What does it mean when a client reports a history of big-T (Trauma) and expresses no interest in regular, frequent therapy sessions?

From the Guidelines

When a client with a history of significant trauma (big T trauma) says they are not looking for regular frequent sessions, it is crucial to prioritize their concerns while also considering the potential risks of inadequate treatment, as evidence suggests that trauma-focused treatments can be effective without a stabilization phase, even for individuals with complex PTSD 1. This approach raises clinical concerns as trauma treatment typically requires consistent engagement to be effective. I recommend having a transparent conversation with the client about their expectations and concerns, while explaining that trauma processing generally requires regular sessions to establish safety, build therapeutic rapport, and provide adequate support during difficult emotional work. Consider offering a compromise such as starting with less frequent sessions to build trust, then gradually increasing frequency during active trauma processing phases. Alternatively, phase-based trauma treatment could be structured with varying session frequencies depending on the treatment phase. The client may be experiencing avoidance (a common trauma symptom) or have had negative previous therapy experiences. Whatever approach is taken, ensure the client understands the treatment rationale and feels they have agency in the therapeutic process, as supported by the most recent and highest quality study on trauma-informed care 1. Some key points to consider include:

• The importance of evidence-based treatments (EBTs) with demonstrated efficacy for individuals who have experienced trauma 1
• The potential benefits of trauma-focused treatments without a stabilization phase, even for individuals with complex PTSD 1
• The need for a transparent and collaborative approach to treatment, taking into account the client's concerns and expectations 1
• The potential risks of inadequate treatment, including symptom worsening, emotional dysregulation, and suicidal behavior 1

From the Research

Understanding the Client's Statement

When a client says they are not looking for regular frequent sessions but has a big T trauma history, it may indicate that:

• The client is hesitant to commit to regular therapy sessions due to the intensity of their trauma history 2
• The client may be unsure about how to process their trauma and is hesitant to confront it in a frequent session setting 3
• The client's statement could be a coping mechanism to avoid feelings of overwhelm or anxiety associated with their trauma history 4

Implications for Treatment

Considering the client's big T trauma history, it is essential to:

• Establish a safe and supportive therapeutic environment to help the client feel comfortable opening up about their trauma 2
• Offer flexible session scheduling to accommodate the client's needs and comfort level 3
• Consider evidence-based treatments such as cognitive-behavioral therapy with a trauma focus (CBT-TF), cognitive processing therapy (CPT), or eye movement desensitization and reprocessing (EMDR) 2
• Pharmacological interventions, such as selective serotonin reuptake inhibitors (SSRIs), may also be effective in reducing PTSD symptoms, but should be considered on a case-by-case basis 5, 6

Key Considerations

• The client's trauma history and treatment preferences should be prioritized when developing a treatment plan 2
• The therapeutic relationship and establishment of trust are crucial in helping the client feel comfortable discussing their trauma 3
• Ongoing assessment and monitoring of the client's progress and comfort level are necessary to ensure the treatment plan is effective and supportive 4, 5, 6