I think it's really important that the process of therapy be crystal clear for both therapists and clients. And part of that - which should be a part of any informed consent for treatment - is the potential risks of being a part of therapy. Therapists should already know this stuff, so I am really talking more to the clients of therapy. Therapists & therapeers, feel free to read on and contribute in the comments if you've got a thought to share.
Therapy is supposed to be a place where people can go to work through emotional or cognitive obstacles that are interfering with their basic life functioning. Or maybe those are obstacles in achieving some new level of success and they need the help of an expert in clearing the way. (Yes, somatic elements are absolutely important, but it's typically the thoughts and emotions that bring people to therapy.)
Sadly, clients sometimes find that therapy is not what they were expecting, wanting or needing it to be. And they may have even found it to be so unpleasant that they gave up on therapy altogether. Furthermore, they may have found it retraumatizing. I want to discuss two potential paths to retraumatization through therapy. One of these is unethical behavior and the other is a potential common therapeutic mistake or misunderstanding in the field.
1. Therapeutic Unethical Behavior Retraumatization
Therapy can go way way wrong and be obviously retraumatizing.
A good example of therapeutic unethical behavior is covered in this Bad Therapy episode I did on my Stuck Not Broken podcast -
This type of retraumatization can look extreme, like manipulating a client into a sexual relationship (therapy never includes sex, btw) or a secondary financial one. A therapist (or anyone else with ill intent) can exploit someone's dependency on another. Therapy is not supposed to be a relationship of power or dependency, but the inherent dynamic of the situation could result in a manipulation of others if the therapist is coming from their own selfish intent.
Therapy is a contextual relationship of one person in need, going to another for help. The person in need may also be in desperate need and unwittingly open to possible exploitation. If this individual has a history of poor attachment or otherwise lives stuck down their Polyvagal ladder, they may not be able to identify red flags from others. This is especially true in a relationship that has an imbalance of power, like a therapeutic relationship. (This has also been seen in exploitation of parishioners by various religious leaders.)
Unfortunately, therapy can be delivered as or viewed as an expert dispensing some sort of remedy. The expert therapist is "normal" and the client has the problem. The expert identifies the problem, labels it and then provides treatment for the problem. The client is the one in need, seeks out a remedy and then receives the treatment. This is a very medical model of therapy and has limited usefulness, in my opinion. This view of the therapeutic alliance can be exploited by someone holding the power who also has ill intent.
Of course, therapy should not be an imbalance of power, but it also kind of is. Therapy should be collaborative. Therapy should be two individuals meeting and working on a goal. Yes, a therapist is an expert in the room. But there is also another - the client. The therapist is an expert on psychology and technique, but the client is the expert on their life. The two meet and work together. This understanding forms the collaborative therapeutic relationship.
A therapist may act outside of the profession's norms, ethics and laws. I wouldn't call this therapy. It's more like a therapist behaving badly. Exploitation of others is not therapy. Even when done by a therapist. If a plumber were to play video games at a client's house, that wouldn't be called plumbing. Even though it was done by a plumber while they were on the job.
But even in the context of typical therapeutic practice, retraumatization can still occur...
2. Narrative & Experiential Retraumatization
Therapy can also inadvertedly retraumatize someone, even despite the best efforts of the therapist. We're commonly taught in therapy schools that to "get over" or "heal" from a trauma, clients need to talk about it directly. Clients need to talk about it in detail even and confront their feelings.
There's an entire modality built around the idea of sharing the trauma narrative - Trauma Focused Cognitive Behavioral Therapy. This is a modality that has telling the trauma narrative at its very core. The client is expected to tell and retell the narrative until it no longer has a triggering charge over them. Sharing the story with a trusted other at the end of tx is also expected. The client is also expected to not simply tell the story verbally, but to create it in some way, like through collage or writing.
EMDR utilizes exposure through memory and expects the client to explicitly revisit the traumatic incident in the 3rd step of the modality - assessment.
In this step the client actually begins to target a specific memory. The therapist may build up a full image of the target by asking questions about the incident, such as what happened, when, where, and also what negative beliefs about themself that they hold in relation to this memory. The individual components of the target image are brought out.
I don't think either of these modalities are inherently retraumatizing. No. In fact, they both have features built into them that are supposed to soften the intensity of the narrative, like bilateral stimulation or gradually telling more of the trauma narrative in each iteration of the narrative. These and other modalities are not my immediate concern (as long as the therapist is implementing to fidelity and with the client’s consen). I am more concerned about a prevalent belief amongst therapists - that clients need to confront and share their narratives - even if they're not ready. Even if they don't know how to ground themselves in their Polyvagal state of safety.
Too early for trauma work
What ends up happening is that clients are pushed into talking about something that they are simply not ready for. So these clients end up in a Polyvagal defensive state, like flight/fight, shutdown or freeze. There's a good chance that the client is triggered back into the moment of the event(s) that they are trying to get help for in the first place. They are back in the defensive state and are unable to self-regulate into their safety state. They leave the session dysregulated and retraumatized. Their stuck autonomic nervous system state is simply reinforced.
The therapist is not intentionally doing so. They may even believe they are doing a "good job." They're getting their clients to confront their past and that's good, right? They're getting their clients to "feel their feelings"... that's good therapy, right? They're getting the client to feel those difficult feelings and then to "sit with them." Yay... right?
No. At least - no, for now. All of these things can be helpful. Confronting, feeling, sitting with... these can be great. Just not before the client is ready. The priority in doing trauma work is to maintain the client's access to their Polyvagal state of safety and social connection. From there, the client can actually feel the stuck flight/fight, shutdown or freeze states. But those states won't be felt in the same way. A stuck fight sympathetic state won't be experienced as uncontrollable anger. It may instead turn into power and a sense of possibility and motivation. Even if it is experienced as anger, it won't be out of control. Instead, it will be tolerable and the client is able to process it.
The priority for trauma work is safety
The client needs to be anchored in their state of safety. This means that their biological pathways (ventral vagal) responsible for connection will be active. When these myelinated pathways are active, they will keep the heartbeat of the client at a calmer pace, which keeps the flight/fight potential lower. If the safety pathways are off, then the heart rate goes up and the sympathetic flight/fight state kicks in, resulting in feelings like anxiety and anger, possibly panic or overwhelm. This is a concept called the "vagal brake," which you can learn more about in my Polyvagal 101 course. If you're a therapist, this and other Polyvagal concepts are necessary knowledge for your practice.
Safety comes first. Then, once anchored in safety, the client can turn their attention toward the more difficult experiences they are having. Once they are anchored, then they can delve into their grief, shame, trauma and more. But even while doing the more difficult work, they still need to be checking in with themselves to gauge their capacity to continue. When the defensive energies surface - which they will - they need to be balanced out by safety. It's completely okay for those defensive Polyvagal states and feelings to come up. It's going to happen. But we want to be able to balance it with feelings of safety: connection, calm, joy, confidence and more.