Why Trauma Therapy Goes Bad

We’re in the golden age of trauma therapy. We have research-supported treatments that are effective, efficient, and well-tolerated by clients. A lot of traumatized people are getting a lot more better than they ever dreamed was possible.

Yet many people who contact me for help are leery, because they’ve already tried trauma therapy and had a bad experience.

So you get into a room with a therapist and start opening up about the worst things that ever happened to you. What could possibly go wrong?

Well… a lot of things. The problem is that many therapists who are trained in a particular trauma resolution method (such as EMDR, PE, TF-CBT, etc.) are not very well trained as trauma therapists. Here are the treatment mishaps I hear about the most.

Wrong Therapist

This isn’t specific to trauma-focused therapy. Now and then I hear a story about some therapist who did something bone-headed, or (less egregious) just didn’t click with the client. It happens. And when the client doesn’t feel comfortable or safe with the therapist, it’s hard to get much done.

For example, someone told me that she brought up an important issue and her therapist responded by saying, “If it upsets you, you shouldn’t talk about it.” (Yes, this is a true story.) She didn’t go back to that therapist.

Inadequate Preparation

It’s important that a client be adequately prepared for trauma work:

  • They should understand how their trauma history is impacting their current situation, and how trauma healing can help them to get to their goals.
  • They should be stable enough and strong enough to be able to face the trauma work.
  • They should be prepared for some emotional pain during the therapy session.

Without adequate preparation, some clients report having felt blind-sided by the trauma therapy experience. If you don’t understand why the therapist is having you do it, or if you’re not expecting the (sometimes) intense emotional pain, you’re probably not going to hang around for much more.

No Chance

Some people report having worked with a therapist but never gotten around to working through the trauma memories. One way this can happen is by meeting so infrequently – every couple of weeks, or even once per month – that therapy can’t ever move beyond checking in, catching up, and perhaps a little pep talk or work on coping skills.

More commonly, the client has so much instability that it’s hard for therapy to get past a focus on stabilization and self-management skills. Unfortunately, that may only lead to more of the same. And sometimes the therapist is overly cautious and does not encourage the client to move past this, into the trauma work that could lead to lasting improvement.

Risky Target Order Strategy

This one will be more controversial, because we haven’t yet published our research, and because anyway our research is only preliminary. So take this as my personal clinical judgment, based on years of experience (and providing supervision) as well as preliminary research findings. People report that their previous therapists used what I consider risky “target order” strategies – that is, which memories to treat (target) in which order. I consider the following strategies risky.

  1. Going right for “the big one” or the memory that precipitated the symptoms the client is coming to therapy about.
  2. Treating whichever memory the client feels like working on at the moment.
  3. Within a cluster of similar memories (for example, a cluster of memories regarding exposure to domestic violence), using strategies 1 or 2.

Why do I say these are risky? Because of what I call the sore spot reaction. Let’s say that something bad happens at age 5 that creates a psychological wound, or sore spot. Something else bad happens at age 10, and because it hits that sore spot (from the earlier memory), it feels even worse than it would have. If you work first on the age 10 memory, it may go poorly because of the sore spot reaction from the earlier unresolved memory. If you work first on the age 5 memory, it will likely go well because there’s nothing underneath. And then when you get to the age 10 memory, having already worked on the earlier one, the later memory will go smoother as well.

Not that you can’t get away with these “risky” strategies sometimes. Many therapists routinely use these strategies and enjoy a fair bit of success. Which perhaps convinces them that they are doing therapy properly.

And we get some of their failures.

We Can Do Better

Many people who come to us have already tried therapy elsewhere. People may report that they were working with a trauma-trained therapist who did not do trauma work with them. And I often hear some variation of, “I tried EMDR, but it didn’t work.” Or worse, “It messed me up.” In those cases, when I inquire about what happened in the treatment, it almost always turns out that the client was not adequately prepared, and/or the therapist used a risky target order strategy.

We don’t take every case, because I don’t think everyone’s suitable for intensive trauma-focused therapy. We do take many cases in which the previous therapist either did not initiate the trauma work, or did but with poor outcome. Yet in nearly every case, the client is successful in their treatment with us. This tells me that it’s not that the client couldn’t do it.

There are plenty of excellent trauma therapists out there. But too many trauma trainings do not include sufficient focus on how to adequately prepare clients for the trauma work, and/or how to determine an effective target order strategy. The result is that well-intentioned therapists, who believe they have been properly trained, end up providing substandard treatment to some clients. Then the clients have to suffer for longer, and some may never be willing to try trauma therapy again.

We can do better, and we must. Now that we have the ability to help clients to heal from their psychological wounds, we have to get better at enabling them to get through the treatment. This is why some of our current research is focusing not only on treatment effectiveness and efficiency, but on how to help clients better tolerate trauma therapy so that they are able to hang in there and get the job done. This is why, when we teach trauma therapy, we do not offer brief training on EMDR or PC; we only offer full-length training programs that teach the entire trauma therapy approach. And this is why, when we provide therapy, we thoroughly prepare clients, and then work through the trauma memories in chronological order.

 40,470 reads

24 Responses

    1. Thanks Robin! That would be a special case of Wrong Therapist. There are many people out there who are still “old school,” read different scholarly journals than we do, and don’t have dissociation, or even trauma healing, on their radar.

      Or maybe I should have added a category: Incompetent Therapist. For those therapists who claim to know what to do with trauma, but simply don’t.

  1. Or the therapist doesn’t manage to organise ANY sort of safety, in the sence off: starting sessions on time, do what she promised (e.g. managing her FB-profile so future clients don’t get confronted with the sickness of close relatives – i’ve confessed googling her, she thanked me for it, promised to change the settings and it took 4 months to actually do so), offering to go to twice a week, and then forgetting the next session, which left me standing for 20 minutes in a hallway as I didn’t know which office she’d be in, etc. etc.
    We’ve talked about it, she’s said sorry, but nothing ever changed.
    She just couldn’t see she took on more than she could manage.
    I’ve decided to not go back.
    Feeling absolutely marooned, as I did attach to her, and I care for her deeply. Worry for her, cause she’s taking on too much.
    I’m losing this struggle to stay alive.

    1. Liz, I’m sorry you had this experience. This would go into the category of “wrong therapist.” Therapists are supposed to be helpful, not add problems. It’s good that you were able to recognize what was wrong, and ultimately to walk away. I hope you’ll try again and have better luck with the next one. BTW an earlier blog post talks about how to find a good trauma therapist.

  2. Therapist could be unaware of current emotional abuse the person is suffering and the impact that this might be currently playing in that person’s life. I’ve witnessed firsthand what kind of damage this can do to a family when a therapist starts this type of therapy without understanding the entire family dynamic and the risk for all family members.

    1. Matt, that’s another good point. It’s very difficult to treat trauma that is not over; or to treat something else when trauma is ongoing. And therapy can indeed increase risk in certain abuse situations.

  3. My therapist, who came highly recommended by someone I trust, refuses to even look at goals for this work. He refuses to talk with me about coping skills. He insists that I “drive the bus”, and then he makes liberal use of ridicule, judgement, hostility, and changing the subject when I tell him what I want to explore. When I asked him what training he has received for working with victims of childhood sexual abuse and cPTSD, he said, “Oh, the usual….I’ve read a handful of articles and two books.” When I say this isn’t working for me, he says that I will fare no better with any other therapist because everything is my fault. And then he states that he is the only one in the state who is capable of working with me. I cannot figure out what is so satisfying to him about retraumatizing me and then indicting me for being traumatized.

    1. Yikes. I hope this is your former therapist. Unfortunately there are bad eggs in the psychotherapy profession, as there are in every other. I hope your next one will be a lot better! At least it sounds like you know your way around.

  4. I hoped the competence of therapists had improved in the last few decades, but I cannot find one who can imagine that there could be a future for me. The prevailing sentiment seems to be that if you were abused as a child, you have to accept that your life is ruined.

    1. I guess you don’t know the same people I do :^)

      In much of the trauma therapy community — particularly among those using EMDR, PC, and TIR, perhaps a couple of other methods — the prevailing sentiment is “Let’s get to work and get your healing done.

    2. I’m so glad some people like me are receiving the help they need. I wish I could somehow find a therapist like the ones you know.

    3. If you’d like some assistance in this regard, please send me an e-mail. (Click on the e-mail link on the bottom left of the page.)

  5. Hi I have just been through a terrible time with a therapist. I mentioned the awful abuse I have been going through. I told the therapist I wished these people dead from all my trauma. she looked at me and promptly told me I am evil and what ever happened to me is my fault . right now I am hurting badly. My abusers are still in my life I know I must help myself get out of this situation however, when a therapists blames you it is retraumatising in the worse possible way
    Thank you again
    Linda

    1. I’m so sorry you had that experience! Unfortunately, mental health professionals are not superior human beings, and we have just as much variation in our profession as in the general population. I hope you will find a better therapist!

  6. Recently completed my first session of EMDR and since then (3 days) I’m having nightmares, I can’t stop shaking, I’m over the top paranoid, I jump at every noise, my ocd is intensified… It’s like all of my symptoms have grown. Is this supposed to happen??

    1. No, it’s not supposed to happen that way. But things like this can happen. It’s important to tell your therapist about this, right away, so the therapist can help you to get out of this activated state.

  7. I might add that in certain cases (and this reflects my own experience) both therapist and client may be unaware of the trauma. In my experience, I had normalized the abuse and thus didn’t realize that I needed to bring it up in therapy. This resulted in treatment for anxiety symptoms without taking trauma into account.

    The treatment was way too triggering for me, and I found that the therapists interpreted my becoming triggered as “difficult” behavior on my part. Unfortunately, several rounds of this layered on additional trauma to the point where even seeking therapy is highly triggering, and actually going to an appointment requires 24-48h to recover (even if no actual therapeutic work is done at all).

    1. It’s not the client’s job to know how to guide the treatment. They should be able to rely on the professional for that.

      We train therapists to obtain a trauma and loss history in every case. And then to treat the trauma/loss component of every client’s presenting problem, along with working on coping skills or whatever else is called for.

      Therapy might still be an ordeal. But at least the therapist should know what they’re dealing with, and the trauma history should be on the table. In my opinion.

  8. Where are you in N. California?

    How do you know if one is prepared for the intensive trauma therapy?

    My client may be somewhat abusing Rx amphetamines, had been an addict and escort when young, is paranoid.
    Source may be childhood sexual abuse that their parents didn’t protect or help them heal from.
    Recently 5250d by client’s parent, who is accusing them of over-medicalizing grandchildren (illness is real, and girl was cyber-groomed, but client likely is over-protective due to their trauma).

    So what would client need to do to be ready for your intensive?

    And, are you accredited by any organization?

  9. My therapist tried emdr with me today and when she turned on the vibrating handles I became completely calm in the memory and her opinion was that the trauma is too deep and that my brain is shutting it off (maybe not her exact words). Is this true? Was I supposed to feel more emotional?

    1. I don’t have enough information to tell you what happened or why. That is a somewhat unusual response, and it could mean a number of different things. Sorry I can’t be more informative.

Leave a Reply

Your email address will not be published. Required fields are marked *