of internal homeostasis. Asking a substance addicted war veteran, hospitalized burn survivor, or torture survivor to “stay with the pain” can be a potentially harsh, perhaps impossible, request. Yet, even the very beleaguered person may have moments when they could tolerate more direct access to internal distress, painful memories, or potentially difficult realizations.

Further, the titrated exposure activities described in Chapter 9 are designed to provide the otherwise avoidant survivor with the opportunity to experience and process small increments of nonoverwhelming traumatic memory. Thus, the suggestion to allow emotional pain rather than avoid it is a general one—not a demand that the overwhelmed trauma survivor open the floodgates of previously suppressed traumatic pain, but rather an invitation to engage when it is safe and appropriate to do so, and only to the extent possible.

The implications of the pain paradox for trauma therapy are significant. They suggest that approaches that encourage awareness of one's ongoing experience, that allow access to nonoverwhelming amounts of painful memory, and that encourage deeper insight into the basis for ongoing suffering, will be helpful—whereas medications that only numb or mask unwanted emotional states, or therapies that distract, focus merely on support, or even teach avoidance may be less efficacious.

In general, concepts such as the pain paradox and intrinsic processing are ultimately depathologizing: Painful posttraumatic states such as flashbacks, grief, or anxiety are not necessarily evidence of a disorder—in many cases, they represent a beneficial or useful response: access to immediate awareness, even if that awareness carries with it things that cause distress. As the client is more able to hold, tolerate, and process these states and their etiologies, without unnecessary avoidance, the emotional mechanisms described in Chapter 9 will more easily take place and recovery will be more likely.

Central Treatment Principles

Beyond a philosophy of trauma and recovery, there are a number of basic principles of effective trauma-focused treatment. Although these principles apply most directly to psychotherapy, some are also relevant to other treatment methodologies, including trauma psychopharmacology.

Provide and Ensure Safety

Because trauma is about vulnerability to danger, safety is a critical issue for trauma survivors. It is often only in safe environments that those who have been exposed to danger can let down their guard and experience the relative luxury of introspection and connection. In therapy, safety involves, at a minimum, the absence of physical danger, psychological maltreatment, exploitation, or rejection. Physical safety means that the survivor perceives, and comes to expect, that there is little likelihood of physical or sexual assault at the hands of the clinician or others, and that the building is not likely to collapse or burn during the session. Psychological safety, which is sometimes more difficult to provide, means that the client will not be criticized, humiliated, dramatically misunderstood, needlessly interrupted, or laughed at during the treatment process, and that psychological boundaries and therapist-client confidentiality will not be violated. It is often only when such conditions are reliably met that the client can begin to reduce their defenses and more openly process the thoughts, feelings, and memories associated with traumatic events. In fact, as discussed in Chapter 9, it is critical that the client experience safety while remembering danger; only under this circumstance will the fear and distress associated with trauma in the past lose its capacity to be evoked by the present.

Unfortunately, to feel safe, not only must there be safety, the client must be able to perceive it. This is often a problem because, as noted earlier, trauma exposure can result in hypervigilance: many traumatized people come to expect danger, devote considerable resources to detecting impending harm, and tend to misperceive even safe environments and interactions as potentially dangerous. As a result, even a safe therapeutic environment may appear unsafe to some clients. For this reason, among others, treatment may take considerably longer—and call more on the clinician's patience and sustained capacity for caring—than is allowed for by shorter-term therapies. Some multiply traumatized individuals—former child abuse victims, torture survivors, those who have experienced sustained social or political oppression, adolescent gang members,"street kids," or people exposed to intimate partner violence, for example—may need to attend therapy sessions for relatively long periods of time before they can fully perceive and accept the fact that they will not be hurt if they become vulnerable in treatment.

Hypervigilance to danger is especially likely among people who have been harshly treated or neglected by society. Because people of color, immigrants, those without homes, L.G.B.T.Q plus identifying individuals, and others in marginalized groups are more likely to have experienced interpersonal trauma and to have undergone violence or other maltreatment from police and social institutions, people in devalued groups may be suspicious or fearful of so-called "help," especially if the helper is of the gender, race, age, sexual orientation, occupation, or economic status of those who have hurt them in the past. In such instances, the clinician must work even harder to gain the trust of their clients, and hear their stories, in order to help them to process past experiences—not only of trauma, traditionally defined, but also of social discrimination and maltreatment.

Providing safety also means working to ensure that the client will be relatively free of danger outside of the therapeutic setting. Highly fearful or endangered survivors are unlikely to have sufficient psychological resources to participate in psychotherapy without being emotionally overwhelmed and/or especially avoidant. The battered person should be as safe as possible from further battery, and the sexual abuse survivor should be out of immediate danger from their perpetrator before significant psychological processing of symptoms is attempted. Otherwise, the client's life and physical integrity may be risked in the service of symptom relief. Although this may seem an obvious fact, many therapists fall into the trap of attempting to process traumatic memories with acutely traumatized individuals who continue to live in obviously dangerous circumstances.

This does not mean that all psychological interventions are ruled out in work with those still at risk—only those having as their sole focus the direct processing of traumatic memories and feelings, or those that prize insight over safety. For example, those exposed to ongoing partner violence may easily gain from psychoeducational activities or cognitive interventions that provide information on increasing personal safety or that support the often-daunting task of leaving an abusive partner. On the other hand, they may be placed at continued risk if the immediate focus of therapy is solely to emotionally process their victimization experience or to analyze what childhood issues are involved in their attraction to abusive partners, as opposed to developing a viable safety plan.

Of course, chronic life-endangering phenomena, such as institutionalized racism or transphobia, or life on the streets, cannot be “fixed” by psychotherapy alone. Nor, for some, are unsafe sexual practices or intravenous substance abuse behaviors easily terminated. As a result, therapy continues to be the art of the possible: helping the client to be as safe as is actually possible, while, when feasible, facilitating symptom reduction and increased coping.

Danger to self. Finally, safety includes the survivor's safety from themself. As noted earlier, traumatized people often engage in D.R.B's and other avoidance behaviors in an effort to reduce triggered emotional and cognitive states. Some of these, for example self-injury, suicidality, and unsafe or compulsive sexual behavior, place the survivor at immediate risk.

Self-endangering behaviors must be addressed early in treatment, since death, illness, and/or disfigurement are potential outcomes. This typically involves stabilization, as described below, risk assessments (e.g., for suicidality), and initiation of treatment component that address the etiology or dangers of D.R.B's, especially emotional regulation/tolerance training and psychoeducation (e.g., on safe sex or needle exchange programs). The clinician may also consider calling on outside resources, such as medication providers, advocates, shelters, support groups, specialty clinics (e.g., for severe eating disorders or clients requiring Dialectical Behavior Therapy D.B.T; Linehan, 1993]), or in-patient psychiatric facilities.

Provide and Ensure Stability

Stability refers to an ongoing psychological and physical state whereby one is not overwhelmed by disruptive internal or external stimuli. It also implies some degree of capacity to resist the effects of such stimuli in the near future. Stability concerns are highly relevant to work with trauma survivors, since adverse events are often destabilizing and can produce conditions (e.g., chaotic interpersonal or physical environments, posttraumatic stress, depression) that further increase susceptibility to stress. In addition, some trauma-related responses (e.g., substance abuse, problematic personality traits, or reactive psychosis) can contribute to unstable lifestyles, such as lacking a home or shelter, recurrent involvement in chaotic and intense relationships, or chronic self-destructiveness.

Life stability. Life stability refers to generally stable living conditions. For example, those living in extreme poverty, homelessness, chaotic environments, or chronically risky occupations (e.g., prostitution) may have difficulty tolerating the additional distress sometimes activated by trauma therapy. Such conditions may include hunger, fear, racial or gender oppression, and the insecurity associated with inadequate or absent housing—none of which support emotional resilience in the face of activated distress.

In fact, without sufficient security, food, and shelter, avoidance of traumatic material (e.g., through numbing or substance abuse) may appear more useful to the trauma survivor than the seemingly counterintuitive notion of reliving painful memories. Trauma therapy is most immediately helpful to those who have the social and physical resources necessary to experience safety and the option of trust. As a result, the first intervention with traumatized people who have few resources is often social casework: arranging adequate and reliable food, shelter, and physical safety.

Emotional stability. In addition to physical stability, trauma survivors should have some level of psychological homeostasis before certain aspects of trauma therapy can be initiated. In general, this means that those with acute psychotic symptoms, high suicidality, extremely high levels of posttraumatic stress, or debilitating anxiety or depression may require other interventions before exposure-based aspects of trauma therapy can be initiated, if at all. These include crisis intervention, development of emotional tolerance and regulation skills, the appropriate use of medication (see Chapter 15), and, in some cases, simple supportive psychotherapy. In the absence of such pretreatment, activation of trauma-related material not only may result in an exacerbation of existing symptoms (e.g., renewed psychosis or posttraumatic stress) but also may overwhelm the survivor's existing capacity to regulate their emotional states, producing new distress and dysfunction. Exacerbated or newly activated symptoms, in turn, may result in increased avoidance behaviors, such as substance abuse or suicidality, as well as increasing the likelihood that the client will drop out of treatment.

It is not always easy to determine when symptoms are too intense to warrant immediate trauma-specific interventions, as opposed to being worthy targets of treatment. For example, when is posttraumatic stress or anxiety too severe to support therapeutic exposure to traumatic memory, and when are these symptoms in the range that would be appropriate for such treatment? Specific assessment approaches that may shed some light on these issues were presented in Chapter 3. Most generally, the issue is whether the symptoms in question have significantly reduced the client's capacity to regulate the almost inevitable upsurge of emotion that follows therapeutic exposure to unresolved trauma memories. If the increased activation is not overwhelming, classic trauma treatment is usually indicated. If the response to treatment would be to become flooded with overwhelmingly negative states, more grounding, skills-development, and/or supportive psychotherapy will be required until greater psychological stability is present.

Importantly, some forms of disorder traditionally assumed to be synonymous with psychological instability may not always be contraindications for emotional processing of past trauma. For example, some traumatized individuals diagnosed with B.P.D or low-level chronic psychosis may be sufficiently stable to tolerate trauma treatment, whereas others with seemingly less diagnostic severity (e.g., generalized anxiety or mild to moderate depression) may not. Clinicians often have appropriate concerns when working with psychotic or personality disorders because such disturbance is frequently associated with emotional regulation problems and more extreme dysphoria. However, the critical issue is less the type of disorder, per say, than the client's relative capacity to tolerate the emotions associated with exposure to traumatic memories.

Maintain a Positive and Consistent Therapeutic Relationship

One of the most important components of successful trauma therapy appears to be a good working relationship between client and therapist. In fact, studies indicate that therapeutic outcome is best predicted by the quality of the treatment relationship, beyond the specific techniques used. Although some therapeutic approaches stress relationship dynamics more than others, it is probably true that all forms of trauma therapy work better if the clinician is compassionate and attuned, and the client feels accepted, liked, and taken seriously. Even in short-term, highly structured treatment approaches (e.g., some forms of cognitive-behavioral therapy), clients with good relationships with their helpers are more likely to persevere in treatment, adhere to whatever regimen is in place, and, as a result, experience a more positive clinical outcome. Longer-term and more interpersonal treatment approaches, in which relational issues are more prominent, are even more likely to benefit from a strong therapeutic relationship.

Because trauma therapy often involves revisiting and processing painful relational memories, as well as potentially reactivating feelings of danger and vulnerability, successful treatment is especially contingent on therapeutic support and connection.

Distant, uninvolved, or emotionally disconnected client–therapist relationships are, in our experience, quite often associated with less positive therapeutic outcomes (see Dalenberg, 2000, for an empirically based discussion of this issue). At a minimum, a positive therapeutic relationship provides a variety of benefits. These potentially include decreased treatment dropout and more reliable session attendance, less avoidance and greater disclosure of personal material, greater treatment adherence and medication compliance, greater openness to—and acceptance of—therapist suggestions and support, and more capacity to tolerate painful thoughts and feelings during therapeutic exposure to trauma memories.

In addition to supporting effective treatment, the therapeutic relationship is more likely to be helpful to the extent that it both (1) gently activates memories and schemas associated with prior relational traw-muz and (2) provides the opportunity to process these activations in the context of therapeutic caring, safety, and support. As is described in more detail in Chapters 9 and 10, even the most benign client–therapist relationship may trigger at least some rejection or abandonment fears, misperception of danger, or authority issues in survivors of extended or severe trauma. When these intrusions occur at the same time that the client is feeling respect, compassion, and empathy from the therapist, they may gradually lose their generalizability to current relationships and become counterconditioned by positive relational feelings. In this sense, a good therapeutic relationship is not only supportive of effective treatment, but it is virtually integral to the resolution of major relational traw-muz.

Tailor the Therapy to the Client

Although a review of some currently available treatment manuals might suggest that clinical interventions are applied more or less equally to all mental health clients with similar complaints, this is almost never the case in actual clinical practice. In fact, the highly structured, sometimes manualized nature of some empirically validated therapies more directly reflect the requirements of treatment outcome research (i.e., the need for treatment to be highly similar and equally applied for each client in a given study) than any clinically based intent to provide equivalent interventions for all presenting clients. In the real world of clinical practice, clients vary significantly with regard to their presenting issues, culture, comorbid symptoms, and the extent to which they can utilize and tolerate psychological interventions. For this reason, therapy is likely to be most effective when it is tailored to the specific characteristics and concerns of the individual person. We next describe several of the more important individual variables that should be taken into account when providing mental health interventions, including trauma therapy.

Emotional regulation and memory intensity issues. As noted previously, emotional regulation refers to an individual's relative capacity to tolerate and internally reduce painful emotional states without undue avoidance. People with limited emotional regulation abilities are more likely to be overwhelmed and destabilized by negative emotional experiences—both those associated with current negative events and those triggered by painful memories. Since trauma therapy often involves activating and processing traumatic memories, individuals with less ability to internally regulate painful states are more likely to become highly distressed, if not emotionally overwhelmed, during treatment.

The emotional regulation construct can be oversimplified, however. For example, some people are better at tolerating or regulating one type of feeling (e.g., anxiety) than another (e.g., anger), despite the common implication that any given person has a generalized capacity to regulate emotions. As well, some people's emotional responses may be more intense than others' as a function of having been exposed to more painful experiences.

In this regard, it may take more emotional regulation capacity to downregulate emotions associated with some very painful memories (e.g., of torture) than those associated with less intense memories (e.g., of an automobile accident). It is rarely enough to decide that someone has “emotional regulation difficulties” without also determining the affective load that requires regulating.

Variability in emotional regulation capacity—and the severity of the memory-triggered emotions to be regulated—has significant clinical implications. Most generally, individuals with impaired affect regulation—especially in the context of easily triggered, highly painful memories—are more likely to experience overwhelming emotionality when exposed to upsetting memories during treatment and to respond with increased avoidance, including “resistance” and/or dissociation. Such responses, in turn, reduce the client's access to traumatic material and to the healing aspects of the therapeutic relationship. As described in Chapter 9, treatment of those with impaired emotional regulation capacities and/or a heavy trauma load should proceed especially carefully, such that traumatic memories are activated and processed in smaller increments than otherwise might be necessary.

Often described as titrated exposure or working within the therapeutic window or the window of tolerance, this usually involves adjusting treatment so that trauma processing that occurs within a given session does not exceed the capacities of the survivor to tolerate that level of distress—while, at the same time, providing as much processing as can reasonably occur (see Chapter 9). In individuals with substantially reduced emotional regulation capacities (and/or especially distressing memories), this level of exposure and processing may be quite limited at any given moment. Nevertheless, over time, even seemingly small amounts of trauma processing tend to add up, ultimately leading to potentially significant symptom relief and greater emotional capacity without the negative side effect of overwhelming affect.

Preponderant schemas. As noted in Chapter 2, trauma exposure often has effects on cognition. Depending on the type of trauma and when in development it occurred, this may include easily triggered perceptions of oneself as inadequate, bad, or helpless; expectations of others as dangerous, rejecting, or unloving; and a view of the future as hopeless. Such distortions inevitably affect the client's perception of the therapist and of therapy. For example, the survivor may expect the therapist to be critical, unloving, or even hostile or abusive.

Early child abuse and neglect may result in latent gestalts of preverbal negative cognitions and feelings that are easily evoked by reminiscent stimuli in the immediate interpersonal environment. These relational schemas, when triggered, may result in sudden, intense thoughts and feelings that were initially encoded during childhood maltreatment and that are hard for the survivor to discriminate from current, real-time perceptions. As a result, the adult abuse survivor may experience sudden feelings of abandonment, rejection, or betrayal during psychotherapy and attribute them to the therapist.

Because the cognitive effects of trauma vary from client to client, as a function of the individual's specific history, therapy must be adjusted to take into account each client's preponderant schemas of self and others. In general, this means that the clinician should do as much as possible to (1) respond in ways that specifically do not reinforce the client's negative expectations and (2) avoid (to the extent possible) triggering underlying cognitive-emotional gestalts related to broader themes such as interpersonal danger or rejection. The individual with a tendency to view important interpersonal figures with distrust, for example, may require a therapist who is especially supportive and validating and who is careful not to trigger too many memories of maltreatment. This does not simply involve statements to the client that they are safe or positively valued—more important, the therapist should act and respond in such a manner that safety and caring is demonstrated and can be inferred. Because the distrustful client will be predisposed to miss such signs, and perhaps even actively misinterpret them, therapeutic interventions must be even more explicit and obvious in these areas than is the case for those without (or with less of) this cognitive set.

It is important to note here that tailoring one's treatment approach to a given person's major cognitive issues does not mean that these distortions or disruptive schemas are no longer evoked in therapy. As noted in Chapter 10, no matter how hard the clinician tries, the survivor who has been substantially maltreated in the past is likely to view some of the therapist's behaviors as punitive, critical, or abusive, and thus issues in this area almost unavoidably become a topic of discussion during therapy. However, because the therapist is working hard to minimize the extent of these misattributions and triggered schemas, whatever emerges over time in therapy is likely to be less intense and more easily demonstrable as archaic and contextually inaccurate. The repetitive experience of fearing that one's therapist is cold and rejecting, for example, and yet finding, over time, that these perceptions are manifestly untrue, often can be extremely helpful.

Significantly, although clinicians works hard to communicate an absence of criticism or rejection, this does not mean that they discourage the client's discussion and processing of these perceptions and feelings as they relate to subtle client–therapist dynamics or to others in the client's environment. Ultimately, the goal is to make treatment possible for those who are especially sensitive and suspicious of the vulnerability, connection, and intimacy that are part of the normal operating conditions of psychotherapy. Knowledge that client X has “abandonment issues,” client Y tends to perceive caring as intrusive or sexual in nature, or that client Z responds to authority figures with expectations of hostility or domination can allow the therapist to adjust their approach so that it does not unnecessarily activate these issues and thereby unduly interfere with the process of treatment.

Gender issues. There is little doubt that men, women, and those who identify as nonbinary undergo many of the same traumatic events and suffer in many of the same ways. Yet, it is also clear that (1) some traw-muz are more common among those socialized or appearing as one gender than another, (2) North American culture tends to punish those who do not conform to traditional gender/orientation expectations, and (3) gender-role socialization often affects how such injuries are experienced and expressed. These differences, in turn, have significant impacts on the content and process of trauma-focused therapy.

As noted in Chapter 1, on average those identified as women in our culture are more at risk for victimization in close relationships than are men, and girls and women are more likely to be sexually victimized than their male counterparts. In contrast, those identified as boys are at greater risk than girls of childhood physical abuse, and boys and men are more likely to experience nonintimate physical assaults than girls and women. And, regardless of perceived gender, individuals identifying as transgender or nonbinary are more likely to be victimized than their cisgender peers.

In addition to trauma exposure differences, people socialized as men and women tend to experience, communicate, and process the distress associated with traumatic events in different ways. Although there is major variation among people within any gender category and across cultures and sexual orientations, those socialized as women are often taught to express more directly certain feelings, such as fear or sadness, but are taught to dampen or avoid others, such as anger, whereas those socialized as men are often more permitted the expression of anger, but may be socially discouraged from communicating “softer” feelings, such as sadness or fear.

Those socialized as men and women may also differ in how they act upon feelings and needs. In many cultures, men are to some extent taught to externalize or cognitively suppress unpleasant feelings, and to act on the environment in order to reduce pain or distress, whereas women are often socialized to express their distress to trusted others, and are, overall, less prone to externalizing their pain through acting on the environment. These gender-role-related differences in symptom expression and behavioral response often manifest themselves during trauma-focused psychotherapy. All things being equal, for example, trauma survivors in treatment who were socialized as males may be more prone to expressions of anger—or to denying posttraumatic distress entirely—than female survivors, whereas those socialized as female may be more open to emotional expression, especially of feelings of sadness, fear, or helplessness, but avoid discussing any angry feelings.

Given these sociocultural influences, the therapist should be alert to ways in which trauma survivors express or inhibit their emotional reactions based on gender-role based expectations. Often, this will involve supporting the client to express the full range of feelings and thoughts associated with a traumatic event, as opposed to only those considered socially appropriate to their gender. In fact, to the extent that (as described in Chapter 9) feelings and thoughts are more easily processed when fully expressed during treatment, unaddressed gender-role constraints are likely to inhibit full psychological recovery.

The therapist also should be aware of gender differences in how trauma is cognitively processed. Because those socialized as boys and men are often trained to present themselves as strong and able to defend themselves, victimization may be more of a gender-role violation for them than it is for girls and women. Such social expectations can result in different responses to trauma. Some victimized men, for example, may struggle with feelings of inadequacy, shame, and low self-esteem associated with the social implication that an inability to fight off maltreatment reflects, irrespective of sexual orientation, lesser masculinity or competence.

In addition, some sexually assaulted or abused males have sexual orientation concerns related to their trauma. In the case of childhood sexual abuse, for example, heterosexual boys and men may fear that molestation by another male has caused them to be (or be seen as) latently homosexual —a response that, in a homophobic culture, may result in compensatory hypermasculinity or overinvolvement in heterosexual activity. Conversely, for example, gay or bisexual men who were sexually abused by males as children may believe that their sexual orientation somehow caused them to be abused by men or that their abuse caused them to be paradoxically attracted to men.

This is a complex issue, since some studies indicate that L.G.B.T.Q plus people do disproportionately report childhood histories of, for example, sexual abuse, and gender nonconformity is associated with physical assaults in childhood. It is also unclear what role early sexual contact with older people, violent or otherwise, play in influencing sexual orientation. Above-and-beyond these issues, however, social attributions of responsibility can be internalized by the survivor to suggest that their nonconforming gender expression or nonheterosexual orientation means that they asked for or deserved what happened to them, leading to misplaced feelings of guilt, shame, and self-hatred.

Gender-role expectations also affect how some traumatized women view their victimization. Those socialized as women may have been made to believe that they in some way enticed their perpetrators into raping them—a concern that reflects the traditional stereotype of females as sexual objects who are intentionally or unintentionally seductive. Similarly, women assaulted or otherwise abused by their partners may believe that their supposed lack of subservience or failure to perform as an adequate mate means that they deserved to be maltreated.

Given these gender-specific influences on trauma-related cognitions, the clinician is likely to be more helpful if they closely attend to concerns about unacceptability, self-blame, low self-esteem, shame, and sexual orientation as they are expressed in survivors' cognitive reactions to trauma. Traumatized people socialized as men may require additional reassurance that they are not less masculine (regardless of sexual orientation) by virtue of having been victimized and may gain from interventions that support the full range of emotional and cognitive expression without fear of stigmatization. Especially relevant in this regard is the need for some victimized men to process feelings of shame associated with viewing themselves as deviant and socially unacceptable. Some women survivors, on the other hand, may gain from interventions that support self-determination and that help them to reject feelings of responsibility for their abuse, including the unwarranted notion that they somehow sought out or otherwise deserved maltreatment.

Be Aware of—and Sensitive to—Sociocultural Issues

Social maltreatment. As described in Chapter 1, social, gender, economic, and racial discrimination, as well as marginalization of people who identify as L.G.B.T.Q plus, are associated with a greater risk of trauma and are likely to have direct negative psychological effects that are, in a sense, posttraumatic. Social maltreatment and marginalization also means that many traumatized people continue to have reduced access to appropriate mental health services, let alone trained, trauma-informed clinicians. Combined with the discrimination often experienced by racial, ethnic, and gender minorities—and the relatively dangerous living environments in which many are forced to live—social inequality provides a vast depot of trauma and trauma impacts in North America. For these reasons, it especially important that therapists take the reality and effects of social injustice into account when providing services to socially marginalized clients and work to ensure that their therapeutic responses are manifestly antisexist, antiracist, and fully accepting of L.G.B.T.Q plus people.

Refugees, asylum seekers, and other immigrants. Immigrants are notably at risk of discrimination and maltreatment in North American and other cultures because they tend to arrive with little social status or money and often are of minority racial or ethnic status in their new country. Further, officials of many countries (including the United States) have been known to arrest and jail undocumented migrants, separate them from their children, and/or place them in overcrowded holding facilities until their immigration status can be adjudicated. The stress of relocation, in combination with such adversities, has been shown to increased anxiety, depression, posttraumatic stress, and other psychological difficulties.

Beyond socioeconomic, racial, and immigration issues, refugees often carry with them traw-muz experienced in transit or from their countries of origin. Mental health centers specializing in refugee, asylum seekers, or immigrant issues regularly deal with the effects of holocausts or mass murder (e.g., ethnic cleansing), political imprisonment, war, torture, trafficking, “honor” killings, sexual violence, and extreme ethnic or gender discrimination. The effects of such experiences tend to be especially long lasting. In one sample of 80 Vietnamese refugees resettled to Norway, for example, the majority still had very high symptom scores on a standardized measure 23 years later. The combination of social adversity and ethnic variation means that cultural and historical issues are often highly relevant to the process and content of trauma-focused psychotherapy and should not be overlooked.

Cultural variation. Partially because ethnic and racial minorities are more likely to be traumatized, and partially due to the general multicultural mix present in many modern societies, individuals presenting for trauma services are likely to reflect a wide range of cultures and ethnic groups. Such cultural differences are not merely a function of race: People of low socioeconomic status often have different world views and experiences than those of the same race or ethnicity who have more economic and social opportunities. Similarly, merely knowing that someone identifies as, for example, “African American,” “Hispanic,” “Asian,” or “American Indian” says little about their cultural context. An individual from Vietnam, for example, may be quite different in perspective, language, and emotional style from a person raised in Japan.

These wide cultural differences often translate into different trauma presentations and idioms of distress, as described in Chapter 2. In addition, above and beyond their social status in North America, people from the various cultures and subcultures of the world have widely different expectations of how clinical intervention should occur, and the ways in which clinicians and clients should interact. In one culture, for example, eye contact between clinician and client is a sign of respect; in another, it may be the opposite. Similarly, in some cultures, certain topics (e.g., sexual issues, visible loss of dignity) are considered to be more embarrassing or shameful than in others, and thus should be raised only when relevant to treatment, and then with great sensitivity.

Overall, a central point should be made: Cultural awareness and sensitivity are important parts of any psychotherapeutic process—including trauma therapy. Clinicians who find themselves, for example, regularly working with Cambodian refugees, Hmong clients, or immigrants from Mexico have a responsibility to learn the primary rules of clinical engagement with people from these cultures, as well as something of their culture, history, and, ideally, language.

Monitor and Control Counteractivation

An additional important concept in trauma-focused therapy is what is commonly referred to as countertransference (described as counteractivation in self-trauma theory [Briere, 2002b]; see Chapter 10). Although this phenomenon has many different definitions, we use it here to refer to occasions when the therapist responds to the client with cognitive-emotional processes (e.g., expectations, beliefs, or emotions) that are strongly influenced by prior personal experiences. In many of these cases, these experiences involve childhood maltreatment, adult traw-muz, or other upsetting events. Of course, all behavior is influenced by past experience, and not all counteractivation responses are negative. Even positive countertransference, however, must be monitored by the therapist, since it may produce unhelpful responses such as idealization of the client, the need to normalize what are actually problematic client behaviors or symptoms, or even sexual or romantic feelings. Ultimately, the concern is that counteractivation can interfere with treatment by leading to either (1) a deleterious clinical experience for the client or (2) processes that disrupt the treatment process.

For example,

- Therapist A was raised by a critical, psychologically punitive parent. They now find that they tend to experience angry or guilty feelings when their clients complain about any aspect of the therapy.

- Clinician B experienced a traumatic miscarriage a month ago. Upon hearing her client's excitement about a new pregnancy, she experiences unexpected anger and distress.

- Therapist C, who is dealing with a recent traumatic death of a loved one, finds that they are prone to feelings of extreme sadness and emptiness while treating a client whose son was killed in a fire.

- Clinician D grew up in a violent, chaotic family atmosphere, where safety and predictability were rarely in evidence. Their supervisor notices that Clinician D has a strong need to control the process of therapy and tends to see certain clients as especially manipulative, malingering, or engaging in therapeutic “resistance.”

● As a child, Clinician E was often protected by a supportive aunt when his mother would go into angry, abusive tirades. He is now treating an older, kindly woman whom he has a difficult time seeing as psychologically compromised, despite her obvious symptomatology.

● Clinician F was raised in a family where cynicism and confrontation were the norm and any “abnormal” behavior or role violations were sharply criticized. As an adult, they tend to dismiss the concerns of clients who report seemingly unusual symptoms, such as severe dissociative responses or

episodes of posttraumatic reliving, or who describe especially horrendous and complicated abuse scenarios.

An additional form of counteractivation involves therapist denial or cognitive avoidance of certain subjects or themes during the treatment process. A clinician who tends to avoid thinking about unresolved traumatic material in their own life may unconsciously work to prevent the client from exploring their own trauma-related memories and feelings. In such instances, the clinician may even become resentful of the client for restimulating their own avoided memories or feelings or may reinterpret appropriate client attempts to confront the past as hysteria, self-indulgence, or attention seeking.

The primary manifestations of an unconscious desire to distance oneself from the client's distress are attempts to avoid discussion of the client's trauma history and generally decreased emotional attunement. In each instance, the underlying strategy is the same: reduced therapeutic contact as a way to reduce the likelihood of triggered emotional pain. When this response is especially powerful, the clinician may slow or neutralize therapy by decreasing the client's exposure to traumatic material to such a point that it is not processed. At the same time, therapist distance or lack of attunement may activate client abandonment or neglect issues, further impeding treatment.

Reducing counteractivation. As noted earlier, not all counteractivation is necessarily problematic, and, in fact, probably all therapists experience some degree of counteractivation in their work. When it interferes with treatment, however, steps must be taken to reduce its influence.

One of the best preventive measures against countertransference problems is regular consultation with a seasoned clinician who is familiar with trauma issues and, hopefully, the therapist. Another option is to form a consultation group with one's peers. However structured, such meetings should allow the clinician to share the burden of their daily exposure to others' pain as well as to explore ways in which their own issues can negatively affect therapeutic outcome. In many instances, inappropriate identification or misattribution can be prevented or remedied by the consistent availability of an objective consultant who is alert to countertransference issues in general, and the clinician's vulnerabilities in specific.

An additional intervention, for clinicians who acknowledge the impacts of trauma in their own lives, is psychotherapy. It is an ironic fact that, at least in some environments, clinicians endorse the power of psychological treatment for others yet eschew it for themselves as somehow shameful or unlikely to help. This double standard is unfortunate, since having experienced psychotherapy is usually a good thing for therapists. Therapy is not only likely to reduce the clinician's trauma-related difficulties; it can also increase the richness of their appreciation for human complexity and can dramatically decrease the intrusion of their issues into the therapeutic process.

Practice Ethically and Within the Standard of Care

A final topic in this chapter is that of ethical and professional practice. Because the trauma client is often in a vulnerable state, and psychotherapy generally involves a relative power imbalance between client and therapist, it is very important that the clinician attend to any issues or dynamics that might even remotely result in maltreatment, exploitation, or inadequate care.

In many cases, ethical and risk-reducing activities correspond to what would be good therapeutic practice in any event. For example, honoring the client's boundaries, refraining from any form of exploitation or maltreatment, reporting and (when appropriate) intervening in potential danger to the client and others, and guarding the client's confidentiality all reflect activities that increase safety, support identity development and functioning, and encourage a positive therapeutic relationship. Similarly, therapists should take care to not overdisclose their personal history, relationships, preferences, or ideas about things unrelated to the client, and should limit the extent to which the client and therapist interact outside of the treatment environment. This not only allows them to better manage the client's trauma activations, but it also addresses professional and ethical issues around dual relationships, clinical boundaries, and professional standards of care. Finally, professional requirements regarding documentation and charting allow the clinician to monitor the client's progress in therapy, such that treatment interventions correctly address the client's current needs, as well as providing relevant information to other professionals when warranted.

As noted earlier, because the form of treatment outlined in this book emphasizes relational connection with—and positive regard toward—the trauma survivor, issues associated with counteractivation are especially salient. Although compassion—requiring nonegocentric caring and the need for the therapist to be interpersonally “present”—is an important part of trauma-focused psychotherapy, these issues occasionally can be challenging for the clinician. For example, when are one's caring feelings for the client based on compassion and appreciation of their suffering, and when do they potentially represent the clinician's own needs for intimacy or connection, or unprocessed sexual, romantic, or attachment issues?

Similarly, how is the therapist to discriminate and address understandable anger at the client's trauma perpetrator, or sadness at their irrevocable losses, from counteractivation of the clinician's own childhood memories? What is the exact boundary point that must be reinforced when the client requests additional attention, caring, or self-disclosure from the therapist? In some cases, responsibility and slightly increased connection or attunement can be helpful, if it is appropriate to the situation and monitored for counteractivational distortions.

In other cases, the therapist's overresponse to such demands or requests may reflect co-transferential dynamics and produce problems.

Although this is obviously a complex topic, we offer several suggestions:

Therapy boundary violations, including voyeurism, emotional gratification, exploitation, dual relationships (inside or outside of the therapy environment), romanticization, or any sexual behavior are unethical and potentially very harmful to the client. If the clinician believes that any of these phenomena might be occurring, they should proceed under the assumption that the concern is valid. Under such circumstances, outside help, consultation, or (in the case of actual behavior) intervention should be sought.

Authoritarian or overly directive treatment can have negative impacts. A corollary of this is that the therapist should not be definitive when the issues are complex, the client is, in some ways, unknowable to the therapist, and absolute truth is hard to find. Interventions that involve lecturing or heavy-handed declarations of fact are likely to go awry and may be bad practice. Examples include the following:

● Telling the client that they have or have not been abused, despite their statements to the contrary or a lack of evidence one way or the other

- Making definitive interpretations about the meaning or etiology of the client's current behavior when such hypotheses are largely speculative

- Validating or supporting prejudicial social messages about sex, race, age, ethnicity, sexual orientation, gender identity, or socioeconomic status

● Reinforcing dependency or acquiescence in someone who needs to become more entitled, self-referenced, and independent

● Rejecting or dismissing extreme trauma symptoms such as identity dissociation or prominent somatic symptoms as not real or the products of fantasy

- Making value judgments about things that are best seen nonjudgmentally, for example “bad” or “immoral” behavior

Duty to report trumps confidentiality. If the therapist becomes aware—or has reasonable suspicion—of child, elder, or dependent adult abuse, or of the client's danger to themself or others, the clinician must do whatever is required by law and professional ethics to ensure safety. This may involve the child welfare system, law enforcement, or involuntary hospitalization.

Issues in this area are sometimes hard for clinicians to confront, especially when the correct action goes against the wishes of the client. There are no easy answers to the breach of trust that the client may feel in such circumstances. We strongly recommend, however, that clients be informed at the onset of therapy about what the law or professional ethics require. the therapist to report or intervene in, so that such actions at a later date are less surprising.

Clinician counteractivation responses are, in our experience, typically triggered ones. If the therapist notes a sudden, significant change in their internal state or perspective, or intrusive phenomena similar to those outlined for trigger management in Chapter 8, they should entertain the hypothesis that such responses are at least partially a function of their own history, as opposed to solely client-level stimuli. Although this is not always true—sometimes sudden affective or cognitive shifts reflect insight or compassion—we generally recommend the psychoanalytic dictum that if the therapist suddenly wants to make an exception to the relational rules in therapy, the best advice often is not to do it and to reflect on the impetus.

As a correlate to the above, be wary of very strong feelings or reactions during therapy, even if they seem to be about social justice, the client's entitlements, or things that have been done to them. It is entirely appropriate to be on the client's "side," even to be their advocate when necessary and therapeutically appropriate. And social injustice should be confronted whenever possible. However, if the therapist detects strong anger, outrage, overidentification with the client, or an intrusive need to protect or parent, it is at least possible that they are being triggered and is responding to their own needs rather than solely those of the client.

Such instances violate a significant principle of relational treatment: The central unit of reference in psychotherapy is the client, not the therapist. All of this is difficult to parse in some instances, and we do not mean that the therapist should be distant or uninvolved. Rather, we suggest that the attuned and helpful clinician is someone who carefully scrutinizes their therapeutic behaviors to make as sure as possible that they are dedicated to the client's safety and well-being, as opposed to reflecting their own history, needs, or inappropriate expectations.

This work is sometimes very difficult, albeit important and meaningful. As noted earlier, we recommend that the trauma-focused clinician (as well as other helpers) access resources that can provide the support necessary to sustain this process—whether in consultation, supervision, or one's own psychotherapy. The clinician's willingness to hear painful things, connect with people who may have difficulty with interpersonal connections, and do this work rather than something else, is a tremendous gift to the traumatized client. But such work should not be done alone.

The reader is referred to the following sources for more detailed information on ethical practice, counteractivation/countertransference issues, and professional standards of care related to trauma treatment: Courtois and Ford (2012);; and Kinsler et al.,.

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