The Trauma Reprocessing Debate

Q: There’s been a lot of talk recently about whether to simply stabilize survivors of complex trauma, or go deeper with trauma reprocessing. How do I know which is the best fit for my client?

A: The symptoms of PTSD are intrusive, whether it’s the mental image of an abusive family member, a sinking feeling in the stomach, the overwhelming weight of shame, or the constant murmur of negative self-talk. Then there’s complex trauma, or CPTSD, which has all the symptoms of PTSD and three additional symptoms: low self-esteem, emotion dysregulation, and difficulties in relationships, which are all remnants of trauma that hurt the client’s sense of self and make it hard for them to gain traction in therapy.

Most therapists who specialize in trauma know where to begin. They know how to do assessments, spot the signs of overwhelm, navigate triggers, and manage emotional dysregulation. They might understand the relationship between the client’s identity, race, or culture and their trauma. But even experienced trauma therapists are often stumped by a common clinical dilemma: when it comes to treating complex trauma, should you offer trauma reprocessing, or simply focus on stabilization?

Trauma reprocessing involves intentionally and directly addressing the client’s most disturbing traumatic memories, the ones most linked to their intrusive and recurring symptoms, and the ones that contribute to any beliefs that exacerbate those symptoms. Trauma reprocessing models are known as trauma-focused therapies, and with these therapies, the traumatic memories not only become less distressing, but the client makes meaning from the experience. In this work, the therapist intentionally targets these memories, rather than simply touching on them briefly.

Stabilization is typically provided at the beginning of trauma work. It includes providing psychoeducation on PTSD and symptomatology, particularly if the client has comorbidity. It also focuses on teaching and helping clients practice coping skills to help with emotion dysregulation and symptom management. Stabilization focuses on the here and now to help clients cope with ongoing stressors and trauma triggers, through direct discussions and assessments of sleep hygiene, nutrition, self-care, and support systems. In and of itself, stabilization can build trust and a working alliance in therapy, as well as help decrease symptoms to a baseline.

For clients with complex trauma, the three-phase approach has been a staple for decades: the stabilization phase, in which we teach the client coping skills, the reprocessing phase, in which we address the traumatic memories contributing to the symptoms, and finally, focusing on the client’s present-day life. But there’s an ongoing debate in our field around whether a phase-oriented approach is even necessary. Prolonged exposure therapy and cognitive processing therapy (CPT), long considered gold standards for PTSD treatment, don’t have a stabilization phase. And some critics believe that focusing too much on coping skills creates an avoidance of trauma reprocessing, which they argue is a faster, better way to resolve PTSD. But some clients need coping skills to function prior to trauma reprocessing, or to simply get through the day.

So how do you choose between stabilization and trauma reprocessing? In my experience, you should offer trauma reprocessing. While stabilization can help clients better understand their symptoms and feel more empowered to cope with them, their symptoms will often persist and continue to interfere with their life. But there’s a caveat: you should always adjust your interventions on a case-by-case basis. Whether you’re doing prolonged exposure, cognitive processing therapy, EMDR, or trauma-focused CBT, evidence-based trauma reprocessing models work. But the APA’s clinical practice guidelines on trauma are clear that the decision of whether to offer trauma reprocessing depends on a central question: Do the benefits outweigh the risks?

Most research on these models focuses on a 12-session framework, the timeframe in which most therapists find clients experience therapeutic gains and decreased symptomatology. In many cases, clients experience relief within three sessions of trauma reprocessing, and in many cases, these gains stick. This means clients have less emotional and somatic reactivity when they recall traumatic memories, and their ability to make meaning from these experiences improves as well.

Not only does a trauma memory become less distressing, but the story the client has internalized—what the trauma means about them—changes. For example, the belief I’m bad or It’s my fault or I’m not good enough becomes It wasn’t my fault or I didn’t do anything wrong or I was betrayed and manipulated. And rather than getting stuck in fight, flight, freeze, fawn, or flop, the client will also usually relate to the traumatic event with a more adaptive, flexible nervous system.

Why does trauma reprocessing work? A relatively new theory posits that the mechanism of change in all trauma reprocessing models is memory reconsolidation, a neuroplastic, biochemical process that occurs when a memory is repackaged in the brain with new information. In other words, trauma reprocessing works because you guide the client to focus on a particular traumatic event and create a mismatch experience that makes the memory network malleable so new information can be encoded.

For example, in prolonged exposure therapy, this mismatch happens when you invite the client to use breathing techniques as they recall the most difficult part of their traumatic experience. In cognitive processing therapy or any CBT-based model, you create the mismatch by using Socratic questioning to challenge the client’s stuck points or distorted beliefs. In EMDR, you do this by having the client focus on bilateral stimulation while simultaneously focusing on their sensory experience when they remember the trauma. In Internal Family Systems, the client extends compassion and a corrective emotional experience to an exile carrying the beliefs and burdens. The result might be the creation of a new meaning, less intense emotions and somatic reactivity, or a new bodily felt sense.

Of course, trauma reprocessing also involves risks. No matter what model you use, it’s normal for clients to experience physical and emotional fatigue after a trauma reprocessing session. It’s also normal to experience a brief increase in symptoms. It’s important to assess beforehand how much stress and physiological arousal your client can tolerate, as well as what they usually do to manage stress. Do they use substances? Do they self-harm? Do they dissociate? If so, you might want to consider stabilization first.

If you and your client decide to do trauma reprocessing, it’s crucial to share both the potential benefits and risks to give a realistic expectation of treatment and set yourself up for success.

Into the Basement

There’s an analogy I find helpful when I’m introducing the idea of trauma reprocessing with a client. I tell them it’s a little like going into your basement and unpacking a long-sealed box. In trauma reprocessing, we intentionally revisit beliefs—open a box—change how its contents are arranged, and discard what we don’t need. Then, we close the box. Now, it doesn’t feel as heavy. The client feels less burdened, better able to move through everyday life.

My client Joette was a 34-year-old Black woman who’d been married for seven years. She came to therapy after repetitive conflicts with her husband, which she said made her sad and worried about the future of her marriage. In the intake, however, it became clear that lurking under the initial presenting problem were CPTSD symptoms that Joette was struggling with daily. She met the criteria based on multiple traumatic events that had occurred over the course of her life, including childhood sexual abuse, military sexual trauma, and combat trauma during her deployments to Afghanistan.

Joette also told me about flashbacks whenever her partner touched her, as well as insomnia and difficulty maintaining friendships. Many nights, she’d have nightmares, or wake up thinking she was still in her childhood bedroom or the barracks where the sexual abuse had occurred. I soon realized that Joette could benefit from trauma reprocessing given her symptomatology, and discussed this option during the treatment planning stage, as well as the benefits, side effects, and risks.

Joette told me she was open to giving it a try, but soon after we began, she expressed concern about even opening the basement door. So, I immediately pivoted to stabilization, and we spent the next several sessions working on developing coping skills that Joette could practice during and outside of sessions. Sometimes it took more than one coping skill to calm her overwhelm or feelings of shame—especially after a flashback or nightmare. But gradually, Joette learned to trust the process, and told me she felt ready to take the next step.

A few months into treatment, we decided to give trauma reprocessing another try using EMDR. Joette responded well to it, and a few weeks later, reported that she’d been feeling much more relief in her day to day.

Next, therapy shifted into the third and last phase of treatment: focusing on the present day. We worked on how Joette now related to herself with more self-compassion. Her CPTSD symptoms were below the diagnostic line, and she told me she’d felt a big shift in her capacity to manage everyday stress. She also realized after EMDR how much her CPTSD had been impacting her relationship with her husband. Now, finally, we could focus on what had brought her into therapy in the first place.

Proceeding with Caution

After you describe the benefits and risks in trauma reprocessing and ask, in plain language, whether your clients would like to try it, there are a few additional considerations before getting started. The first is whether your client has suicidal thoughts. If they do, but have no plan or intent, research supports proceeding—while, of course, providing appropriate crisis hotlines and resources. If the client is actively psychotic, experiencing a manic episode, or actively suicidal or homicidal (i.e. has a plan or plan and intent), then we need to pause on trauma reprocessing and instead offer crisis counseling and a referral for medication management. During crisis counseling, your job is to assess whether the client can keep themselves and others safe, or whether they need a higher level of care.

What if your client isn’t sober or clean? Can you still do trauma reprocessing? The literature has recently shifted on this matter. Ultimately, you’ll want to work on a case-by-case basis, but the general recommendation is to use specialized trauma reprocessing models within a structured trauma-informed substance abuse treatment protocol, such as trauma-focused CBT, concurrent treatment of PTSD and substance use disorders using prolonged exposure (COPE), and the Buzzkill protocol in EMDR.

Even experienced clinicians are wary about doing trauma reprocessing with clients who dissociate or have a dissociative disorder. But the research shows that both CPT and EMDR (specifically Flash or EMDR 2.0 protocol) support trauma reprocessing with these clients. But what if your client is dissociating in session or during the trauma reprocessing itself? Dissociation responses can show up in sessions in a lot of ways. The client suddenly falls asleep, begins to nod off, or tells you they feel like they’re going to faint. They might become dizzy, spacey, or say they feel numb or “nothing.”

If any of these symptoms occur during a session, it’s important to slow down and use grounding and orienting techniques to help the client come back to the present moment. This might be the classic 5-4-3-2-1 exercise, where we ask the client to name five things they see, four things they can physically touch, three things they hear, two things they smell, and one thing they taste. You can also gently decrease nervous system arousal by asking them to do something experiential, like roll a ball.

Each model has guidance on how to proceed if symptoms occur during trauma reprocessing. For example, in the EMDR 2.0 protocol, it’s recommended that you use techniques to tax the client’s working memory through distraction, perhaps by having them focus on engaging music, or a spelling task, or an experiential activity like having them stand up and move their body while saying a phrase at the same time. This keeps the client in the present, which will gradually bring down arousal and help them move out of a dissociative state.

Even if we’re trained in evidence-based models for PTSD, our own anxiety about doing trauma reprocessing can get in the way of doing it effectively. So, as is the case with so much of our work, we need to turn to our own internal processes. Ask yourself: Do I have any fears or concerns about providing trauma reprocessing to my clients? If you notice these concerns with just one or two clients, maybe it’s your clinical intuition. Maybe you feel hesitant for valid reasons. But if you feel generally anxious about trauma reprocessing, I recommend you seek consultation and additional training in your respective model to find out why, build more confidence, deepen your skillset, and strengthen your competency.

One of the most common things I hear from therapists who are on the fence about trauma reprocessing is that it will cause their client to feel intense feelings. That’s true. Trauma reprocessing is intense. But it’s important to remember that the client has already lived through the trauma. I like to think the process is akin to grief therapy in that clients experience feelings in big waves that gradually dissipate over the course of treatment. And in my experience, it’s worth the journey. Trauma reprocessing gives our clients the opportunity to change their relationship with the trauma, to know in their body that it’s in the past. Over time, nearly all of my clients have been able to fully feel and release their painful feelings. And for me, not just hearing their stories, but bearing witness to their transformation and recovery, has been an immense privilege.