Trauma & recovery

Does Talking About It Make It Worse?

It is the most common reason people give for not starting trauma treatment. It has also been studied directly, more than once.

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The fear, stated plainly

The worry is specific and reasonable. If the memory is this destabilising when it arrives uninvited, deliberately going into it in a therapist's office sounds like a way of making things worse, not better. People also worry about the practical version of that: falling apart, and then having to drive home and go to work in the morning.

This is worth taking seriously rather than reassuring away, partly because it is the single most common reason people postpone treatment for years.

What was actually measured

Foa and colleagues (2002) examined this directly, asking whether imaginal exposure exacerbates PTSD symptoms. Reliving the traumatic event in the early sessions increased the frequency of intrusive memories in only a minority of patients, and where symptoms did rise, this did not predict a worse outcome from treatment or make dropping out more likely.

A later and larger analysis reached a similar conclusion. Larsen and colleagues (2016) looked at symptom exacerbations across three trauma-focused treatments, prolonged exposure, cognitive processing therapy, and a version of CPT without a written account. Exacerbations happened to a minority of people in all three. They were associated with somewhat higher symptoms, but they did not predict non-completion, and people who had them still improved substantially overall.

What about dropping out?

The related fear is that exposure-based treatment drives people out of therapy. Hembree and colleagues (2003) searched the literature for controlled trials of cognitive-behavioural treatment for PTSD reporting dropout data and found no difference in dropout between exposure therapy, cognitive therapy, stress inoculation training, and EMDR.

In other words, the treatment with the frightening reputation does not lose more people than the alternatives.

How to hold both things at once

None of this means the work is comfortable. A temporary increase in distress is a real possibility for some people, and anyone offering this treatment should say so before you start rather than after. What the evidence does not support is the further step people usually take, which is that a difficult few weeks means the treatment is harming you or is not going to work.

There is a practical difference between distress that is part of the work and distress that means something needs to change. That judgement is the clinician's responsibility, and it is a reasonable thing to ask about directly in a first conversation.

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