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My client shows no emotion during reliving – what should I do?

We all differ in how we express emotion, often influenced by our upbringing and culture. In therapy, the way in which our client expresses their emotions is perhaps less important than whether they are allowing themselves to experience them.

During imaginal reliving, we are trying to help our clients stay in the therapeutic window – accessing the memories and their associated meanings and emotions, without becoming so overwhelmed that they lose track of the here and now or feel so distressed that they need to stop. We take ratings (usually at the end of reliving) of distress and ‘nowness’ to help us monitor this. We also ask gently how they found reliving, if they learnt anything new, and if they were holding back in any way from the memory.

If somebody shows no visible signs of distress but rates their distress highly and does not report holding back, we can assume they are accessing the memory and continue as normal. We might comment on the fact that they did not seem outwardly distressed and ask a little about it, as this might reveal a safety behaviour that could be a useful treatment target later on if it causes any problems e.g. ‘people will judge me negatively if I seem upset’. But, for the purpose of processing the memories and accessing the worst meanings for us to update, visibly showing emotion isn’t necessary, as long as they feel it.

However, if someone reports that they did not feel distressed when they did the reliving, or that they felt they were holding back, we need to address this further to help them get into the therapeutic window. This is important because it will be difficult to change the meanings associated with the trauma memories without accessing them at an emotional level.

Here are some reasons why memories might be under-activated, and what to do:

· It isn’t actually PTSD. If someone experiences very little distress or arousal when they relive the trauma memories, it is worth checking that they have re-experiencing symptoms of PTSD (vivid intrusive and unwanted memories, flashbacks, nightmares and/or emotional and physiological arousal when confronted with reminders). If someone is having terrifying nightmares about the trauma but doesn’t experience distress when they talk about the trauma, then it is very likely a case of under-activation. However, if they aren’t having re-experiencing symptoms, it may be that they ruminate about the trauma or their feelings, but PTSD is not the most fitting understanding of their problem and, if so, a different treatment option might be more appropriate.

· Low imagery ability. A minority of people struggle to form mental images so will find

treatment techniques that rely on imagination, including reliving, very difficult, frustrating, and unlikely to be helpful. You can check imagery ability by asking your client to generate a neutral image (e.g. a sunrise) or relive a recent memory like their journey to therapy that day. If they struggle to bring visual images to mind, you may need to use forms of memory work that rely less on imagination, like written narratives or ‘playing out’ the trauma using spatial maps.

· They were numb during the trauma. If someone felt numb at the time of the trauma, they may feel numb when accessing the trauma memories. The problem here is not that they can’t activate the memories, but that the peri-traumatic numbness is being re-experienced. Clients can sometimes recall whether they felt numb at the time of the trauma or not. Another way of checking is to monitor the feelings attached to re-experiencing symptoms. If, when a client has flashbacks or nightmares, they re-experience a sense of numbness, this is probably how the memories were stored (and how they felt peri-traumatically). If so, you don’t need to adjust reliving, but focus on the parts of the trauma which are associated with strong emotions, as these will be the distressing parts of the memories.

· Beliefs about emotions. Clients will understandably avoid feeling strong emotions if they have negative beliefs about them e.g. fearing going mad or being overwhelmed. For some people, this avoidance is conscious and deliberate, but often it happens automatically. We all have emotional schemas - belief structures that we hold about our emotions, typically linked to our upbringing and cultural influences. It is worth discussing your client’s views on emotions, especially if they are reporting holding back in some way. We can validate and normalise these, and use guided discovery (such as reviewing evidence) to address any catastrophic beliefs e.g. ‘I’ll lose control and lash out if I become upset”. Behavioural experiments can be useful here, for example allowing emotions to increase to a certain level (e.g. a SUDs rating of 30/100) by deliberately thinking of something upsetting, and then monitoring what happens if the emotion is not suppressed.

· Beliefs about the therapist’s reaction. Sometimes the beliefs that emerge through discussions about the emotional impact of memory work relate to the therapist. Some of our clients believe that we will judge them negatively if they tell us about the trauma or if they become emotional in sessions. Others feel protective towards us and don’t want us to hear something unpleasant in case it causes us harm. If so, it can help to provide some information about the therapist’s context and training; for example, that therapists have regular supervision that addresses technical aspects of their work and also provides them with emotional support. Clients may be reassured to hear that their therapist has worked with many other people who have experienced traumatic events and has heard about a wide range of experiences, including very disturbing material. We sometimes use the metaphor of therapy as a ‘laboratory’, with ‘psychological protective equipment’ and systems in place designed to make the work safe for both of us, just as if we were handling toxic substances. It can also help to remind clients about confidentiality, and that upsetting details they choose to tell us will not be repeated elsewhere. Be aware that clients who are embarrassed or ashamed may be closely monitoring us for signs of distaste, judgment, and distress. We need to clearly signal unconditional positive regard for our clients, both verbally and in our manner, to model that we are not shocked by, or critical of, what they tell us.

· Beliefs about the meaning of the trauma. The final type of beliefs that can contribute to under-activation is those related to the meaning of the trauma. For some people, the trauma has such a painful personal meaning that their only means of coping is to numb themselves or find another way of suppressing the memories. Again, this can be a very deliberate process, can be more like a habit, or feel entirely automatic and outside their control. If so, we can work on these difficult personal meanings ‘outside’ the trauma memories before we revisit them via reliving. This way, we will be prepared with updates that we can immediately bring into the memories during reliving, hopefully minimising distress.

Working on these barriers to emotions will hopefully help our clients into the therapeutic window. For some people, the avoidance or numbing is so hard-wired that they struggle to access emotions even when they try. If so, it can be helpful to increase the emotional intensity of the reliving. This is also useful for people who are easily distracted or struggle with mental imagery. To increase the intensity, we ask the client to speak in the first person, present tense, closing their eyes, dim the lights in the therapy room, and reduce any distractions, like closing the window blinds and turning off the screen of a computer. We intervene minimally, to avoid distracting the client from the memories, and only take ratings after reliving. Some of our clients feel self-conscious and prefer us to turn away or close our own eyes during reliving.

Through questions that direct their attention, we also encourage our clients to focus on the emotions and physical sensations they experienced at the time of the trauma. Be vigilant to the client avoiding difficult moments, slipping into the past tense, or giving a very rehearsed or matter-of-fact account of the trauma that minimises the emotionality. Gently prompting them to describe their feelings and physical sensations (e.g. what they feel in their gut at those worst moments, plus tastes, smells, and touch) should increase the intensity of the experience.

Especially for our clients who struggle with generating images, it is possible to activate the trauma memories by introducing triggers in the session. Combinations of triggers can be used for a stronger response. An even more powerful way of introducing triggers is to revisit the trauma site. Although usually undertaken towards the end of therapy, under-activated trauma memories are a good example of when to use a site visit earlier in treatment. This can be done virtually if necessary, but an in vivo site visit is usually more effective if possible, as there will be many triggers to the trauma memories.

Key practice points

· Expressing emotions during reliving is less important than the client experiencing them, thereby entering the therapeutic window.

· If they do not display emotions, but do feel them, reliving can proceed as usual.

· However, if they cannot access emotions during reliving, we need to understand why.

· It is worth checking they have re-experiencing symptoms of PTSD in case they have been misdiagnosed.

· Some people have low imagery ability so benefit from techniques that rely less on imagination.

· Others may be re-experiencing peri-traumatic numbing and reliving does not need adaptation.

· Some clients have negative beliefs about emotions leading them to understandably hold back, which can be address through guided discovery including behavioural experiments.

· Some may be anxious about the therapist’s reaction and benefit from psychoeducation about the structure supporting the therapist’s role, their experience and confidentiality.

· Lastly, clients may hold back if the meaning of the memory is very toxic, in which case this can be addressed before returning to reliving.

· Increasing the intensity of reliving, focusing on emotions and sensations, introducing triggers and/or site visits can all help to activate the memory.

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