The Unspoken Truths of Being a Therapist: What If They Get Worse?
This continues our series exploring the human realities of therapeutic practice. Today we examine one of the most anxiety-provoking aspects of our work: the fear that we might inadvertently cause harm.
The 5 AM Wake-Up Call
It's 5 AM and you're wide awake, replaying yesterday's session with Emma. She'd been making steady progress with her anxiety, but today she seemed more agitated than usual. She mentioned having "dark thoughts" and when you explored this, she clammed up and ended the session early.
Now you're lying in bed, your mind racing: What if I pushed too hard? What if those "dark thoughts" were suicidal ideation and I missed it? What if she doesn't come back next week? What if she hurts herself and it's my fault?
This is the fear that haunts many therapists: What if our interventions, our questions, our presence somehow makes things worse for our clients?
The Weight of Professional Responsibility
Lisa, a therapist with five years of experience, shared this in supervision:
"I had a client who'd been stable for months. We decided to process a childhood trauma she'd been avoiding. The next week, she had her first panic attack in over a year. She was angry, said therapy was making her worse, and threatened to quit. I kept thinking: Did I push too fast? Should I have left that memory alone? Did my need to 'fix' her trauma actually destabilise her recovery?"
This scenario captures something most of us face: the anxiety that our well-intentioned therapeutic work might sometimes cause the very distress we're trying to alleviate.
The Paradox of Therapeutic Change
Here's what makes this fear particularly challenging: real therapeutic change often involves a temporary increase in distress. Research consistently shows that many clients experience what looks like deterioration before breakthrough—sometimes called "negative therapeutic response" or the "worse before better" phenomenon.
Consider these common therapeutic realities:
Trauma processing often initially increases anxiety, nightmares, or emotional volatility before integration occurs.
Depression treatment may initially increase awareness of painful feelings that were previously numbed.
Couples therapy frequently brings relationship conflicts to the surface before resolution.
Addiction recovery typically involves intense discomfort and craving before stability develops.
So how do we distinguish between necessary therapeutic turbulence and harmful iatrogenic effects?
Understanding Iatrogenic Effects
Iatrogenic effects—unintended negative consequences of treatment—are a real concern in psychotherapy. Research identifies several ways therapy can potentially cause harm:
Symptom substitution: Focusing narrowly on one symptom without addressing underlying causes may lead to symptom shifting.
Premature termination: Clients may drop out feeling worse than when they started if not properly prepared for the therapeutic process.
Re-traumatisation: Inappropriate or poorly timed trauma work can overwhelm clients' coping capacity.
Dependency creation: Overly supportive therapy may inadvertently foster unhealthy dependence on the therapeutic relationship.
Cultural harm: Imposing therapeutic approaches that conflict with clients' cultural values or worldview.
But here's the crucial distinction: most therapeutic distress is not iatrogenic. It's often the necessary discomfort of growth and healing.
The Neuroscience of Therapeutic Disturbance
Understanding what happens neurobiologically during therapy helps normalise temporary increases in distress:
Memory consolidation: Processing traumatic memories often temporarily destabilizes them before they're re-stored in a less threatening way.
Neural plasticity: Creating new neural pathways involves disrupting established patterns, which can feel destabilising.
Emotional regulation: Learning new coping skills often means experiencing emotions more intensely while new systems come online.
Attachment repair: Developing secure attachment may initially trigger old abandonment fears or defensive patterns.
Clinical Indicators: Therapeutic Disruption vs. Harmful Effects
Learning to distinguish between necessary therapeutic discomfort and concerning iatrogenic effects is crucial:
Normal Therapeutic Disruption
Increased emotional awareness and expression
Temporary anxiety when addressing avoided topics
Initial resistance to change processes
Heightened interpersonal sensitivity
Dreams or memories surfacing
Fatigue from emotional processing
Concerning Iatrogenic Indicators
Sudden onset of previously absent symptoms
Rapid deterioration in functioning
New self-destructive behaviours
Complete loss of hope or motivation
Severe dissociation or disconnection
Thoughts of harming self or others
Risk Factors for Therapeutic Harm
Certain factors increase the likelihood of unintended negative effects:
Therapist factors: Inadequate training, personal unresolved trauma, boundary violations, cultural incompetence
Client factors: Severe mental illness, active substance abuse, minimal social support, history of treatment trauma
Process factors: Premature or inappropriate interventions, lack of informed consent, mismatched treatment approach
Systemic factors: Insufficient session frequency, managed care restrictions, organizational pressures
The Anxiety Spiral
When we fear we've caused harm, several dynamics often unfold:
Hypervigilance: We become overly focused on signs of deterioration, sometimes missing signs of growth.
Overcorrection: We may become overly cautious, avoiding necessary but challenging therapeutic work.
Self-doubt proliferation: One concerning case can trigger doubts about our competence across all our clients.
Supervision avoidance: Shame about potential harm may lead us to avoid seeking the very support we need.
Protective Strategies
Comprehensive Assessment
Conduct thorough risk assessments before intensive interventions
Understand client's current stability and coping resources
Assess readiness for specific therapeutic work
Identify potential triggers or contraindications
Informed Consent Process
Explain that therapy sometimes involves temporary increases in distress
Discuss what therapeutic turbulence might look like
Establish clear protocols for crisis situations
Ensure clients understand they can pause or slow the process
Titrated Interventions
Start with less intensive approaches and build gradually
Monitor client response between sessions
Adjust pace based on client stability and feedback
Maintain "window of tolerance" awareness
Ongoing Monitoring
Regular check-ins about therapy's impact
Use standardized measures to track changes
Ask directly about any concerning symptoms
Maintain contact between sessions when appropriate
The Supervision Conversation
When you're worried about client deterioration, these supervision questions can help:
"What specific changes am I observing, and over what timeframe?" "How does this fit with normal patterns for this type of work?" "What does the client say about their experience?" "Am I responding to actual data or my own anxiety?" "What additional support or resources might be helpful?"
Case Example: Working Through the Fear
Sarah was working with Brian, an armed forces professional with PTSD. After three months of stable progress, they began trauma processing using EMDR. Following the first trauma-focused session, Brian reported increased nightmares, hypervigilance, and irritability.
Sarah's immediate fear: "I've destabilised him. Maybe he wasn't ready for this work."
Through supervision, she learned to:
Normalise the response: Understanding that temporary symptom activation is common in trauma work
Assess safety: Confirming Brian wasn’t at risk for self-harm or dangerous behaviours
Check with the client: Brian reported that despite the increased symptoms, he felt "more hopeful than I have in years"
Adjust pacing: Slowing down the trauma work and increasing stabilization techniques
Maintain support: More frequent check-ins and crisis planning
Within two weeks, Brian’s symptoms decreased to below baseline levels, and he reported significant improvement in his overall functioning.
When Concern Is Warranted
Sometimes our fear of causing harm reflects legitimate clinical concerns requiring immediate action:
Safety issues: Any indication of suicidal or homicidal ideation Severe deterioration: Rapid loss of functioning across multiple life areas New dangerous behaviours: Self-harm, substance abuse, or risky activities Psychotic symptoms: Emergence of hallucinations, delusions, or severe confusion Treatment trauma: Client reporting feeling harmed or re-traumatised by therapy
These situations require immediate consultation, possible referral, and potentially crisis intervention.
The Ethical Framework
Our responsibility as therapists includes:
Competence: Working within our scope of practice and seeking additional training when needed Beneficence: Acting in the client's best interest, even when that means slowing down or referring Non-maleficence: "Do no harm" while recognizing that growth often involves discomfort Informed consent: Ensuring clients understand the risks and benefits of treatment Consultation: Seeking support when we're uncertain about our impact
Training Implications
Training programmes could better prepare therapists by:
Teaching about normal therapeutic turbulence and how to distinguish it from iatrogenic effects Providing supervised experience with challenging cases and deteriorating clients Developing risk assessment skills and crisis intervention competencies Addressing therapist anxiety about causing harm as a normal professional concern
Reframing Therapeutic Responsibility
Our responsibility isn't to prevent all client distress, that is not possible or desirable it's to:
Provide competent, ethical treatment
Monitor client safety and wellbeing
Adjust our approach based on client response
Seek consultation when needed
Maintain appropriate boundaries and scope of practice
Sometimes the most therapeutic thing we can do is sit with clients in their necessary pain, rather than trying to prevent or quickly resolve all discomfort.
Finding Balance
The fear of causing harm, while anxiety-provoking, often reflects our deep care for our clients' wellbeing. The goal isn't to eliminate this concern but to work with it skilfully:
Acknowledge the anxiety without letting it paralyse therapeutic work
Use clinical judgment based on training and consultation rather than fear alone
Trust the therapeutic process while remaining vigilant about safety
Seek support when genuinely concerned about client deterioration
Remember the larger context of therapeutic change and growth
Moving Forward with Courage
Most therapists will occasionally have clients who get worse during treatment. This doesn't automatically mean we've caused harm—sometimes people enter therapy because they're already in a deteriorating process, sometimes life circumstances change, and sometimes therapeutic work needs to get harder before it gets easier.
Our job is to provide competent, caring treatment while monitoring safety and adjusting our approach based on client response. When we can hold both our genuine care for clients and our realistic understanding of therapeutic limits, we can work with courage rather than fear.
The alternative—avoiding all interventions that might cause temporary distress—would actually be a disservice to our clients, depriving them of the transformative power of therapeutic change.
Trust your training. Seek consultation. Monitor carefully. And remember that your concern about potentially causing harm is itself evidence of the ethical sensitivity that makes you a good therapist.
Training Resources
Integrative Trauma Pathway training page
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About The Academy of Integrative Therapy About page Link