When reliving distressing and aversive traumatic memories in therapy, it is entirely normal for people to experience strong physiological reactions that are in keeping both with the original memories and the emotions they generate in recalling them. Activating the emotional and physiological aspects of trauma memories during reliving is really important, as it helps contextualize the memory by ‘timestamping’ it, and helps you identify and update important distressing meanings attached to the key ’hotspots’.
The most common physiological reactions that are activated during reliving are those associated with fear, but other strong visceral emotions such as disgust can lead to inadvertent reactions in sessions such as vomiting. Sexual arousal is also driven by the autonomic response related to strong emotion, so when people feel anxious, excited or scared, it is not uncommon for them to also experience inadvertent sexual arousal.
Unwanted or inadvertent sexual arousal during trauma is a well-recognised phenomenon, often associated with fear and also sometimes arising from aspects of the trauma or the intentional behavior of the perpetrator. Naturally this can trigger secondary emotions such as shame, and a fear of judgement by their therapist if disclosed.
When reliving a trauma memory where there was inadvertent or unwanted sexual arousal, the client may re-experience that sexual response in the session as a part of remembering what they felt like in the memory. Importantly, although this was entirely out of the control of the person experiencing the trauma, they may then interpret the response as if it meant they invited or enjoyed the traumatic experience. This secondary meaning will typically carry a lot of shame and guilt, so how the therapist responds to this disclosure can be very important. Therapists can also find it hard to know how best to respond and so it can be helpful to be prepared for when it happens.
If a client experiences a sexual arousal response in a session with you, and they are concerned about it, it is really important to:
Praise their courage in letting you know, and gently explore their thoughts and feelings in making the disclosure.
Validate how understandable it is they might feel concerned or embarrassed, given they might worry what it means about them, or what others might think.
Reassure them that it is a common reaction to working on trauma memories in therapy, and that is not a problem for you as their therapist.
Normalise the reaction as a well-recognised feature of autonomic arousal associated with fear and distress, and/or recalling a memory of an unwanted sexual response during trauma.
Explore with them how they would want to address it if happens in session, and how they want you as therapist to respond if it happens.
It can be really helpful to offer your client additional psychoeducation about how the autonomic nervous system operates under all situations of stress – whether it be excitement, fear or anger – and how that modulates the sexual arousal response in both men and women, in terms of increasing blood flow to genitals.
This often runs counter to common understandings of the role of fear as inhibiting a sexual response, which in fact only applies when the fear relates to sexual performance itself. Highlight that it is an entirely automatic reaction that is not under the person’s control, unrelated to either sexual interest, sexual pleasure or indeed consent.
Where it relates to an unwanted sexual arousal response in the trauma memory, for example because of the intentional behavior of an abuser in a sexual abuse memory, then it is also important to provide psychoeducation about the effects of mechanical stimulation on genital arousal, again regardless of either interest, pleasure or consent. Here you can explain that in both men and women, mechanical stimulation can create a genital arousal response that is entirely separate from the psychological experience or indeed sexual interest, consent or enjoyment.
It can also be helpful to explain that perpetrators know about and exploit the genital response – often as a means to prevent detection – as it makes the victim (often a child) feel complicit and ashamed, and therefore less likely to report to others. Hence perpetrators may use the arousal response as a tool to facilitate the abuse.
In CT-PTSD, having discussed and normalised the response, it is then important to identify and restructure negative appraisals related to the response e.g., “getting aroused when I recall it means I wanted it, liked it, am as bad as the perpetrator, am disgusting etc.”
Once you have generated appropriate updates, bring them back into the memory hotspot associated with the response using 'updating in reliving', e.g.:
"Holding that moment in mind, with the thought 'I am as bad as the perpetrator for feeling this way', bring in what you know now...that your body experienced (and is experiencing) a genital response out of your control, that it is not your choice but related to how your body reacted to what was happening and the extreme fear you felt, and that it does not mean you wanted or enjoyed it at all”.
By updating the memory, so reducing the nowness and strength of emotion it elicits, the in-session sexual response may reduce, and/or it may help the client feel less distressed or ashamed about it when it happens.
Key practice points
Sexual arousal can occur in sessions when recalling trauma memories associated with strong emotions and/or unwanted sexual responses during trauma.
If a client discloses this happening, validate, normalize and discuss with them how they want to manage it.
Offer psychoeducation about the relationship between strong emotions, the autonomic nervous system and sexual arousal.
Where relevant, offer psychoeducation about the effect of mechanical genital stimulation during traumas such as sexual abuse.
Explain that the reaction is common, out of their control and unrelated to sexual interest, enjoyment or consent.
Use the psychoeducation information to restructure any distressing meanings associated with the sexual response and update trauma memory hotspots related to them.