Posttraumatic stress disorder (PTSD) can get worse before it gets better when you start therapy. Find out why that’s normal and how to handle it.
Have you ever heard the saying: It gets worse before it gets better? Any person that has sought out psychological help is likely to understand what this saying means, myself included. Therapy is designed to draw out uncomfortable emotions, thoughts, and memories. When things start getting tough in therapy for a person with PTSD, it’s often a sign that therapeutic progress is being made.
Though it’s very rewarding when walls start breaking down in therapy for a person with PTSD, it can also be difficult to handle. In trauma therapy, making progress often means confronting scary memories of past traumatic experiences. It can involve facing uncomfortable emotions that have been locked away. Though the psychological healing process is good, it can feel very bad for a person with PTSD. Keep in mind that PTSD often gets worse before it gets better, but it will get better.
What to Do When Therapy Makes PTSD Gets Worse, Not Better
First and foremost, it’s important to remember that trauma therapy happens on your timeline. There’s no time limit on healing. If it feels like your therapist is pushing you too fast, it’s okay to take a step back and reevaluate. A break to focus on self-care and self-compassion is needed at times.
Of course, that’s not to say that we should run away from therapy when it starts to get tough because therapy often makes PTSD worse before it gets better. Sometimes it’s necessary to go through those tough times in therapy, with the hope of healing and peace on the other end. And there are many different methods a person with PTSD can use to self-soothe while facing scary emotions and memories.
Self-Care Tips for People in PTSD Therapy
Because I have tough conversations about my past during trauma therapy, I like to feel as safe and comfortable as possible when I’m in my therapist’s office. Sometimes that means dimming the lights in the room or bringing a weighted blanket to my session. Other times, I use fidget toys to help filter out some of my anxiety. And before every session, I buy an iced coffee as a little therapy day treat.
Feeling safe with your therapist is a crucial part of trauma therapy, so it’s important to keep your therapist in the loop about what you need to feel comfortable during therapy sessions. Divulging tough emotions and thoughts isn’t going to happen if you don’t feel safe, so remember to communicate these needs with your therapist.
Therapy is not meant to be easy. It’s not meant to be clean and straightforward. It can be messy. As you’re going through trauma therapy, don’t be afraid of the tough times. Sometimes PTSD really does get worse before it gets better. It’s normal and natural to face ups and downs when healing from trauma. If you’re going through a rough patch in therapy, hold on to the hope that there is healing at the other end.
Feeling like sh*t after therapy? It’s not (all) in your head.
“Therapy, particularly trauma therapy, always gets worse before it gets better,” says therapist Nina Westbrook, L.M.F.T. If you’ve ever done trauma therapy — or just intensive therapy work — you know this already: It’s not easy. This is not the “believe and achieve,” positive affirmation, discovering your inner power kind of therapy, but rather the “everything hurts” kind.
Jokes aside, digging into past traumas and traumatic events, experiences from childhood, and other similarly deep, fraught memories can take a toll on you — not just mentally, but physically. It’s something that cognitive neuroscientist Caroline Leaf, Ph.D, calls “the treatment effect.”
“The increased awareness from the work you’re doing on your thoughts (which is very challenging, to say the least), increases your sense of autonomy,” says Leaf. “This can also increase your stress levels and anxiety because you’re starting to become more aware of what you’re going through, how you’ve handled your stress and trauma, and why you’ll have to face some deep, internal issues.”
In turn, you might feel pretty beat up post-therapy. This is a very real phenomenon that you may have experienced without even noticing. Was your last migraine on the same day as your last psychotherapy visit? Did you see your therapist and feel completely depleted for the rest of the day? You’re not alone. Experts from all areas of the mental health field verified that post-therapy fatigue, aches, and even physical symptoms of illness are not just real, but extremely common.
“This is why it’s so important for therapists to be upfront about the therapeutic process with their clients,” says Westbrook. “[These symptoms are] very normal and natural, and a perfect example of the mind-body connection. Wellness isn’t just our physical being, but our mental being — it’s all connected.”
First, What Is Trauma Therapy?
Because this phenomenon is especially relevant when undergoing trauma therapy, it pays to explain what it is, exactly.
Many people experience some form of trauma, whether they realize it or not. “Trauma involves something that happened to us that was out of our control, and often results in a pervasive feeling of threat,” explains Leaf. “This includes things like adverse childhood experiences, traumatic experiences at any age, war trauma, and all forms of abuse, including racial aggression and socioeconomic oppression. It’s involuntary and has been inflicted on a person, which often leaves them feeling emotionally and physically exposed, worn out, and fearful.”
What differentiates trauma therapy from other types is somewhat nuanced, but Westbrook shared the gist:
- It can be therapy you receive after a distressing event and you notice changes in your behavior. (Think: PTSD or anxiety is impacting your day to day life.)
- It can be ordinary therapy in which a past trauma comes up through the work with your therapist.
- It can be a specific therapy you seek out in the wake of a traumatic event.
“Trauma in the realm of psychology is when a distressing event takes place, and as a result of that distressing event, a person becomes exceedingly stressed and unable to properly cope, or come to terms with their feelings regarding the event,” explains Westbrook.
Trauma therapy — whether intended or accidental — isn’t the only instance in which you’ll experience a “therapy hangover” of sorts. “All of the feelings that come up throughout the therapeutic process can leave you feeling fatigued or with other physical symptoms,” explains Westbrook. “This is why it is important to note that this is a very normal part of the process, and should eventually subside as the therapeutic process ensues.”
Physical Symptoms from Therapy Work
If you’re not doing trauma work, therapy might actually leave you feeling more relaxed, confident, or energized, says clinical psychologist Forrest Talley, Ph.D. “The most common physiological reactions I’ve seen in my practice are leaving therapy in a more relaxed state, or with increased energy; however, changes in a person’s physiological state are common after more intense psychotherapy meetings.” Here’s why.
The Brain-Body Connection
“Because of the intimate connection between the brain and body, it would be odd for [emotional therapy] to not have an impact,” says Talley. “The more emotionally intense the work, the more likely it is to find some expression in a physical reaction.”
Westbrook says stress can be used as an everyday example to better contextualize and understand this. “Stress is one of the most common feelings in our daily lives,” she says. “Whether you’re studying for an exam, prepping for a presentation, or going out on a date for the first time with someone new, you might feel anxious and excited. Some people would say they have a ‘pit in their stomach,’ while others say they ‘have butterflies,’ — and some people say they’re ‘going to sh*t themselves.’ And sometimes they actually do!” (See: 10 Weird Physical Ways Your Body Responds to Stress)
This is magnified in trauma therapy. “With trauma therapy, symptoms are significantly present, and in a much bigger way,” she says. “There’s a wide variety of physical symptoms [that can occur] from breaking down issues and breaking through during trauma therapy.” For anyone who has foam rolled, you know how much it hurts before it gets better — think of it like foam rolling some super tight fascia, but for your brain.
Packing Away Bad Feelings
You’re likely bringing more to your therapy session than you realize. “When you have stressors that build up — if you don’t take care of them — they continue to build, and they sit in your body physically,” says psychologist Alfiee Breland-Noble, Ph.D., M.H.Sc., director of the AAKOMA Project, a nonprofit dedicated to mental health care and research.
Hence, stored trauma. You don’t like it, so you pack it away, like a mental junk drawer… but the junk drawer is ready to burst from being so full of your worst nightmares.
“We tend to suppress things because conscious awareness of painful toxic memories brings discomfort, and we don’t like being uncomfortable or feeling uncertainty and pain,” explains Leaf. “As humans, we have a tendency to avoid and suppress instead of embrace, process, and reconceptualize pain, which the brain is designed to do to keep healthy. This is in fact why suppressing our issues does not work as a sustainable solution, because our thoughts are real and dynamic; they have structure, and will explode (often in a kind of volcanic mode) at some point in our lives, physically and mentally.”
But don’t feel bad about feeling “bad” — you need to feel those feelings! “We live in an age where we want to feel good all the time, and where feeling uncomfortable, sad, upset or angry are universally labeled as ‘bad,’ although they are actually healthy responses to adverse circumstances,” says Leaf. “Good therapy helps you embrace, process, and reconceptualize your past experiences, which will inevitably involve some degree of pain, but this just means the healing work has started.”
Trauma In, Trauma Out
All that packed trauma? It didn’t feel good when it was stored, and it’s probably going to feel traumatic coming out, too. “You’re literally drawing up established toxic habits and trauma, with their embedded informational, emotional, and physical memories from the nonconscious mind,” explains Leaf.
Digging into this stored trauma and stress will be the most difficult in the first few weeks of treatment, says Leaf. This is “when your thoughts, with their thousands of embedded mental and physical memories, are moving from the nonconscious mind into the conscious mind,” she says. And it makes sense that bringing painful memories and experiences into your consciousness will feel uncomfortable.
“What compounds all those stored stressors is psychological distress and mental illness,” says Breland-Noble. “Put all that together, and by the time you sit with a mental health professional and start processing, you’re not just releasing the immediate thing [you went in to talk about],” she says, but all the experiences, memories, habits, traumas you’ve stored. “It makes sense that it would release in your body the same way it was stored in your body, stored in your cells, in your feelings, in your physicality,” she says.
The Physiology of Trauma Therapy
There’s a physiological, scientific explanation for a lot of this too. “If therapy has resulted in heightened stress (for example, reviewing traumatic memories) then there is likely to be increased levels of cortisol, and catecholamines,” explains Talley.
In a nutshell, cortisol and catecholamines are chemical messengers your body releases during the stress response. Cortisol is a single hormone (known as the stress hormone), while catecholamines comprise several neurotransmitters, including epinephrine and norepinephrine (also called adrenaline and noradrenaline). (Interestingly enough, catecholamines are part of the reason you might get an upset stomach after a tough workout.)
“This may lead to a rapid heart rate, sweating, headaches, muscle fatigue, etc,” says Talley. “[This] is not a complete list of chemical/physical responses to psychotherapy, but just intended to get the main point across. Psychotherapy affects brain chemistry, and this, in turn, is expressed through physical symptoms.”
“The gut-brain interaction is one of the most obvious examples of this — we often feel stress physically in our stomachs,” says Leaf.
“When the body and brain are in a highly tense state, which happens during and after therapy, this can be seen as [changes in] activity in the brain, as well as erratic changes in our bloodwork, right down to the level of our DNA, which impacts our physical health and our mental well-being over the short and long term periods if not managed,” says Leaf.
Breland-Noble shared that this has shown up in epigenetic studies of Black patients. “Data with Black women and Black men has shown something called the weathering effect — it impacts bodies on a cellular level, and is transferable genetically,” she says. “There are actually changes to African American bodies because of the daily stressors related to exposure to racial trauma, and there is epigenetics that demonstrate it.” Translation: The trauma of racism makes actual changes to how their DNA is expressed. (See: How Racism Can Affect Your Mental Health)
Most Common Post-Therapy Symptoms
Every expert here shared similar examples of symptoms to look out for, including the below:
- Gastrointestinal and gut issues
- Headaches or migraines
- Severe fatigue
- Muscle aches and weakness, backaches, body aches
- Flu-like symptoms, general malaise
- Irritability
- Anxiety and panic attacks
- Mood problems
- Sleep-related problems
- Lack of motivation, feelings of depression
Wild, right? All from trying to feel better — but remember, it does get better.
How to Prepare for Intense Therapy Appointments
Breland-Noble referred back to a Benjamin Franklin quote to express the importance of this step: “An ounce of prevention is worth a pound of cure.”
If you know you’re headed for a deep dive into some of your worst memories and experiences, be strong! You can prepare for this (very necessary) work. Because everyone’s brain is different, there are different approaches to this. “No matter what strategy is used, it should be one that encourages you to develop a stronger mindset, to come away confident that you will prevail in your struggle,” says Talley.
He suggests giving yourself the following intention: “You want to leave a trauma therapy session firmly convinced that, ‘Yes, I’ve been there, survived, and have gone on with my life. I faced down those demons and won. The things that disturb me are in the past. My life is here in the present and in the future. What tried to beat me down failed, and I’ve triumphed.'”
Fortunately, healthy habits you may have picked up for other reasons — eating well, getting quality movement in your day, logging good sleep — may have a significant contribution to how you feel during and following trauma therapy. Breland-Noble noted this is part of stress inoculation training, which she explains as building up your reserves and skills to have resilience against many forms of stress. All those things can help your body stay strong against mental and physical stress.
What Do Do After Therapy to Feel Better
Did you find this article post-therapy and you didn’t get a chance to do all that prep work? Not to worry — the experts shared their ‘fixes’ for post-therapy fatigue, but, of course, the best techniques will vary for everyone. “Some patients do best by having work or projects to throw themselves into after an intense therapy meeting,” says Talley. “Others do best by having time to themselves to organize their thoughts.”
Pause. Breland-Noble suggests taking the rest of the day off from work if you’re able. “Take a pause,” she says. “Don’t walk out of therapy and go straight back to work — take five minutes, don’t turn anything on, don’t pick up any devices, don’t call anybody. That’s the pause you need to reset your mind for the next activity.” Remember to not waste your money (therapy is not cheap, unfortunately!) and make the best use of your investment, plan to really process the work you’re doing, she says.
Journal. “Write down one or two things that you got out of your session that you can incorporate, then put that journal away,” says Breland-Noble.
Recite your mantra. Reflect and remind yourself: “I’m alive, I’m breathing, I’m happy I’m here, I feel better today than I felt yesterday,” says Breland-Noble. And when in doubt, try Talley’s mantra: “The things that disturb me are in the past. My life is here in the present and in the future. What tried to beat me down failed, and I’ve triumphed.”
Stimulate your mind. Engage in something new and interesting to take advantage of your brain’s development, suggests Leaf. “A simple way to brain-build post-therapy is to learn something new by reading an article or listening to a podcast, and understanding it to the point where you can teach it to someone else,” she says. Because your brain is already in a rewiring and rebuilding mode from therapy, you can jump in there and keep working. This is a very different approach to the suggestions from other experts above; this is where you can choose what feels right for you or for that particular day post-therapy.
It *Does* Get Better!
“This is hard work, and scary, (especially at first) because it will feel like things are a little bit out of your control,” says Leaf. “However, as you learn to control the process through different mind-management techniques, you can start looking at the toxic thoughts and trauma differently, and see the challenges they bring as opportunities to change and grow instead of the pain that you need to ignore, suppress, or run away from.” (See: How to Work Through Trauma, According to a Therapist)
Think of it as the anxiety before you do something really scary or daunting. “Remember the stress of preparing for a test — all that intense anxiety leading up to it,” says Westbrook. It’s typically worse and more intense than the test itself, right? “Then you take the test, and there’s this weight lifted off you once you get through the tough work; you’re elated, ready to party. That’s what [trauma therapy] can be like.”
This transition from “ugh” to elated may happen gradually (think: less intense symptoms after therapeutic sessions over time) or all at once (think: One day you cry it out and have an “a ha!” moment and feel like a new person), says Westbrook.
That said, if you seem to be in the icky part for a really long time, that’s not normal. “If the intense trauma work never ends, it’s time to find a new therapist,” says Talley. “Too often people with trauma enter therapy and end up getting stuck in rehashing the past without moving beyond it.”
Above All, Be Kind to Yourself
If you feel like you got mono mixed with the flu with a side of migraine after you saw your therapist, be kind to yourself. You’ve got a therapy hangover. Go to bed. Take some ibuprofen if you’ve got a headache. Binge Netflix, make tea, take a bath, or call a friend. It’s not frivolous or overindulgent or selfish to make sure you heal properly.
“The experience of trauma is vastly different for each person, and the healing process is also different,” says Leaf. “There’s no magic solution that can help everyone, and it takes time, work, and the willingness to face the uncomfortable for true healing to take place — as hard as this can be.”
You’re doing unimaginably difficult work. You wouldn’t run a marathon and expect to function at 100 percent the next day (unless you’re a superhuman) so give your brain that same grace.
