"I'm not going to ask you to tell me about all the worst moments in your life and then schedule you for another appointment to do it again next week." I often share this bit in my first sessions with individuals who have experienced trauma. While it may go without saying, this is what many imagine trauma-focused therapy could be like. Unfortunately, I've heard many nightmarish stories that likely encourage this myth.
Processing and moving toward healing of trauma involve walking on sacred grounds. These are often some of the most painful memories we have. In the case of PTSD, what may seem like innocuous reminders of the event can shoot into a flurry of agonizing memories, emotions, and thoughts. It's like tapping on an infected tooth. It hurts!
Still, when those events are effectively processed, the level of freedom experienced is equally powerful. A person might be able to sleep through the night for the first time in years. They can drive down roads that at one time reminded them of the experience to the point that they took detours. There is a newfound sense of peace and often post-traumatic growth.
Still, psychotherapy that addresses trauma is intense and has the potential to harm if not done well. It needs to be done in a timely and intentional manner, gaining feedback all through the way. There are several evidence-based treatments for trauma, ranging from eye movement desensitization and reprocessing therapy to cognitive processing therapy. Still, any trauma therapy delivered poorly can cause significant psychological suffering and setbacks.
Most therapists do not aim to cause harm. Rather, we monitor for adverse reactions as we move through these delicate spaces. Sometimes, unfortunately, harm is difficult to predict.
These are 10 common mistakes made in trauma therapy.
1. Your Therapist Asks You to Tell Your Trauma Story on the First Session
The telling of secrets in safe places is one of the most healing things there is. Yet, in an initial therapy session, we are still working on creating that safe space. Therapeutic rapport needs to be built and assessments provided. You may choose to share briefly about relevant events you wish to work on. Still, no therapist should open a first therapy session with, "Tell me about your trauma." We need to assess where you are in your journey so that we can navigate the many ways your disclosures may affect you.
2. Your Therapist Insists That There Has to Be a Trauma Behind Every Issue You Bring Up
Trauma-informed care highlights the high prevalence of trauma and its interwovenness in a variety of aspects of psychological suffering. Still, we have to be careful when looking through a trauma-informed lens not to mislabel things as trauma-based that might not be. Your fear of abandonment could be related for example to a trauma of losing a parent, or it could be related to obsessive thoughts that are not trauma-related. A careful assessment is necessary to pinpoint what is and is not related to trauma.
3. You Are Telling the Same Story Over and Over
OK, so I will put a caveat here. Certain therapies such as prolonged exposure and cognitive processing therapy do involve some repetitive retellings of the story as various aspects are explored and faced. In addition, what any individual finds helpful varies widely. If you are finding that telling your story repeatedly is helpful for you, then that is OK. Still, the trauma targets you are approaching and the order these are approached is typically an ongoing conversation with your therapist. Your therapist may have a case conceptualization plan of how your memories relate to treatment targets and how these will be addressed.
4. Your Therapist Is Telling You What You Found Traumatic.
Perhaps nothing is more individualized than trauma. What one person finds traumatic, such as a hospitalization, another person might not. Things like the level of support you had, how the event fits in with the overall story of your life, the important people involved, whether a sense of betrayal was present, and the resources you had to heal all play a role in how any given happening will impact a person. If you found something traumatic, that is valid. When it comes to therapy, for example, it doesn't matter if the state intervened, if marks were found, or if other people said what happened was abuse, if you were impacted it was traumatizing. Similarly, not all potentially traumatizing events are. What might be the most shocking part of your story to others may not be the most troubling for you. You are the best expert in your life.
5. Your Therapist Is Encouraging You to Isolate
Another caveat here; there are situations where a therapist may encourage you to withdraw from something harmful. For example, if you have been in a domestically violent relationship and are thinking about going back to that relationship, your therapist will likely express some concern. Similarly, in anonymous groups, there is a saying, "Different playground, different playmates." If you are seeking addiction recovery, you may explore with your therapist potential triggers, such as the people you use with, and you may find it necessary to leave some of that relationship behind. Still, who you want to associate with is ultimately your choice. If you independently decide that distance from your family is best for you, for example, that is your right. Your therapist should not be coercing you to cut people off.
6. You Have Been in Therapy for a Long Time and Do Not Know What the Goal Is
Psychotherapy is typically goal-focused. Even an abstract objective, like "self-discovery," is a goal. If you are going to therapy regularly and have for years without seeing progress toward a goal, this is potentially worrying. Therapy is a relationship with a skilled professional to work on specific aspirations. When therapy runs adrift over a long period, there is a risk of that purpose becoming stagnant and the therapeutic relationship becoming more similar to a friendship.
7. Your Therapist Does Not Ask for Feedback
How a therapist imagines a session does not always line up with the client's experience. In trauma therapy especially, feedback is essential. Requests for feedback might happen at the end of a session or with check-ins throughout sessions with questions like, "I noticed you looked away there, what's happening for you right now?" In trauma therapy, it is also critical to check in as to how events may have continued to process throughout the week. Remembering a traumatic event can bring up a whole treasure chest of emotions. These could come up over a week in things like dreams, how someone reacts to triggers, anxiety, and emotional intensity or numbing. Some changes are normal, and to be expected. Still, these need to be monitored, so that your therapist can gauge how you are responding to therapy and adjust accordingly.
8. Your Therapist Does Not Check in On Your Stability at the End of Session
Trauma therapy, especially when you are processing the event, such as through discussing a trauma narrative or going through an EMDR set, can be temporarily destabilizing. Most often, the trauma processing will end a few minutes before the end of a session so that your therapist can check in on you and help you ground if necessary. If this is not happening, you could leave the room spinning and struggling with PTSD symptoms.
9. Your Therapist Has Not Given You Tools to Manage Between Sessions
It is common for there to be some temporary increase in PTSD symptoms at the beginning of trauma-focused therapies. If you are in addiction recovery, for example, this can spark cravings to use. Before processing your trauma, your therapist is likely to discuss with you strategies you can use to restabilize during an uptick in symptoms. Strategies might include skills like imagery, relaxation techniques, or where to reach out for support.
10. Your Therapist Does Not Have Training in a Trauma-Specific Modality
Almost all therapists receive general training in graduate school on topics such as diagnosis, assessment, and an overview of therapeutic models. We then often continue on to receive additional training according to what we wish to specialize in. Trauma is a specialty that usually requires additional training. If your therapist is still in graduate school or has not had sufficient trauma-focused training, they may not be ready to help you with this particular challenge. Trauma therapy is not something that can be learned "on the fly." It is usually developed through training, supervision, and practice. Similar to how your dentist might refer you to an endodontist for root canal treatment, many therapists refer clients to trauma therapists when the client's needs are beyond what they can meet.
To find a therapist, please visit the Psychology Today Therapy Directory.
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