emotional exposure and regulation

Utilizing exposure-based and emotion-focused interventions, the therapist helps the patient revisit traumatic material within a secure therapeutic container to transform fragmentation into coherence. Overtime, physiological arousal decreases while narrative coherence increases—an empirically supported indicator of trauma resolution (Craske et al., 2022; Greenberg & Pascual-Leone, 2006; van der Kolk, 2014).

When Cain hears the question, “Can you tell me about the betrayal?”, he likely experiences increased sympathetic nervous system activation, such as a flood of biochemicals in the body, increased heartrate, muscle tension, and sweating. The therapist understands that Cain may respond with, “No.” Avoiding this traumatic material is, in some cases, the safest option.

It’s not always wise to be vulnerable. To expose oneself to danger, perceived danger, or imaginal danger in the re-living of a traumatic event is to risk being harmed. When a patient decides to bravely affirm and delve into their traumatic memories, the therapy space becomes a sanctuary for healing, assuming the therapist is properly equipped to manage their own unconscious responses to the patients traumatic material. If the therapist is at all squeamish, then psychological transformation isn’t their purview, and Cain would be better off keeping his mouth shut.

Both the therapist and patient are exposed to psychologically harmful material.

Assuming the therapist in this case is sturdy in the face of vicarious trauma, as Cain begins to tell of the bloody mess he made of someone, it’s not out of the question for the therapist to shiver in fear. However, when the patient begins to shiver uncontrollably himself, the therapist must contain the space with an air of confidence, “Place your feet flat on the ground and control your breath.”

The therapist follows up by asking Cain how he feels, helping him identify the somatic symptoms of the unintegrated psychological trauma. When the patient appears stable, the therapist asks, “Would you like to continue telling me the story?”

“I grabbed my weapon…” as he describes the terror on his victims’ faces, Cain begins trembling again, this time sobbing. At this point the therapist realizes it’s too much and closes the traumatic dialogue. The aim at this point is to simply help the patient regulate his emotions and regain access to the parasympathetic nervous system through the ritualized grounding practice described earlier.

This process is something the dialogue intentionally traverses, over and over again. The pair are intentional about the telling of this story, experiencing the unintegrated emotions, and grounding themselves to embody the sacred container of the therapeutic space. When the story is only partially told, as in the instance above, then the team returns to it next session. Over time, this consistent and gradual exposure to traumatic material is the primary mechanism of healing.

For all of this to work, the therapist must remain here and now, focusing on what the patient is experiencing during the therapy hour and supporting the body’s capacity to metabolize the biochemical material released during exposure. It’s not wise for the therapist to share their interpretation, analysis, or opinion with the patient about their story at this stage in the process. Simply staying with the patient’s present experience, supporting emotional regulation, and taking copious notes is enough.