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How can I do physical updates if the trauma involved sexual violence?

As ever, when we update hotspots in a trauma memory, our focus is on what they mean to the client, and our updates follow that. Meanings are always highly individual, so we don’t make assumptions about what will help. For example, during a sexual assault, there might be meanings related to fear (e.g. ‘they are going to kill me’), guilt (e.g. ‘it’s my fault for getting into this situation’), shame (e.g. ‘I’m pathetic for not fighting back’), anger (e.g. ‘how dare they do this to me’), disgust (e.g. ‘his semen is all over me, I’m contaminated by him’) and so on. Often there are multiple hotspots in a trauma memory, and each hotspot might have more than one layer of emotions and meanings attached.


When we update hotspots, we try to bring in new information that addresses the appraisal at the time e.g. ‘they didn’t kill me’. Sometimes a simple verbal update like this is enough but, to really make the update stick, and to help with any head-heart gaps (i.e. knowing something but not really feeling it), we often try to introduce evidence to confirm the update and also “time stamp” the memory as in the past. Hence we also use multiple modalities in the update, including movements, actions, images, or sensations. For example, with our ‘they didn’t kill me’ update, we might want somebody to elaborate how they know they didn’t die e.g. to look at a recent photo of them spending time with their family, to move around to show they still can and look in a mirror to show they are alive.


Often hotspots related to sexual assault can be highly sensory, both because of the intensity of the physical threat experienced, and also due to the effects of dissociation on fragmenting the trauma memory. So, as your question implies, physical updates might be really important in helping update very physically and viscerally experienced memory hotspots. Often during sexual violence people are frozen, trapped, pinned down and may feel suffocated. Therefore, movement is helpful as an update to combat the sense of helplessness, despair and panic that commonly occurs. Standing up, shaking out all the limbs, taking deep breathes etc while holding these trauma hotpsots in mind can all help elaborate an update like ‘I’m not trapped anymore, I can move, I can breathe, I’m in control of my body, my attacker isn’t here anymore’.


Some clients may find it helpful to touch parts of their body where they were held to show themselves they are free and/or clean e.g. to touch their wrists to show they aren’t being gripped any longer, their neck and mouth if they were strangled or choked during the trauma, or their skin to show there are no bodily fluids there.


Touching their own sexual organs can be helpful too, but needs to be approached carefully to make sure this feels appropriate and safe. This would include a conversation prior to updating about what the client is comfortable in doing, making sure they are giving informed consent to the technique and its rationale, that they feel in control of what and how they do it, and are able to tell us anything they don’t want to do. We’d also suggest discussing this in supervision prior to the session. This is particularly important if you are a different gender to your client and/or match the gender of the person who assaulted them. Clients may also prefer to only use this update outside of the therapist’s view and/or only when they practise updating outside of the therapy sessions.


An alternative or additional type of update might incorporate imagery. This can be particularly powerful to incorporate themes of mastery (if the client felt helpless peri-traumatically) and cleanliness (if they felt contaminated or disgusted during the trauma). Images might simply be used as updates, for example imagining the perpetrator now in prison to strengthen a new meaning like ‘he can’t hurt me anymore’, or they can be rescripts where we ‘re-write’ the trauma memory in imagination. Imagery rescripting usually aims to address the meaning of the trauma memory by giving the client the emotional experience of a different outcome. For example, for a sexual assault where the main cognitive theme was helplessness, the client could imagine overpowering their attacker and kicking them out or sending them to jail, shrinking them down so they are the size of an insect and squashing them, or developing magic powers which allow them to zap the perpetrator into submission or have a magic cloak which now protects them from harm.


In our experience, some clients really like creative, fantastical imagery, while others prefer something closer to reality. We discuss ideas together and work out what feels emotionally congruent for the client. For a contamination or disgust experience, a client could imagine a way to feel completely clean, for example by teleporting to a waterfall which washes them clean. Regina Steil and her team (Jung, & Steil, 2011) have developed a two-session protocol which has been shown to be highly effective with sexual assault survivors (Jung, & Steil, 2013). In the first session, they calculate how many times the cells in the relevant part of the body have regenerated since the assault (for example, cells in the vagina regenerate every 7 days, so a sexual assault 3 years ago would mean that they have regenerated 156 times). In the second session, they generate an image to represent this new information, for example imagining the contaminated skin shed like a reptile, leaving a clean, uncontaminated skin beneath. There is a video demonstration of this on the OxCADAT resources website.


Remember that as hotspots can have multiple levels of meaning, our updates need to as well. An imagery rescript can incorporate different elements to address these. For example, a client who felt angry and alone during a sexual assault could try a rescript where they enter the scene as themselves now, strong and with special powers, and rescues and comforts the younger self as well as carrying out some revenge on the perpetrator. If you aren’t sure about using revenge imagery rescripts, check out another of our blogs on this topic.


References

Jung, K., & Steil, R. (2012). The feeling of being contaminated in adult survivors of childhood sexual abuse and its treatment via a two-session program of cognitive restructuring and imagery modification: A case study. Behavior modification, 36(1), 67-86.

Jung, K., & Steil, R. (2013). A randomized controlled trial on cognitive restructuring and imagery modification to reduce the feeling of being contaminated in adult survivors of childhood sexual abuse suffering from posttraumatic stress disorder. Psychotherapy and Psychosomatics, 82(4), 213-220.


Key practice points

· Updates address individual personal meanings attached to hotspots in the trauma memory

· They can be verbal, but are often enhanced by actions, sensations, movement, and images

· Physical updates are often important, particularly around movement and touch

· Updates that involve touching their own sexual organs can be helpful but require careful discussion in therapy

· Images can be used to enhance updates and imagery rescripts are often helpful to access a different emotional experience of the memory

· These can be fantastical or logical, but need to make emotional sense to the client

·For sexual assault, rescripts that include elements of mastery and decontamination can often be helpful.







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