How do I use trigger discrimination techniques following a sexual assault trauma?

Usually with trigger discrimination, we are helping our clients to focus on the differences between ‘then’ (the trauma) and ‘now’ (the trigger) and we deliberately introduce triggers during therapy sessions to practise the technique (there is a great video demonstrating this on www.oxcadatresources.com). But of course there will be limits to which triggers we can introduce following a sexual assault trauma. For example, if your client is triggered by sexual touching, the smell of semen etc, these cannot be recreated in session.

The first step is to identify the exact triggers. There may be some which can be safely introduced in session. For example, if a sexual assault included choking and they are triggered by pressure on their neck, your client could practise placing their own hands around their neck, wearing a necklace or scarf and using ‘then vs now’ while gently applying pressure. Other tasks will need to be set up as homework. If your client is in a relationship, it is usually helpful to involve their partner in these discussions, if both parties are willing. You can explain the technique and then agree tasks to practise in between sessions e.g. a tight embrace while your client tunes into everything which is different from the trauma (where they are, that it is their partner not the perpetrator that they holding, that it is consensual, that they can stop at any time etc). It is important that your client feels fully in control of these tasks. Their partner can also help with discrimination e.g. by pointing out everything which is different and with grounding your patient if they dissociate. Resuming sexual intimacy if it has not previously been possible in a relationship can lead to unexpected changes in the relationship dynamics, so discuss these with your client and encourage them to take things slowly and maintain open communication with their partner.

For clients who are not in a relationship, there may still be triggers you can work on. They could recruit a trusted friend for some limited work e.g. around hugging, touching some parts of the body, although they will need to discuss and set boundaries carefully. We have also used tasks like going to a salsa class to practise stimulus discrimination while touching/holding people of the opposite sex where this has been a trigger for our clients. Alone, clients can experiment with using trigger discrimination while exposing themselves to sexual content such as watching films with love or sex scenes (PG or 15-rated), or reading women’s magazines with articles about sex, as part of overcoming sexual triggers. If they so wish, they could progress to masturbation, reading erotic literature or watching pornography. They may also want to plan for future sexual encounters by writing down or recording a video or voice message to themselves, with the help of the therapist, explaining trigger discrimination and how to use it, which they can access in the future when needed.

As always, it is important to negotiate these tasks collaboratively, making sure your client has full ownership over the interventions, understands the rationale and is comfortable with each task. They should never feel pushed into something where they do not feel comfortable. For clients who have experienced sexual assaults and abuse, sex may be associated with fear, disgust and coercion – this work may form part of a larger goal of reclaiming sexuality and associating sex with pleasure, control and consent again.

Lastly, for some clients, it isn’t the sensory elements of sexual contact which are the triggers, but the emotional experience of being vulnerable or intimate with another person, particularly when trust has been damaged. Here, triggers might relate more to opening up to another person or forming new interpersonal connections. Again, with a little creativity, these triggers can be introduced through homework tasks e.g. telling a friend something personal or messaging someone through a dating app. These assignments will also form part of behavioural experiments to test beliefs such as ‘if I am open with another person about my feelings, they will take advantage of me’.

Key points

• Stimulus discrimination includes deliberately introducing triggers to re-experiencing symptoms in therapy and practising ‘then vs now’.

• Some triggers may be possible to recreate in therapy (e.g. self-applied pressure to the neck), but others (e.g. sexual touching) will not be appropriate or safe.

• If the client is in a relationship, their partner can be involved in therapy and homework tasks set to introduce sexual triggers while using discrimination.

• If the client is not in a relationship, homework tasks can still be used to encounter some types of triggers e.g. non-sexual touching with a friend, or by themselves by accessing sexual material in films or magazines.

• Client consent and control in all such tasks is important.

• Triggers may also include emotional experiences of vulnerability and intimacy. These can be recreated in homework tasks involving interpersonal connections.