Expected Distress vs. Retraumatisation: How to Tell the Difference in Trauma Therapy

Many clients and therapists feel anxious about the stage of therapy that involves direct trauma processing. Clients may worry about becoming overwhelmed, or fear that once they start thinking about the trauma they will not be able to stop. This is understandable, as PTSD often involves a strong avoidance drive, which is the mind’s way of protecting itself from overwhelming emotion. Therapists also carry concerns. We may wonder whether a client’s mental state will worsen, or feel uneasy watching them in visible distress, worried that we are causing harm. These are valid concerns and highlight the importance of safeguards and preparation before trauma processing begins.
It is important to be realistic. Even with the most effective approaches we have, such as EMDR, somatic therapies, prolonged exposure, some level of distress is unavoidable. In EMDR, for example, the memory must be activated for processing to work. The client needs to feel some level of disturbance so that unresolved emotional and physical reactions can be reprocessed. This allows the brain to reorient to the present and make new meaning from a past event. Ideally, clients stay within their “window of tolerance,” where emotions are strong but still manageable. Yet trauma work is unpredictable, and at times big waves of feeling will arise. What matters most is that therapist and client have a trusting relationship and confidence that these states can be navigated safely together.
The question then becomes, how do we tell the difference between a normal level of disturbance and retraumatisation? With EMDR specifically, it is common, and we prepare clients for this, to experience some residual disturbance after sessions. Processing often continues for a few days. Temporary increases in intrusions, re-experiencing, anxiety, avoidance, or changes in dreaming and nightmares are within the normal range. These reactions do not mean retraumatisation is occurring. The key point is that these symptoms should settle and not cause a major shift in functioning. Therapist and client should stay in close communication, monitoring how the client is managing and adjusting pacing when needed. Larger traumatic memories, which cannot always be resolved in one session, often lead to some between-session disturbance that is best understood as part of the therapeutic process.
We become more concerned if new trauma symptoms appear that were not part of the client’s baseline, such as nightmares when there were none before, or panic attacks that had not been present. A marked and persistent worsening of functioning, such as significant drops in mood, increased irritability, or an escalation of suicidal or self-harming urges, can also indicate that retraumatisation may be taking place. The distinction lies in whether there is a temporary spike in distress that then settles, or a sustained decline in stability and functioning that does not improve.
If these kinds of negative shifts appear, it is important to pause and reassess. Clinicians can use standardised tools such as the International Trauma Questionnaire to track symptoms over time. If deterioration is substantial and persistent, we need to ask whether life stressors are overwhelming the client’s capacity to process trauma right now, whether more resources and preparation are needed, or whether the therapist should seek consultation or supervision.
The bottom line is that some distress is unavoidable and even necessary in trauma therapy, but substantial and prolonged declines in functioning are not part of the expected process. When that happens, both client and therapist need to take it seriously, pause the trauma processing, and address what is going on.

Summary Table: Expected Disturbance vs Concerning Signs in Trauma Processing