My PTSD Symptoms Got Worse After I Started Therapy: Why, And What Now?

People with PTSD start attending talk therapy because they want and need to get better — because the reality of living with post-traumatic stress disorder means they're stuck in a solid orbit around past trauma that affects every single aspect of their lives in one way or another, and they want out. 

Therapy is often a huge step for people diagnosed with PTSD and those who would have been diagnosed if they'd ended up in a therapist's office earlier. To get there, we may have had to fight through fears of the treatment itself, scars inflicted by previous negative experiences with the healthcare system, and concerns about the stigma of participating in therapy — not to mention long wait lists or financial barriers to treatment. 

Why might this happen, and what can you do if your symptoms get worse after you start therapy, or you even acquire some new ones?

Your PTSD symptoms may be suppressed before you start therapy

Post-traumatic stress disorder is often described as a trauma-related anxiety disorder, but it's also characterized, research has found, by alterations in memory processing. That is, your brain often doesn't process and "file" traumatic events the same way it does everything else you experience. Rather, those memories have been found to "float around" the subcortical and primary perceptual areas of the brain. 

The result? Many people with PTSD are — as the fifth edition of the diagnostic and statistical manual of mental disorders points out in point 1 of criterion D — unable to remember important aspects of the trauma they lived through. On the other hand, the intrusion symptoms so characteristic of post-traumatic stress disorder mean that even subtle reminders of the trauma can trigger intrusive memories and flashbacks. 

Some people with post-traumatic stress disorder don't have flashbacks, research shows. The worst intrusion symptoms can be suppressed by strong avoidance symptoms — the bit where you and your brain go to great lengths to evade reminders and memories of the trauma — and this may actually indicate more severe PTSD and dissociation. 

While some people with PTSD are overwhelmed by trauma-related emotions, like fear, horror, guilt, shame, and anger, others cope by going emotionally numb. You may spontaneously find yourself unable to experience positive emotions (DSM-5 criterion D, point 7), or you may even have taken conscious steps towards emotional numbness by, for instance, keeping busy to distract yourself or engaging in substance abuse to take some of the pain away. 

Therapy can open the floodgates and invite PTSD symptoms in

Though research shows that various kinds of talk therapy, from cognitive behavioral therapy to exposure therapy and psychodynamic therapy, can help you reach remission from PTSD, it has indeed been shown that therapy initially exacerbates symptoms for some people. 

By the time I personally started therapy for post-traumatic stress disorder, I'd worked out a physically and emotionally unhealthy way of coping that nonetheless kept me functional. Pre-therapy, I was emotionally numb, with anger and fear being just about the only feelings I could consciously experience. I was hypervigilant, quick to startle, and had trouble sleeping (in part because of nightmares), but I was really good at avoiding memories of the trauma and didn't experience many intrusive memories or flashbacks. When I did, I worked hard to suppress them. 

After therapy sessions, that all changed. I was often able to hold it together in therapy, only to become completely overwhelmed after. The fear I already felt became more emotional than reactive, and deep feelings of sadness and loss joined in. The autopilot switched off, and I often found myself unable to do much for days after a session. The flashbacks and intrusive memories I developed dominated my life. 

Therapy had opened the wounds I'd kept sealed off but that were festering under the surface. It wasn't pretty, but it was a sign I was making progress in therapy. Sticking with it ultimately allowed me to reach remission. As I worked on processing an aspect of the trauma, I found that it had to get worse before it got better.

If therapy worsens your PTSD symptoms, tell your therapist

If you feel completely drained by therapy sessions and the memories you're discussing in therapy stick with you for days afterward, make sure to discuss this with your therapist. Not only will this allow your therapist to get a better idea of how you're progressing and how therapy is affecting you, it will also enable them to work through possible coping strategies with you or figure out what to change about your sessions. Keeping a symptom diary to bring to sessions can be really helpful.

Don't feel like worsening symptoms necessarily mean that therapy isn't working for you or that you need to quit — but if you do have those feelings, talk about those with your therapist, too.